Why women need to be more aware of heart disease
Forget the male stereotype, female sufferers are twice as likely to die of it as they are from breast cancer. Here’s what to look out for.
It is estimated that more than 800,000 women in the UK are living with coronary heart disease and it is known to kill twice as many women as breast cancer every year. Yet according to the British Heart Foundation (BHF) the perception that heart attacks happen only to men persists. “A lot of women believe there is not as much risk for them and that symptoms of heart disease are not relevant to women,” says Joanne Whitmore, a senior cardiac nurse at the BHF. “It needs to change.”
Women under the age of 50 seem particularly unaware of the risks, says Dr Hannah Douglas, a consultant cardiologist at the London Bridge Hospital who specialises in treating female heart disease. Several recent studies, including a paper in the European Heart Journal, have suggested that heart attacks and deaths from heart disease have been rising among women under 65.
Cardiologists at the University of North Carolina reported a rising trend in young women aged 35-54 suffering heart attacks, which they said could be in part down to them “having risk factors for heart disease at an earlier age” with high blood pressure, obesity and high cholesterol all becoming more prevalent.
“If I look for a stock photo to use in a presentation, all that’s usually available is an image of a middle-aged, slightly overweight and stressed-looking man in a suit who is clutching his heart,” Douglas says. “This has become the image many women think of in relation to heart disease and is why it’s such a revelation when we tell them their health might be at risk.”
But what signs should women be looking for - and how do they know when the risk is rising?
Symptoms are similar for men and women
One of the longest-standing medical myths is that women suffer unusual heart attack symptoms and that warning signs for heart disease are different from those for men.
“A gender gap exists in terms of awareness and treatment, but not in terms of symptoms,” Douglas says. “When it comes to warning signs, they are pretty much the same.”
For a BHF-funded study published in the Journal of the American Heart Association, researchers at the University of Edinburgh recorded the reported symptoms of those attending the Edinburgh Royal Infirmary who were given a troponin test, a blood test that measures a protein released by damaged heart cells because of a suspected heart attack, but before diagnosis has been made. They found that 48 per cent of men and 49 per cent of women reported their main symptom to be pain in their left arm. More women had pain that radiated to their jaw or back and 33 per cent experienced nausea in addition to chest pain, compared with 19 per cent of men. But heartburn, back pain or stabbing pain similar to indigestion were more common in men (41 per cent) than in women (23 per cent).
“Both men and women present with an array of symptoms, but our study shows that so-called typical symptoms in women should always be seen as a red flag for a potential heart attack,” says Amy Ferry, a cardiology research nurse at the University of Edinburgh and lead author of the paper.
If you are under 55, check these seven risk factors
Smoking, under-exercising, being overweight and having high blood pressure or raised cholesterol are known risk factors for heart disease. But last year researchers at Yale University identified sex differences in risk factors and came up with seven most likely to trigger acute myocardial infarction (AMI), or a heart attack in women under 55, for a paper in JAMA Network Open. For women, they found the highest associations with a heart attack to be, in order of risk, diabetes, smoking, depression, high blood pressure, low household income, family history of heart attacks and hypercholesterolemia. For men under 55 the top risk factors were smoking and family history.
“Type 2 diabetes is predominantly related to lifestyle issues including excess weight and a high intake of sugar and fat that also stack up to increase the risk of cardiovascular disease,” Douglas says. “Type 1 diabetes is a dreadful condition which can cause blood vessels to stiffen over time and that is very risky.”
Monitor your blood pressure
According to the charity Blood Pressure UK, 26 per cent of women in England have high blood pressure (it’s 31 per cent of men). It’s one of the most important controllable risk factors for cardiovascular disease, yet often it is ignored or remains undiagnosed. A normal adult blood pressure is considered to be between 90/60mmHg and 120/80mmHg but some studies have shown that even mildly elevated readings are riskier for women than men. A study led by Ester Kringeland of the University of Bergen found that even slightly elevated readings of 130-139mmHg over 80-89mmHg were associated with a higher risk of heart disease in women than in men over the next 16 years.
“Young women have on average lower blood pressure than men, but a steeper increase is observed in women starting in the third decade,” she said of her findings published in the European Journal of Preventive Cardiology. Previously researchers had shown that blood pressure begins to increase at younger ages in women than in men and then goes up at a faster rate. You can keep tabs on your readings with a cheap blood pressure monitor, Whitmore says. “A one-off high reading is usually nothing to worry about, but if it remains high for long, around two or three weeks, see your doctor or nurse.”
Get the tape measure out
Measuring your waistline is a better predictor of heart disease risk than hopping on the scales. “Waist measurement gives an indication of abdominal fat, which can indicate a build-up of fat around internal organs,” Whitmore says. “It’s a measure that is now included in the NHS health check because the body mass index and weight alone do not tell us much.”
