Women and coronary artery disease

Why is it important for women to learn about coronary artery disease?

Coronary artery disease is the number one cause of death of women in the United States. More women die from coronary artery disease than from the next five leading causes of death combined (cancer, chronic obstructive pulmonary disease, Alzheimer's, diabetes, and accidents).

But many women underestimate the threat coronary artery disease (CAD) poses to their health. Surveys show that about half of women do not know that heart disease is the number one cause of death of women.¹

What is coronary artery disease?

Coronary artery disease is caused by the gradual buildup of plaque (made of fat, cholesterol, and other substances) on the inside walls of the coronary arteries. These arteries supply oxygen-rich blood to the heart. Over time, the plaque deposits grow large enough to narrow an artery's inside channel, decreasing blood flow to the heart muscle. If the plaque becomes unstable and ruptures, a blood clot can form at the rupture site and block blood flow, resulting in a heart attack.

What factors lead to coronary artery disease and death in women?

The rate of coronary artery disease increases 2 to 3 times after menopause, the time of life when a woman's menstrual periods stop.¹ This increase is not completely understood, but cholesterol, high blood pressure, and fat around the abdomen-all risk factors for coronary artery disease-also increase around this time.

In the past, medical research on heart disease was primarily focused on men. Now, researchers recognize that there are significant differences in coronary artery disease in women and men. For example, men usually have typical heart attack symptoms: chest pain that grips the chest and spreads to the shoulders, neck, and arms. Although women can have these symptoms too, women are more likely to have less common symptoms such as breathlessness, heartburn, nausea, jaw pain, back pain, or fatigue. Heart attacks in women are often brought on by anxiety or mental stress, and even sleep. Heart attacks in men more often come on with exercise or exertion.

Because women do not always have the classic heart attack symptoms or typical onset of heart attacks, they may delay seeking care or, when seeking care, may not be treated as aggressively as men.

What can women do to prevent coronary artery disease?

In response to these concerns, the American Heart Association published specific guidelines for preventing and treating coronary artery disease in women.² These guidelines address lifestyle changes, medicines and supplements, and hormone therapy in menopausal women. Ask your doctor which recommendations are appropriate for you.

Lifestyle changes

• Stop smoking and avoid secondhand smoke.
• Do at least 30 minutes of moderate-intensity activity, such as brisk walking, on most-preferably all-days of the week.
• Eat a heart-healthy diet and limit saturated fat to less than 10% of calories, limit cholesterol intake to less than 300 mg per day, and avoid trans fatty acids.
• Keep your body mass index (BMI) between 18.5 and 24.9 kg/m² and your waist circumference less than 35in..
• If you have coronary artery disease, be evaluated for depression.
• If you drink, do so in moderation (an average of 1 drink a day for women). If you do not drink, do not start.
• Adopt the DASH (Dietary Approaches to Stop Hypertension) eating plan, and reduce daily salt intake if you have high blood pressure. For more information, see:

  Tips for following the DASH diet.

Medicines

• When high blood pressure (140/90 mm Hg or higher) cannot be controlled with lifestyle approaches, consider medicines to control it.
• Lipid-lowering medicine (usually statins) and lifestyle changes are recommended for women at intermediate to high risk of coronary artery disease or when cholesterol levels cannot be controlled with other medicines.
• If you have diabetes, keep your hemoglobin A1c (A1c) level at less than 7%. A1c is a blood test that measures how well blood sugar levels have remained within a safe range over the previous 2 to 3 months.
• Daily, low-dose aspirin is recommended for most women who are at high risk of coronary artery disease. The routine use of low-dose aspirin in healthy women at low risk of coronary artery disease is not recommended.
• Beta-blocker medicines, which slow heart rate and reduce the workload on the heart, are recommended for women who have had a heart attack or those who have chronic chest pain (angina).
• Angiotensin-converting enzyme (ACE) inhibitor medicines, which lower blood pressure and reduce the workload on the heart, should be used by most women at high risk for coronary artery disease.
• Angiotensin II receptor blocker (ARB) medicines, which also lower blood pressure and reduce the workload on the heart, should be used by high-risk women with heart failure who cannot take ACE inhibitors.

Hormone therapy

Taking estrogen with or without progestin does not prevent coronary artery disease. In fact, if you are 10 or more years past menopause, taking hormone therapy may raise your risk of coronary artery disease.³

Talk to your doctor about your risks with hormone therapy. And carefully weigh the benefits against the risks of taking it. If you need relief for symptoms of menopause, hormone therapy is one choice you can think about. But there are other types of treatment for problems like hot flashes and sleep problems. For more information, see the topic Menopause and Perimenopause.

How will my doctor determine my risk for coronary artery disease?

Your doctor will calculate your risk for coronary artery disease by assessing the number of risk factors you have. Risk factors include:

• High LDL cholesterol level (greater than 130).
• Low HDL cholesterol (less than 40 mg/dL).
• Cigarette smoking.
• High blood pressure (140/90 mm Hg or greater) or taking medicine to treat high blood pressure.
• Family history of early coronary artery disease in father or brother before age 55 and/or heart disease in mother or sister before age 65.
• Being older than 65, or having gone through early menopause.

Citations

1. American Heart Association (2006). Heart disease and stroke statistics-2006 update. Circulation, 113(6): e85–e151.

2. Mosca L, et al. (2007). Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation, 115(11): 1481–1501.

3. Rossouw JE, et al. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA, 297(13): 1465–1477.