Heart disease in women - the numbers are staggering. Cardiovascular disease, which includes heart disease, hypertension and stroke, is the number one killer of women, according to the American Heart Association. It kills half a million American women each year. That figure exceeds the next seven causes of death combined. Moreover, women are 15% more likely than men to die of a heart attack. And they are twice as likely to have a second heart attack in the six years following the first.
Yet in a 2000 national heart association survey, only 34% of women correctly identified heart disease as a leading cause of death.
And "only 8% of women saw it as their biggest health threat," says cardiologist Sharonne Hayes, MD, director of the Mayo Clinic Women's Heart Clinic in Rochester, Minn. "There's a disconnect. They know it's a major disease, but they think they're going to die of breast cancer."
Major issues surrounding women's heart health and medical care were brought to light in a survey of 204 women with heart disease reported in the January/February 2003 issue of Women's Health Issues. Hayes, who is Director of Mayo Clinic Women's Heart Clinic in Rochester, Minn., co-authored the report, funded by WomenHeart: The National Coalition for Women With Heart Disease. Among the issues women raised were:
- Mental illness resulting from heart disease
- Failure to diagnose heart disease
- Problems related to physicians' attitudes
- Dissatisfaction with medical care, including major hurdles in getting support for recovery
Hayes says that awareness about women's heart health is gradually growing among women and healthcare professionals, but there's much room for improvement.
Mental Health and the Heart
One survey result has already changed how Hayes conducts her practice. She was surprised by the high percentage of women -- 57% -- who said they suffered depression, anxiety or both as a result of heart disease. "Following the survey, our women's heart clinic got a psychologist much more integrated in terms of evaluating patients and giving us cardiologists some insight into mental illness that we're not trained for."
That insight may help explain why only 14% of women made lifestyle changes following a heart attack. "If you're depressed, you're unlikely to be able to make the lifestyle changes that you need to prevent another heart attack," says Hayes. But the knowledge should now help healthcare professionals see and treat mental health problems brought on by heart disease.
In spite of being a psychotherapist herself, the 44-year-old wife and mother didn't recognize the signs of the condition until the second year after her surgery. "The first year I was in shock," she says. "When you go through trauma like that, you stay numb." She relates the trauma to the surgery itself, pain and humiliation caused by a nurse, and continued poor health after the surgery. "I worked through it, but these experiences change your life."
Missing the Diagnosis
Many women with heart disease say they were misdiagnosed in the early stages. In the survey, only 35% of the women and 68% of their doctors associated their symptoms with heart problems. Yet most of the women surveyed had typical cardiac symptoms, such as chest pain and arm pain or pressure, or shortness of breath. Others reported dizziness, nausea, fatigue, and back pain, which are less common symptoms.
Kastan was a 41-year-old non-smoker and a trim athlete when she began experiencing shortness of breath. She attributed it to asthma, which can be brought on by exercise. But it kept getting worse. On one bike ride, the symptoms became severe. Kastan's husband, a physician, said he doubted she had heart disease, nevertheless suggested she see a cardiologist. The cardiologist proclaimed her healthy. The very next week she collapsed in the mountains. "This time I had classic Hollywood heart attack symptoms with chest pain radiating up into my jaw and down my arm, shortness of breath, pasty pale skin and nausea," she says.
She immediately went to a second cardiologist. "He said to go home and exercise and we'll see what happens. The minute I started running I collapsed again." She finally had the cardiologist put her on the treadmill and raise the level of exertion. "Then he was the one who turned pasty pale. He said I had a blockage" in the arteries. The doctor quickly confirmed his suspicion by inserting a catheter to look into her arteries.
Kastan, who is now president of WomenHeart and on the board of the American Heart Association, says a walking treadmill test hadn't raise her heart rate sufficiently to pick up the blockage. "Dr. Hayes and the heart association are pushing for physicians to supplement a treadmill [stress] test with an EKG or thallium stress test [in women with suspected heart disease]," she says. "Those are more effective than treadmill tests, but none are 100%. The only way to see [a heart blockage] is with cardiac catheterization."
Hayes says health care providers need to become aware that heart disease is the number one killer of women, and to recognize gender differences that occur with heart disease, heart failure and arrhythmias. "When they have a woman in the office who is complaining of symptoms . . . they need to rethink their approach," she tells WebMD. Women need to be evaluated differently than men.
Physicians' Attitudes: Part of the Problem?
Doctors' lack of understanding may contribute to difficulty diagnosing heart disease in women. In the survey, 58% of women blamed problems in their medical care on physician attitudes and communication styles. "My husband thinks a lot of this has to do with the way I communicated, but I believe there's a lack of respect for what women say to their physicians," says Kastan. "I was seeing my second cardiologist three times a month. He'd put me on the treadmill and nothing would show up. The entire time I was talking to him, I didn't feel I was heard or believed. I felt I was annoying him."
She says he couldn't believe what he was seeing and perhaps had preconceived notions about young women and heart disease. "I don't know how much it was a feminist issue or his frustration at not being able to get me well," she says.
Kastan remained ill following double bypass surgery. "Friends started wondering if some of this was in my head," she says. She contacted WomenHeart for support and was urged to go to a women's heart clinic. She went to Hayes. "She listened. She may challenge me, but she always supports me. She'd never question me as an intelligent human being or question my feelings."
Obstacles to Recovery
Here's something else you may not know: women who have heart attacks may not recover as quickly or as fully as men. In the survey, 52% of the women were unhappy with their medical care, and faced major hurdles getting the help and support they needed for recovery.
Following her bypass surgery, Kastan couldn't walk without having chest pains. But she says her recovery began within a week after she went to the women's heart clinic.
One study has shown that 35% of women compared to 18% of men have a second heart attack within six years of the first. "We don't completely understand that, but we have theories," Hayes tells WebMD. "We know women are not treated as aggressively as men after a heart attack. They're less likely to be on statins or ACE inhibitors or beta blockers, all of which reduce the risk of a second heart attack. Women receive fewer angioplasties and bypass operations and even less aspirin."
Is the disparity due to a true sex difference or because women are undertreated? The only way to find out, says Hayes, is for doctors to "start treating women the same as men."
The Take-Home Message
Kastan, who speaks around the country about women and heart disease, has seen doctors' attitudes improve in the past couple of years. "They're more aware of women and heart disease and aren't dismissing women as readily," she says.
She urges women to pay attention to their bodies and become more active consumers of health care. "I was uncomfortable going to the Mayo Clinic [for a second opinion] because I didn't want to hurt my cardiologist's feelings," she says. "That shouldn't have been my concern. Be your own best advocate."
Hayes says momentum for change is rising due to recent health campaigns and research results. "We've got a snowball going," she says. "More people are aware. Whether they're taking action is another issue."
She wants women to know they're more likely to die of heart disease than anything else. It's important to know the risk factors and symptoms, and take preventive steps.
"Lifestyle changes, like diet, really help," she tells WebMD. "Women use the excuse that they don't have time because they're too busy with jobs and caring for families. I say, anything they do for themselves, such as changing their diet or taking walks, helps their families. You think it's selfish to take care of yourself, but you're doing this for everyone in your family."