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Resource Description: 
This site is an excellent first place to turn to for more information all cardiac concerns, including cardiomyopathy. Of particular interest for women is their Go Red for Women heart disease awareness movement.
This site has a wealth of information on heart disease, including a pdf version of their 106-page Healthy Heart Handbook for Women.
This non-profit group is an organization dedicated to ending unnecessary deaths from undiagnosed and untreated cardiovascular disease (CVD).
The Congenital Heart Information Network (C.H.I.N.) provides information and support services to families of children with congenital heart defects, as well as to adults with these problems. The site includes a listing of local, regional, and national support groups throughout the globe for families and adults with CHD.
The American Dietetic Association (ADA) offers valuable information about heart healthy diets.
This is a site from the National Women's Health Information Center of the U.S. Department of Health and Human Services. Included is a section on how to talk to your health care provider about heart disease and heart health.
This article originally appeared in the November-December 2003 FDA Consumer and contains revisions made in February 2004 and May 2004.
Episode number: 
209

Heart disease is women's No. 1 killer. It's also a leading cause of disability among women.  The good news is that heart disease can be managed and even prevented.  Your first step in arming yourself against it is to understand it.

The coronary arteries are the blood vessels that bring blood to the heart.  When these arteries become hard and narrowed, the blood supply to the heart becomes reduced.  Arteries usually harden and narrow because they get clogged with a fatty substance called plaque.  This build-up of plaque in a blood vessel is called atherosclerosis.  The plaque itself can block the flow of blood through the blood vessel.  Or, the plaque can rupture or tear and a blood clot can form, which can also block the blood vessel.  When the vessel is a coronary artery, a heart attack can result.

A heart attack means the supply of blood and oxygen to the heart has been so drastically reduced that cells in the heart die.  The more severe the heart attack, the more of the heart that dies.  The heart is essentially a muscle whose main job is to pump blood to all parts of the body, bringing needed nutrients and oxygen and removing waste products. The technical name for the heart muscle is the myocardium, and the most widely used technical term for a heart attack is myocardial infarction.  But you may also hear the terms "coronary thrombosis" or "coronary occlusion." 

Some other terms to know:  "Cardiovascular disease" or CVD refers to conditions or diseases of the heart and blood vessels in general, including coronary artery disease, congestive heart failure, high blood pressure, and stroke.  "Coronary artery disease" or CAD refers specifically to atherosclerosis of the coronary arteries. "LDL-cholesterol," commonly called "bad cholesterol" or simply "cholesterol," is a fat made up of several substances that is a major component of plaque in the arteries and therefore a major cause of atherosclerosis.  "Ischemia" is a general term that means the flow of blood (and therefore oxygen) to a part of the body has been reduced; "cardiac ischemia" means not enough blood and oxygen are flowing into the heart. 

Stroke is related to heart disease.  Just as a heart attack results from an interruption of blood flow to the heart, a stroke is the interruption of the flow of blood to any part of the brain.  Just as a heart attack damages or destroys heart tissue, a stroke damages brain tissue.  And just as a heart attack can be caused by atherosclerosis of the coronary arteries, a stroke can be caused by atherosclerosis of the carotid arteries – the arteries that supply blood to the brain. Therefore, the steps taken to prevent heart attack can also help prevent stroke.  Get more information by looking at our Second Opinion section on Stroke, Episode 205.

Quick Facts

  • How often does the average heart beat (expand and contract) each day? About 100,000 times.  How much blood does it pump?  About 2,000 gallons. If you live to age 70, your heart will beat more than 2.5 billion times.
  • Although some risk factors for a heart attack are beyond our control, many more are not.  To prevent a heart attack, live in a "heart-healthy" way.  That means:
    • get more physical exercise
    • eat a heart-healthy diet
    • keep your blood pressure under control
    • keep your cholesterol under control
    • stop smoking
    • stop drinking alcohol heavily
  • Fewer than half of all women are aware that heart disease is the number 1 killer of American women. Most women identify cancer as the leading cause of death.
  • One in ten American women 45 to 64 years of age has some form of heart disease, and this increases to one in four women over 65.  It kills ten times more women than breast cancer each year, and more than all other cancers combined.
  • According to one study, nearly one fourth of women who died of heart disease were between the ages of 35 and 44.
  • Heart disease is a different disease for women than it is for men.
  • Smoking is the most prevalent and preventable risk factor for cardiovascular disease in women younger than 45.
  • African-American women are more at risk for heart disease than Caucasian women.

*Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.

Ask Your Doctor

This list questions will provide a good starting point for a discussion with your doctor.  However, it is not a complete list.

  • What is my blood pressure?
  • What are my cholesterol numbers?
  • What is my blood sugar level, and does it mean I'm at risk for diabetes?
  • What is my risk for heart disease? 
  • What is the current condition of my heart and coronary arteries? 
  • What life-style changes (such as diet, exercise, etc.) should I make to prevent heart disease?
  • Do I need screening tests, even though I don't have heart disease symptoms?
  • I've noticed these symptoms:  . . .  What medical tests should I take to get an accurate diagnosis?
  • How can I tell if I'm having a heart attack?

If your doctor finds evidence of heart disease:

  • How dangerous is my condition?
  • What life-style changes (such as diet, exercise, etc.) should I make to treat my condition?
  • What medications can I take to slow down the progression of my condition?
  • What are the treatment options, and what are their benefits, risks, and side effects?
  • What follow-up care will I need?
  • If I have pain, how will it be managed?

Key Point 1

Heart disease is the leading cause of death in women in the U.S.  However, if you are a pre-menopausal, asymptomatic female, don't overreact.  Tthe most valuable tests to have to indicate your heart disease risk are the old standbys – blood pressure, cholesterol level, weight and blood sugar. 

There's no question that you need to see a doctor when you're not well.  But what about regular visits to the doctor for physical examinations by people who believe they are well?  Think about these facts:

  • Women are at risk for heart disease and heart attacks, just like men. While they develop heart problems later in life than men, by about age 65, a woman's and man's risk is almost the same.
  • Heart disease doesn't happen overnight.  Your doctor can easily identify conditions that increase your risk as well as early warning signs.
  • Heart disease – and even a heart attack – may or may not produce symptoms.
  • Heart disease can be prevented/delayed with appropriate care and life style choices.

In fact, routine well visits to your doctor are extremely useful to help reduce your risk for cardiovascular disease.

  • An unhealthful cholesterol level can be identified by an exam and a blood test.  Today's cholesterol lowering drugs can reduce future risk of heart disease by about 33%.
  • By identifying high blood pressure and prescribing appropriate medication the future risk of stroke and heart attack can be reduced significantly.
  • According to the American Diabetes Foundation 2 out of 3 people with diabetes die from heart disease and stroke.  Simple tests can identify the problem so your doctor can initiate treatment before major damage has been done.
  • Early menopause, natural or surgical, can double a woman's risk for developing heart disease.
  • Doctors may identify one or more of a vast number of differing health problems from observations made during a regular exam.
  • Your doctor can help you stop smoking and build a plan for exercise

If your doctor suspects you're at risk for heart disease, there are a number of traditional diagnostic tools used to look for cardiovascular disease in general and coronary artery disease in particular.  Some of them are heart imaging techniques, that is, ways of creating pictures of the inside of the heart that can show the presence and extent of heart disease.  These diagnostic tools include:

  • Blood tests: when cells (including heart muscle cells) die, enzymes are released into the blood; blood tests can detect the presence and amount of these enzymes
  • Electrocardiogram (EKG, ECG, or cardiogram): a measurement of the heart's electrical activity (which controls the heartbeat) made by an EKG machine, which is attached to the chest with wires called "electrodes" 
    • portable EKG: if an EKG doesn't give conclusive results, one may get a portable EKG machine, called a "Holter monitor," to wear for a day; it monitors the heart rate and notes any arrhythmias (irregularities)
  • Stress EKG (stress test): an electrocardiogram made while the person is exercising (usually by jogging on a treadmill or riding a stationary bike)
    • if one is unable to exercise, a drug can be injected that makes the heart react as it would during exercise
  • Echocardiogram: sound waves are bounced off the heart to produce still and moving images of it (similar to ultrasound imaging used with pregnant women to produce images of fetuses.) 
    • a "stress echo" is a stress test and echocardiogram done at the same time
  • Cardiac catheterization: in this more invasive test, a small tube (catheter) is inserted through a blood vessel and threaded up into the heart, to measure blood flow and pressure
  • Coronary angiogram (also called arteriogram): an x-ray of the inside of the coronary arteries to look for blockages
    • during cardiac catheterization, a contrast dye is injected into the catheter that enables blockages to be seen on the x-ray
    • the process of making an angiogram is called angiography

