Ladies take note, coronary disease symptoms are subtle

Diane Casey of Portland says it took “three slaps in the face,” to make her aware of how sick she was. Those three slaps may have made the difference between life and death.

Casey, a professional photographer who is 52, says her diagnosis of heart disease – and subsequent placement of a stent to resolve a blocked artery – began with a phone call to schedule a routine physical in the spring of 2008. It was almost an afterthought that she mentioned to the nurse at her doctor’s office that she had a chest cold. Walking up the two flights of stairs to her Old Port apartment left her out of breath, she told him. Her chest felt like there was a brick lying on her sternum. Casey says the nurse suddenly peppered her with questions and concluded by telling her she needed to go to the emergency room. That was slap No. 1.

A single mother of daughters aged 11 and 9 at the time, Casey scoffed at the suggestion. She had answered no to all of the nurse’s questions; everything was good. Besides, she had things to do. But the next day, after a meeting at the girls’ school, she went in to Maine Medical Center. All of her tests came back negative. See, Casey thought, she was fine.

That’s when she received slap No. 2: the doctor told her they were going to admit her to the hospital and if she left, as she was insisting, it would be against medical advice. She’d have to sign off before they would let her go. Casey signed the form, left the hospital and went to pick up her younger daughter at a friend’s house. The mother, a pediatric cardiologist, noticed the hospital bracelet and Casey explained.

“She said to me, ‘Diane, when they tell you they want you to stay, you stay. You need to go now.’” That was slap No. 3.

After more stalling and more hesitation Casey finally agreed to a stress test the next morning at the office of her friend’s husband, also a cardiologist.

“There was all this murmuring [by the doctors] and they said they were calling an ambulance.”

Still, Casey resisted. Finally, after making arrangements for the children and insisting that she return home to pack a bag – her cardiologist friend took her – she entered the hospital and underwent the angioplasty to fix the 95 percent blockage in one of her arteries.

Today, nearly two years later, Casey is grateful for those three slaps.

According to cardiologist Dr. Lisa Thomas, a cardiologist with Maine Cardiology Associates in South Portland, heart disease usually presents itself about 10 years later in women than men, says Thomas; estrogen provides some protection prior to menopause. Nonetheless, more women die from heart disease than all other causes combined. Thomas says that each year about 500,000 women suffer heart attacks. More than 250,000 women die of coronary heart disease.

But with the exception of age and family history, the risk factors for women’s heart disease can be reduced. In addition to age and family history – premature coronary artery disease in a first degree relative, which means under age 55 for men or under age 65 for women – risks include elevated cholesterol levels, diabetes, smoking, high blood pressure, evidence of peripheral artery disease and chronic kidney disease.

Desirable cholesterol levels depend on other risks women face, Thomas says. HDL (good cholesterol) levels should be greater than 40 in women.

“Low levels of good cholesterol is more predictive of coronary heart disease in women than men,” she says.

Similarly, high triglycerides present more risk in women than men. All women should have levels below 150, she says.

Thomas says that desirable LDL (bad cholesterol) levels depend on a woman’s other risk factors. If a woman has diabetes, other vascular blockages and chronic kidney disease, her LDL should be below 70. Two or more risk factors that don’t include vascular disease – for example high blood pressure and diabetes – dictate that LDL be below 130. Otherwise the national recommendation for LDL is below 160, says Thomas.

The impact of risk factors varies.

“Diabetes is considered a coronary artery disease equivalent in men and women,” Thomas says, because of the degree to which diabetes affects the vascular system. With respect to smoking, “half of coronary events involve smoking in women,” she says. The younger the woman who smokes, the greater the risk. Even one or two cigarettes a day doubles a woman’s risk of heart disease, says Thomas. Fortunately, quitting smoking can reduce the risk to that of a non-smoker through a period of three years, she says.

The older the woman, the greater the risk posed by high blood pressure, which in women older than 70 is a “strong predictor of coronary artery disease.” And if a woman has peripheral vascular problems, such as blockages in leg or carotid arteries, coronary artery disease is likely, Thomas says.

Obesity and a sedentary lifestyle play a role because they often cause other risk factors, such as type II diabetes (which can lead to kidney failure) or high blood pressure. In addition, Thomas says, studies have shown an increase in mortality with an increase in body surface area. That’s where the body mass index, also known as BMI, comes in.

“Ideally the target BMI is 18.5 to 24.9 and a waist measurement of less than 35 inches,” says Thomas. “As the BMI rises, between 25 and 29, a woman’s relative risk is two times higher.” If a woman is obese, with a BMI over 29, her relative risk is three and a half times greater.

Women can decrease mortality if they increase activity, says Thomas.

“It doesn’t have to mean putting on sweat pants and going to the gym,” she says. It does mean 30 minutes of moderate activity per day, most days. That includes simple walking at a moderate pace.

Symptoms of coronary artery disease in women “are less likely to have classic presentation” common to men’s heart attacks, says Thomas. Chest pain can be sharp and burning, and can be brought on by emotional stress and wake a woman from sleep. In addition, Thomas says, a woman may experience pain in the neck, jaw and back, in addition to nausea, weakness and shortness of breath.

Women experienced a cardiac event “really feel unwell,” says Thomas. That feeling may even include a sense of doom difficult to articulate, she says.

Fortunately, says Thomas, women can reduce their risk by modifying their diets, quitting smoking with or without medical assistance, increasing activities, and treating cholesterol and blood pressure issues and, if exists, diabetes. In addition, a woman with risk factors may benefit from taking a baby aspirin. Although aspirin poses a bleeding risk, it reduces the risk of stroke in women over age 45 and of heart attack over age 65, Thomas says.

Depending on the symptoms and diagnosis, women with heart disease will be treated in a variety of ways. A stress test can identify the presence and severity of heart disease. Blockages can be treated with medicine, stents, or open heart surgery, says Thomas.

The subtly of women’s cardiac symptoms, plus a perception that “women don’t have heart attacks mean women might stay home (from the hospital) longer,” says Thomas.

“If you have symptoms, go, get evaluated,” she says. “We’d rather evaluate a woman without a heart attack than a 68-year old woman who has been suffering for 12 hours.”

Diane Casey is doing fine despite the days of symptoms she initially ignored. She continues to exercise by walking her dog a couple of miles every day. She has switched from whole to skim milk, has given up cheese and stopped using salt. She takes a baby aspirin every day.

Mostly, she urges, women should be evaluated and treated if they have risk factors such as the family history and high blood pressure she had.

“It’s important to pay attention,” she says. And that way, it might not three slaps to get the help that’s needed.

 

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