Mention the term "heart attack" and most people imagine a pudgy, middle-aged man drenched in sweat and clutching his chest. Few people seem to consider cardiovascular disease (CVD) as a woman's disease.

But according to the American Heart Association, cardiovascular disease is the leading killer of women over age 25. It kills nearly twice as many women in the United States than all types of cancer, including breast cancer. Only 13 percent of women think heart disease is a threat to their health.

The misleading notion that heart disease is not a real problem for women can be blamed in part on medical research. For a very long time, heart disease studies have focused primarily on men. Changes are under way, but some doctors still fail to recognize the warning signs displayed by female patients.

EARLY HEART SIGNS

Studies have shown that women have undiagnosed warning signs weeks, months, and even years before having a heart attack.

Significant differences exist in the symptoms displayed by women and men. Men typically experience the "classic" heart attack signs: tightness in the chest, arm pain, and shortness of breath. Women's symptoms -- nausea, an overwhelming fatigue, and dizziness -- are strikingly different and are often chalked up to stress. Women have reported that they have had a hard time getting their doctors to listen to them about these early warning symptoms.

Unusual fatigue, trouble sleeping, shortness of breath, indigestion, and anxiety were the top 5 symptoms reported by both black and white women in the study. However, black women had more intense episodes and reported them more often.

ACT IN TIME

Recognizing and treating a heart attack right away dramatically improves a patient's chance for survival. The typical American, however, waits 2 hours before calling for help.

Studies have shown that drugs that dissolve coronary blood clots during a heart attack can reduce the death rate in both men and women, although women have a higher risk of stroke from the therapy. Unfortunately, statistics show that a woman in the midst of having a heart attack receives clot-busting therapy much later than a man would.

Women coming into the hospital for a heart attack have a higher death rate and higher risk of complications. A premenopausal woman having a heart attack has twice the death rate of a similarly aged man, according to experts.

Know the warning signs and always call 911 within 5 minutes of the onset of symptoms. By acting quickly, a heart attack victim is less likely to experience cardiac arrest (where the heart stops beating).

PREVENTION TIED TO BELIEF

There is no denying that an ounce of prevention is worth a pound of cure. But preventing a disease means believing you are actually at risk -- and many women fail to see that.

Women are advised to take charge of their health by working with their doctor to address risk factors, and keep tabs on cholesterol levels, blood pressure, and lifestyle.

According to the American Heart Association, low blood levels of "good" cholesterol (high density lipoprotein, or HDL) are a stronger predictor of heart disease death in women than in men. Also, a major study showed that post-menopausal women taking hormone replacement therapy have an increased risk of heart attack and death by coronary artery disease.

WOMEN & HEART DISEASE

• Cardiovascular disease kills about one woman a minute.
• Sixty-four percent of women who die suddenly of heart disease have no previous symptoms.
• More women than men will die within the first year after a heart attack
• The rates of women who die from cardiovascular disease are much higher than those who die from breast cancer.

Source: American Heart Association/Go Red For Women

The American Heart Association has published guidelines regarding prevention of cardiovascular disease in women. Women are categorized based on their likelihood of experiencing a cardiovascular event (heart attack, stroke, death) in the next 10 years:

• High risk -- the woman has a greater than 20% chance of an event in next 10 years. Examples of women at high risk include those with have a history of stroke, heart disease, vascular disease in legs, abdominal aortic aneurysm (AAA), diabetes, and chronic kidney disease.
• Intermediate risk -- the woman has a 10 - 20% chance of event in next 10 years. Examples of women at intermediate risk include those with calcium in coronary arteries, metabolic syndrome, multiple heart risk factors, and women with family history of early heart disease.
• Lower risk -- the woman has less than a 10% chance of event in next 10 years. Women at the lowest risk have none of the above-mentioned conditions and one or less risk factors for heart disease.

The guidelines recommend the following lifestyle changes:

• Do not smoke or use tobacco.
• Maintain a healthy weight. Women who need to lose or keep off weight should get at least 60 - 90 minutes of moderate-intensity exercise on most days. To maintain your weight, get at least 30 minutes of exercise a day, preferably at least 5 days a week.
• Women who recently had a heart attack, angina, angioplasty, or a stent procedure should join a cardiac rehabilitation program.
• Eat a heart healthy diet. The diet includes a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, and sources of protein low in saturated fat.
• Watch your weight. Women should strive for a body mass index (BMI) between 18.5 and 24.9 and a waist smaller than 35 inches.
• Get checked and treatment, if necessary, for depression.
• High-risk women should take omega-3 fatty acids supplements.
• Folic acid supplements may be considered in some high-risk women if a higher than normal level of homocysteine has been detected. (These should not be taken after coronary revascularization.)

TREATMENT RECOMMENDATIONS FOR WOMEN

Keep blood pressure under 120/80 mm Hg. Blood pressure drugs should be used when blood pressure is higher than 140/90 mm Hg. (Persons with diabetes may need medication at lower levels.)

Keep cholesterol levels under control:

• LDL should be under 100 mg/dL
• HDL should be greater than 50 mg/dL
• Triglycerides should be less than 150 mg/dL

Depending on a woman's level of risk (low, intermediate, high), dietary changes and medicines may be needed to control cholesterol levels.

New guidelines no longer recommend hormone replacement therapy, antioxidant supplements, or folic acid to prevent heart disease in women.

Aspirin therapy (dose 75 mg to 325 mg a day) or a drug called clopidogrel may be prescribed for women at high risk for heart disease. Aspirin therapy is recommended for women over age 65 to prevent heart attack and stroke as long as blood pressure is controlled and the benefit is likely to outweigh the risk of gastrointestinal side effects. Regular use of aspirin is not recommended for healthy women under age 65 to prevent heart attacks.

Beta blockers should be used in all women with a history of heart attack or who have chronic heart disease, unless there is a medical reason not to.

ACE inhibitors should be used in high-risk women unless there is a medical reason not to.

Angiotensin receptor blockers should be used in women with heart failure or an ejection fraction less than 40% in whom ACE inhibitors did not work.

See also:

• Atrial fibrillation
• Diabetes
• Stroke

Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.