Recently, a new type of imaging test, EBCT (electron beam computerized tomography or "Ultrafast CT" ), has received a lot of publicity and advertising.  EBCT, often called a "heart scan," is a type of computerized tomography (popularly known as CT scan or "CAT scan").  Computerized tomography is a sophisticated imaging system that creates a series of very detailed, cross-sectional images of organs and tissues. EBCT is a variation that works much more quickly.  It provides an accurate measurement of calcium deposits in the coronary arteries.  These calcium deposits are reported as a "calcium score;"  the higher the score, the greater the amount of calcium deposits.  Scores range from 0 (no evidence of calcium deposits) to over 400 (very high amounts of calcium are present).

There does appear to be a correlation between large calcium deposits in the coronary arteries and the development of coronary artery disease.  However, the correlation seems age-dependent; that is, it is stronger for younger people (up to about 50) than older (above 50).  People over 50 seem to develop calcium deposits naturally, so they're not as accurate a predictor of future CAD. 

Moreover, the medical profession believes certain standards must be met before a screening test (a diagnostic tool, such as EBCT) can be called cost-effective. One of these is that it must provide information that will affect treatment and prognosis.  So far, there are no studies showing that EBCT "heart scanning" has any significant effect on reducing deaths from CAD or improving the lives of people with it. 

For example, EBCT will identify small build-ups of calcium (such as 10-20%), but these results generally don't lead to changes in treatment, other than re-emphasizing the importance of reducing risk factors, such as smoking and cholesterol.  Further, the test finds only calcium deposits that have become hard (called "hard plaque"); it does not find "soft plaque" which can also cause heart attacks.

Besides being of limited value in the early detection of CAD, EBCT is unavailable in many areas, expensive, and generally not covered by insurance.  A team of experts from the American College of Cardiology, American Heart Association, and the American College of Physicians-American Society of Internal Medicine concluded that: "The proper role of EBCT is controversial and will be the subject of future ACC/AHA statements."

Three-Dimensional Helical Computed Tomography (or DHCT) is another advanced variation on traditional CT scanning.  Like EBCT, there are many places where it isn't available, it's expensive and generally not covered by insurance, and at present may be of limited value in the early detection of CAD.

    

Key Point 2

Even if you don't think you have risk factors for heart attack, if you are a woman with diabetes, peripheral vascular disease or chronic renal disease, you need to be concerned and do something.  You are at a high risk of having a heart attack.  In fact, you are at the same risk as someone who has already had a heart attack.

Some risk factors (things that increase the chance of getting a disease or developing a condition) for coronary artery disease and heart attack are beyond our control, such as:

  • Genetics: a family history of heart disease and early heart attack can increase one's risk of heart attack
  • A history of coronary artery disease, high blood pressure, and other heart problems
  • Age: the heart muscle weakens with age, so that men over 45 and women over 55 are at a higher risk of having a heart attack
  • Diabetes: uncontrolled diabetes increases the risk of developing coronary artery disease
  • Peripheral arterial disease (clogged vessels in the arms and legs):  people with PAD may form blood clots, increasing their risk of death from heart attack or stroke
  • Chronic renal disease: kidney disease can be a cause or a consequence of cardiovascular disease.  It is also closely related to hypertension and diabetes.

Other risk factors, such as not getting enough exercise, smoking, and having too much cholesterol in the blood, are controllable.  They relate to how we live, and we can always change that if we try.  It's especially important for women at increased risk to live in a "heart-healthy" way.   

If you are at increased risk, your doctor will probably want to do tests before recommending prevention or treatment measures.  See Key Point 1 for more information on tests.

There are a number of ways to treat heart disease.

