Heart Disease Looks Different in Women


Coronary artery disease (CAD) is the leading cause of death among women in the United States, and in some years even more women die from CAD than men. Yet many women don't realize they're at risk.

toshawa-andrews toshawa-andrews that quickly went away. Soon she was consumed by fatigue, "After six or seven months I couldn't carry groceries, I couldn't have sex, I couldn't dance with my daughters without feeling chest pain," says Kupetz.

Karen Sanson, a thin, fit 60-year-old started to wake up in the middle of the night unable to breathe. "I also felt very fatigued," she says, "even though I usually have mounds of energy and go till I drop."

None of these women seemed at risk for heart disease, yet two ended up having (and surviving!) heart attacks and all three were diagnosed with coronary artery disease.

Recognize the symptoms
In the months leading up to a heart attack, as one study of women with CAD found, less than a third of the women felt chest pain, but many experienced fatigue, dizziness, indigestion, nausea, and
shortness of breath.

Kupetz, of Sherman Oaks, Calif., had a family history of heart disease and high cholesterol and had been on cholesterol-lowering medication since age 20. But a stress test and EKG she had after an episode of chest pains and fatigue appeared normal.

She found her way to C. Noel Bairey Merz, MD, medical director of the Women's Heart Center at Cedars-Sinai Medical Center in Los Angeles. "Lori had CAD that failed to be diagnosed for almost a year, but using gender-specific testing we were able to apply lifesaving treatment," says Dr. Bairey Merz. Kupetz had 98% blockage in one of her main arteries and two other blockages—she needed emergency triple-bypass surgery. "It was amazing that I was alive," says Kupetz. "If I hadn't been assertive and aggressive, I'd be dead."

About half of women with CAD will have atypical symptoms that are more likely to be misdiagnosed, says Dr. Bairey Merz, "They might be treated for acid reflux, they might be told they have gallbladder disease or even tennis elbow. But many women do have classic symptoms like chest pain and we don't want them to ignore it."

Know your risks
Though coronary artery disease (CAD) is more common in older women, a recent study coauthored by a researcher with the Centers for Disease Control and Prevention (CDC) found that the death rate for CAD in women ages 35 to 54 increased between 2000 and 2002. Doctors believe the increase is probably due to a rise in CAD risk factors says Pamela Marcovitz, MD, director of the Ministrelli Women's Heart Center at Beaumont Hospital in Royal Oak, Mich.

"Younger women and single women take better care of themselves, but once we reach middle age we let our health go to focus on our careers and our families. And we're also more likely to get obesity and diabetes that can lead to heart disease," says Dr. Marcovitz.

Women of all ages can fail to recognize the warning signs of CAD, and many don't know that a family history of heart disease puts them at high risk.

"I had signs for almost a year before my heart attack, but I didn't know it," says Cleveland resident Karen Sanson. "Then one night I was talking with my husband after work, and suddenly I felt like someone threw a cement block on my chest." Sanson later learned that two of her aunts had died of heart disease.

"Whenever a woman is diagnosed she should talk with her children and her siblings about their increased risk. If we can get women who have the disease to get their daughters and their sons to pay attention early on, that's just one more step to early intervention," says Paula Johnson, MD, chief of the Division of Women's Health at Brigham and Women's Hospital in Boston.

Get the right diagnosis
Shortly after suffering her second heart attack on the ice, Toshawa Andrews, a figure skater from Los Angeles was finally diagnosed with a type of CAD called coronary microvascular dysfunction. Coronary microvascular dysfunction causes plaque to spread evenly throughout the walls of small arteries instead of causing obvious blockage in the main arteries.

"There are an estimated two million to three million women in the U.S. with this disorder, yet most community-based physicians don't know how to test for it or to treat it," says Dr. Bairey Merz. In some cases, women who have bypass surgery or angioplasty for typical CAD continue to experience symptoms because they also suffer from blockage in their small arteries, says Dr. Bairey Merz.

"It could have been caught years ago, after my first heart attack. But my angiogram didn't catch it," says Andrews. Unfortunately conventional angiograms don't usually detect coronary microvascular dysfunction.

Doctors are increasingly aware that heart tests designed for men aren't always sensitive enough for women, but women still aren't getting referred for heart tests as often as men. "You don't want to over-test, but women are under-tested and they're not being listened to and investigated," says Dr. Marcovitz.

"If you're having symptoms that you're afraid of, your doctor should keep looking. You should never feel blown off or discounted," says Dr. Marcovitz.