Age and ethnicity should be taken into account. According to the BHF, women of white European, black African, Middle Eastern and mixed origin whose waist measures 80-88cm are considered to be at high risk of heart disease and those with a measurement of greater than 88cm are at a very high risk. For women of African-Caribbean, south Asian, Chinese and Japanese origin, under 80cm is low risk, but anything above that is very high risk.
Women who gain middle fat during the menopause when hormonal fluctuations influence fat storage on the body are generally at greater risk of heart disease even if their overall weight stays the same, according to a University of Pittsburgh study.
Get your cholesterol checked
Levels of bad LDL cholesterol rise during the menopause and 10 per cent of this increase is due to shifts in sex hormones, according to research published in the European Journal of Preventive Cardiology last year. Their findings also showed that taking hormone replacement therapy (HRT) partly prevented these cholesterol increases and that the greatest cardioprotective effects were seen among women who started HRT early in their menopause.
Because raised blood cholesterol and triglyceride levels are risk factors for heart disease, it is recommended that every adult has a blood test as part of their NHS health check at least every five years from 40-75 but more often if levels are already high or if you have other risk factors - if you smoke, are very overweight, have hypertension or a family history of heart disease. Blood tests are also available at pharmacies, although the cholesterol charity Heart UK says it is best to have one done professionally because DIY kits vary in quality.
Beware overlap of ‘menopause’ and heart disease symptoms
Symptoms associated with the perimenopause, including sweating, palpitations, breathlessness, panic attacks and intolerance of exercise, are also symptoms of heart disease.
“There’s this awful healthcare deficit where women present with these symptoms and are told they are menopausal but don’t qualify for HRT and yet they could be at risk of heart disease,” Douglas says. “It’s an overlap that shouldn’t be ignored.”
If you are a women in your forties or fifties with any of these symptoms you should not be turned away without having heart disease excluded as a risk, she says. “Neither the perimenopause nor the menopause will kill you directly in that there is no increased risk of mortality attached, but undiagnosed heart disease could quietly evolve into a killer,” Douglas says. “Women should be made more aware that the two can present with some of the same symptoms as it could save lives.”
Don’t write off taking hrt
Oestrogen has a protective effect on the heart and cardiovascular system, helping to control cholesterol levels and prevent the build-up of fatty plaques inside artery walls.
It follows that, as levels of this female hormone begin to decline from the perimenopausal years onwards, so a woman’s heart is less well protected and the risk of coronary heart disease rises after she reaches the menopause. Women who reach menopause before the age of 50 are known to be at an increased risk of premature heart disease. HRT is an option, although many women are wary of taking it after scientists at the University of Nottingham discovered that HRT tablets could raise the risk of developing serious blood clots by as much as 58 per cent after 90 days.
The BHF says risk is reduced with an HRT patch or gel rather than a tablet, and that recent studies show that menopausal women taking HRT are not at a higher risk of dying from a heart attack than women who don’t take it. HRT is not for everyone but, Douglas says, “I strongly encourage any of my female patients to chat with their GP about their needs when it comes to HRT. For many women, it improves quality of life way in excess of raising the risk of heart disease and if your other cardiovascular risk factors are low, that will strengthen the argument for HRT.”
Keep running and cycling
Taking up marathons, triathlons and hardcore workouts in middle age has been labelled a fast route to heart attacks by some who suggest the strain of such activities presents a damaging cardiovascular load. “I see a lot of young women in my heart clinics and some of them are ultra-marathoners or triathletes,” Douglas says. “But I do not believe their exercise habits have put them at a higher risk of heart disease than the general population and, as cardiologists, we very rarely tell people to exercise less, almost always to carry on with what they are doing or to exercise more.”
There’s a caveat, she says, for those with rare underlying cardiac abnormalities. “It’s easy to take occasional heart-related deaths of exercisers out of context. People sometimes die of heart attacks in a race or at the gym, but people have heart attacks in libraries, at the supermarket and at work because heart disease doesn’t discriminate in any way.” Her advice? Do as much exercise as you feel comfortable doing provided that you have the go-ahead from your consultant or GP.
Stay active into your nineties
Last year researchers from the University of California compared what they termed the “daily life movement” – housework, gardening, cooking - of 5,416 American women aged 63-97 for a study in the Journal of the American Heart Association. Compared with women with less than two hours a day of such movements, those women who clocked up four hours or more had a 43 per cent lower risk of coronary heart disease and a 62 per cent lower risk of cardiovascular disease death. “The study demonstrates that all movement counts towards disease prevention,” the paper’s lead author Steve Nguyen, a postdoctoral researcher, said.
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