Medicines
The list of medicines now used to treat heart and cardiovascular disease would include:

  • Blood pressure reducers, such as:
    • Beta blockers: drugs that slow down the heart rate, correct arrhythmias (irregular heartbeat) and reduce blood pressure, all of which helps lower the heart's workload
    • Vasodilators: drugs that open ("dilate") the arteries, lowering blood pressure and, therefore, the heart's workload
    • Calcium-channel blockers: another class of drugs that dilate blood vessels
    • Diuretics: drugs that help eliminate excess fluid to aid the heart in working more efficiently
  • Blood clot reducers, including:
    • Anticoagulant drugs:  often called "blood thinners," though they don't actually thin the blood, nor do they dissolve clots already present.
    • Antiplatelet agents:  stop blood platelets (substances in blood that promote clotting) from clumping together to form clots.
    • Aspirin 
    • Thrombolytic drugs: dissolve blood clots already present.  To be effective thrombolytics must be given within one hour of start of symptoms.
  • Cholesterol reducing medicines
    • Statins: currently considered the most important and effective group of LDL-cholesterol reducing medicines. They slow cholesterol production and increase the liver's ability to remove the LDL-cholesterol already there.  Because the body makes more cholesterol at night, these drugs are usually taken in the evening, at dinner or before bed.  Side effects appear to be minimal and studies show that people using statins have reported 20 to 60 percent lower LDL-cholesterol levels.
    • Bile acid sequestrants:  bind with bile acids in the intestines that contain cholesterol.  Then they are eliminated during defecation, reducing the amount of cholesterol in the blood.  Often, these drugs are prescribed in combination with statins. 
    • Fibrates:  lower the level of triglycerides (the main component of fat and therefore another major cause of atherosclerosis) in the blood. 
    • Nicotinic acid:  a non-prescription cholesterol lowering substance.  It's a form of niacin, the water-soluble B vitamin.  When taken in high doses, well above the suggested daily amount, it can be effective in lowering LDL-cholesterol and triglyceride levels. 
  • Antiarrhythmic drugs that regulate the heartbeat
  • Digitalis: a drug that strengthen the heartbeat 

Percutaneous Coronary Intervention (PCI)
PCI basically refers to a procedure known as angioplasty.  Angioplasty is the process of opening or widening a narrowed blood vessel. The procedure was first used in the 1970s to treat coronary artery disease. Now it is being applied to other arteries.  For example, angioplasty of the carotid arteries (which carry blood to the brain) is now seen as a way to help prevent stroke. 

In angioplasty, a small tube called a catheter is threaded up into the arteries to the site of the blockage.  (If the catheter reaches the heart, the process is called coronary catheterization.)  When the blockage is reached, a tiny balloon at the end of the catheter is inflated to open the narrowed blood vessel. (The procedure is also known as "balloon angioplasty.")  After the blood vessel has been widened, the balloon and catheter are removed.  The procedure may also involve using a tiny umbrella-like filter (called a "distal protection device") at the end of the catheter to catch any particles that break free from the artery and prevent them from traveling to and blocking some other blood vessel.

A more recent development is to combine a balloon angioplasty with the placement of a stent. A stent is a tiny tube made of a metallic mesh; it looks something like a wire cage or spring. It's put inside a blood vessel to keep it open and unblocked.  After a blocked blood vessel has been opened by balloon angioplasty, a stent can be slid along the catheter and put in place.  The  most recent development in PCI is to coat the stent with medicines to help prevent further blockages; this type of stent is known as a "drug-eluting stent."  Usually a balloon angioplasty and/or a stent work permanently, but sometimes the procedure has to be repeated after several years.

All forms of PCI are considered "invasive" procedures, because they involve entering the body, but "non-surgical" because no major incisions are involved. 

Besides PCI, there is another non-surgical way of treating coronary artery disease called atherectomy.  In this procedure, the doctor opens the affected artery and, depending on the type of blockage, uses one of several techniques and instruments to physically remove the blockage.

Surgical Options
The best known is popularly called "bypass surgery," technically called "coronary artery bypass grafting" (CABG or "cabbage").  As its name implies, its purpose is to allow blood to bypass or go around a blocked artery.  During the procedure, blood vessels from other parts of the body (usually arteries from the chest and arm and veins from the leg) are grafted into place to create a detour around the blockage in the coronary artery. This process is also known as revascularization.

