Wake up, America. Heart attacks are killing a quarter-million women every year–nearly six times the number who die of breast cancer. “Cardiovascular disease [including heart attack and stroke] kills more women than the next 16 causes of death combined,” says Brian Henry, spokesman for the American Heart Association. At current rates, a third of all women under 40 will develop heart disease during their lifetimes. And those who suffer heart attacks will fare worse than men who do. A recent study from Yale University found that among heart patients younger than 75, women were almost twice as likely as men to die in the hospital. But it doesn’t have to be this way. A woman who knows how to recognize a heart attack (the symptoms aren’t always what you’d expect) is more likely to survive one. And by making the kinds of changes Tucker did, anyone can lower her risk of falling victim in the first place.
How did we ever arrive at the notion that women are immune to heart disease? The idea has some basis in biology–but only until menopause. The sex hormone estrogen protects the cardiovascular system during a woman’s reproductive years (and afterward, if she undergoes hormone-replacement therapy). Estrogen relaxes the blood vessels, reducing blood pressure. It lowers LDL, the “bad” cholesterol that lays down plaque on arterial walls. At the same time, it boosts HDL, the “good” cholesterol that works to clear its evil twin out of the system. That’s important, because narrowed arteries deprive the heart of oxygen-rich blood, causing the excruciating chest pain known as angina. And the plaque itself can break open, causing blood clots to form. If a clot blocks one of the three main coronary arteries, it causes a heart attack. If it occludes one of the blood vessels leading to the brain, it can cause a stroke. Thanks to the protective effects of estrogen, women generally start developing heart disease 10 years later than men. They begin having heart attacks 10 to 20 years later.
This disparity begat the myth that women are not at significant risk. And the myth morphed into medical dogma during the 1950s and ’60s, when scientific studies seemed to support it. Of course, women were rarely included in those studies. “For a long time, there was a bias against including women in clinical trials because it might introduce unique effects related to menstruation and reproduction,” says Dr. Randall Zusman, director of vascular medicine at Massachusetts General Hospital. “It was assumed that the results in men would apply to women, too.”
It took the prestigious Framingham Heart Study to set the record straight. The 50-year study, which began examining residents of Framingham, Mass., in 1948, enrolled women from the outset–not to see why they got heart disease, but to understand why they didn’t. At first, when the Framingham-study population was relatively young, the data confirmed that women were not at great risk. By the 1970s, however, it became clear that the risks rose dramatically after menopause. But by then, generations of doctors had been blinded to the dangers for women. Just 20 years ago, says Dr. Fredric Pashkow, associate director of preventive cardiology at the Cleveland Clinic Foundation, “medical schools were still teaching that if a woman comes in with chest pain, it’s probably psychosomatic.”
Women are now better represented in heart-disease studies. But until they suffer actual heart attacks, they still receive less aggressive treatment than men. As a rule, women have to exhibit more severe symptoms before they’re referred for angiograms, the tests that indicate whether major arteries are dangerously narrow. And because women miss out on angiograms, they’re less likely than men to receive either angioplasty to open clogged arteries or bypass surgery to reroute blood flow. Former NIH director Bernadine Healy, a cardiologist by training, has termed this phenomenon the Yentl Syndrome, for the woman in Jewish literature who had to dress as a man to receive a rabbinic education. “If you act like a man and have a heart attack, then you’ll be treated like a man,” she says. “Up until that point, women tend to be underinvestigated.”
To receive optimal care, it’s important for everyone–both men and women–to know the symptoms of heart attack. Unfortunately, women often fail to display the classic signs: crushing chest pain radiating into the jaw or left shoulder, possibly accompanied by nausea and sweating. Women may have all these symptoms, but the signs can also be as subtle as overwhelming fatigue or shortness of breath. “When we see that in the emergency room, we don’t think of heart attack,” says Dr. Donna Milavetz, co-director of the Mayo Clinic Women’s Heart Clinic. “We think of anemia or thyroid problems.” Perhaps because of these confusing signals, studies have shown that women take longer to call an ambulance during a heart attack. The delay can be fatal. Clot-busting drugs are only effective if given within six hours of the attack’s onset.
To further confuse the issue, sudden chest pain can stem from various causes–from pinched nerves in the neck to esophageal reflux. While these conditions affect both sexes, studies show that women complain of them more often. That’s why it’s especially important for women to know their risk factors for heart disease. If you can explain why you’re at risk, you’ll get the treatment you need instead of being patted on the head and sent home.
But why remain at risk when so many of the risk factors can be drastically reduced? Smoking is the No. 1 preventable cause of heart disease, tripling the chances of heart attack. “It reverses the benefits of estrogen by constricting the blood vessels and increasing bad cholesterol,” says Pashkow. “It’s artificial menopause.” Smoking is especially harmful in women who take oral contraceptives. The two in combination make blood stickier and more likely to clot. (The pill alone is no longer thought to pose a danger.) A second risk factor–high cholesterol–can be reduced through diet, exercise and, if necessary, cholesterol-lowering drugs. The benefits are disproportionate in women. In a 1996 study involving 4,200 heart-attack survivors, Boston researchers found that the cholesterol-lowering drug pravastatin cut the risk of a subsequent heart attack by 20 percent in men, and by 46 percent in women. High blood pressure, the other key risk factor, can often be alleviated through diet and weight control. Staying lean and eating well can also help prevent type 2 diabetes, a disease that eliminates a younger woman’s gender advantage by fostering arterial plaque. “Modifying those three risk factors–smoking, cholesterol and blood pressure–can dramatically diminish the risks of heart disease,” says Dr. Daniel Levy, director of the Framingham Heart Study. So take a tip from Josephine Tucker. There’s no better way to avoid an early death.