Other surgical options depend, of course, on the nature and severity of the CAD and problems the CAD has caused.  For example, CAD can lead to an irregular heartbeat (arrhythmia), which is often treated by implanting a pacemaker in a person's chest.  A pacemaker is a tiny device that sends electrical signals to the heart to restore its regular rhythm.  In the most serious situations, when CAD has led to a severe, very damaging heart attack, a heart transplant may be needed. 

    

Key Point 3

In women at intermediate or high risk of cardiovascular disease, you need to pay special attention to your heart attack risk.  In fact, prevention can't hurt, and all women can benefit from it.  Maintaining a healthy weight, blood pressure and cholesterol, exercising daily and avoiding tobabcco will protect your heart – no matter your risk level. 

Risk factors, such as not getting enough exercise, smoking, and having too much cholesterol in the blood, are controllable.  They relate to how we live, and we can always change that if we try.  In other words, the easiest and most effective way to prevent coronary artery disease (CAD) is to live in a "heart-healthy" way.  That means:

  • Start and maintain a program of regular physical exercise
    • The choices are virtually endless, from taking a simple (but not too slow) walk to swimming to team sports to exercises classes with a professional trainer
  • Stop smoking
  • Stop drinking alcohol heavily
  • Keep your blood pressure under control
    • If you need blood pressure lowering medicine, get it and use it
  • Keep your cholesterol under control
    • If you need cholesterol lowering medicine, get it and use it 
    • Eat a heart-healthy diet, which includes:
      • fruits and vegetables
      • more fish, less meat
      • "good" oils, such as olive oil and canola oil
      • antioxidants
        • antioxidants are nutrients and other substances that protect cells in the body from the damage caused by "oxygen free radicals" (molecules that seek to become oxidized, a process that harms body tissues and has been linked to many diseases, including stroke, heart disease, and cancer); antioxidants are found naturally in food but are also available as dietary supplements (antioxidates found in food work far better than pill supplements)
        • important antioxidants include:
          • Vitamins A, C, E and beta-carotene (found in carrots)
          • Lycopene  (found in tomatoes)
          • Flavonoids  (found in ginkgo biloba, black cherries, blackberries, bilberries and blueberries)
          • Quericetin  - a specialized flavonoid found in apples, onions, tea and red wine
          • Coenzyme Q10 - a vitamin-like substance found in soy, whole grains, mackerel, and chicken
      • folates – foods rich in folic acid, such as:
        • green vegetables
        • strawberries, oranges, raspberries
        • tomatoes
        • nuts and seeds

Most of the ingredients of a "heart healthy" diet have been known for a while.  They're based on long-running heart health studies, such as the Framingham study, which has followed a population in Massachusetts for 46 years.  Recently a group of European doctors used these studies to support the idea of the "Polymeal" diet, their term for a "natural alternative" to the Polypill (discussed below).  The Polymeal daily diet calls for: 

  • fruit and vegetables (400 grams (g) per day; 1 apple = 150 g)
  • fish (114 g four times a week; 3 oz  = 85 g)
  • a garlic clove
  • a small dose of dark chocolate (no more than 100 grams per day; 1 oz = 28 g)
  • a small glass of wine (150 milliliters per day)

Clinical trials have shown that all these ingredients help reduce either "cardiovascular disease events" (such as heart attack) or risk factors for CVD.  That doesn't mean you should instantly start eating only what's in the Polymeal diet. Nor does it mean you should start drinking wine if you're a non-drinker. But it does remind us, once again, that a heart healthy diet, along with regular exercise, is the best preventative against CVD.

The name "Polymeal" was invented, in part, as a tongue-in-cheek response to another recent European cardiac health recommendation by a different group of scientists, the Polypill.   Just as the Polymeal consists of ingredients known to be part of a heart healthy diet, the Polypill consists of a mixture of drugs known to be effective in treating various kinds of heart and cardiovascular disease. 

The Polypill, first proposed in June 2003, would be a "cocktail" of six of these drugs, including a statin, three beta blockers, aspirin, and folic acid to reduce homocysteine levels in the blood.  (Homocysteine is an amino acid made by the body; high levels of it in the blood are associated with atherosclerosis.)  But the Polypill is not yet commercially available; it is still a concept under investigation.

Medline Plus

Medline Description: 

Conduct an off-site search for Women's Cardiac Health information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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