Last updated: Apr 18, 2008
One minute Elizabeth Baska was wrapping Christmas gifts … “and suddenly I couldnt breathe,” says the Seattle mom, who was 36 at the time.


Just as she had done during a similar episode two years earlier, she called 911. And, once again, the paramedics who came diagnosed the incident as an anxiety attack. But this time, Baskas symptoms continued to worsen, so the emergency personnel gave her an EKG—and determined that she was having a heart attack. “If I were a man, I think everyone would have been quicker to realize that it was my heart,” says Baska, who now takes pulse-slowing medications to keep her safe. “I never considered the possibility because I didnt think women needed to worry about heart attacks.”

The truth is, more than 450,000 American women die from heart disease each year. For two decades, it has killed more women than men, and the gap is actually widening as mens heart attack death rates improve faster than womens. Yet only a third of women in the United States consider themselves at risk for heart disease, according to a 2006 poll.

“Most women worry far more about breast cancer than heart disease,” says Elsa-Grace V. Giardina, MD, cardi­ologist and director of the Center for Womens Health at New York Presbyterian Hospital and Health Editorial Advisory Board member. “But for every woman who dies from breast cancer, 10 die from heart attacks.”

There have been advances: Heart disease deaths in women actually declined between 2003 and 2004. But the lifetime risk of dying of cardiovascular disease (CVD) is still nearly one in three for women. And thats why the American Heart Association (AHA) recently released new guidelines underscoring the impor­tance of healthy lifestyles in women of all ages to reduce the long-term risks of heart and blood vessel diseases.


For starters, you need to forget most of what you already know about heart attacks. The conventional wisdom has long been based on the male experience, but doctors are now realizing that heart disease can be very different for women—from symptoms to diagnostic tests to effective treatments.

Two thirds of women who have heart attacks die without ever knowing that theyre having one. In large measure, thats because the symptoms, like Elizabeth Baskas, can differ from mens and are often misinterpreted by the victim or misdiagnosed by their doctors.

“Most people think that if youre having a heart attack, theres going to be chest pain and left arm numbness. But thats not always the case for women,” explains cardiologist Nieca Gold­berg, MD, associate professor of med­icine at the New York University School of Medicine and director of the NYU Womens Heart Program. “Women commonly experience different symp­toms, such as shortness of breath, fatigue, pressure in the abdomen, and jaw pain.” And these are often misidentified as stomach ailments or anxiety attacks, so the early warning signs go unheeded.

Even when doctors suspect heart disease and order an angiography or angiogram (a diagnostic X-ray of the heart and its blood vessels), they often dont see problems, something that has long baffled them. But findings of a 10-year study by the National Institutes of Health—the Womens Ischemia Syndrome Evaluation (WISE) completed in 2006—appear to unravel the mystery.

WISE researchers discovered that two-thirds of the study participants with chest pain had “clear” angiograms, but half of those women had a condition called coronary microvascular sydrome, in which plaque coats small arteries in the heart rather than building to clumps in larger vessels.

“Instead of discrete obstructions, the plaque is evenly distributed throughout the blood vessels, so its pretty much invisible on the angiogram,” says Dr. Goldberg, who's also an AHA spokeswoman.


Nonetheless, the vessels become more narrow and rigid, and less permeable. This, in turn, chokes off the flow of blood and oxygen to the heart muscle (a condition called ischemia), leading to chest pain and potentially a heart attack. Researchers estimate that as many as three million women have the syndrome, sometimes referred to as small-vessel heart disease.

The medical tests used in the WISE study to identify the syndrome are not yet widely available, but one common procedure can spot it: a nuclear stress test, in which thallium is injected into the bloodstream. Using a special camera, physicians then observe how well the radioactive material moves through the blood vessels supplying the heart.

“For years cardiologists thought that stress tests didnt work well for women because, after they turned up problems, the angiogram would come up clear,” Dr. Goldberg explains. “Now we know that the angiogram can sometimes be inaccurate for women.”

Thats why, no matter what the angio­gram shows, a poor result on the nuclear stress test calls for treatment. But standard procedures, such as angioplasty and bypass surgery, arent always the answer. Angioplasty uses an inflatable balloon to open clogged arteries and a mesh tube called a stent to keep them open. And bypass surgery involves grafting blood vessels from other parts of the body, such as the arms and legs, onto the heart to bypass clogs.

With small-vessel heart disease, there are no discrete clogs to clear or bypass; the problem lies in smaller blood vessels coated with plaque. A better solution—and, happily, a much less invasive one—is drug therapy to reduce blood cholesterol (and therefore plaque), to thin the blood (improving flow), and, in some cases, to limit the pace of the heart (easing its burden). Reducing other heart disease risk factors, such as poor diet and lack of exercise, is also effective.


Still, not everything about womens heart attacks is so different from mens. Risk factors, for instance, are nearly identical. “Until about 15 years ago, women were told by their gynecologists that they didnt need to worry about heart disease until menopause because hormones would protect them up to that point, and hormone therapy would protect them afterward,” says Nanette Wenger, MD, chief of cardiology at Grady Memorial Hospital and pro­fessor of medicine at Emory University School of Medicine in Atlanta.

But studies during the last decade have shown that hormones provide little or no protection. In fact, hormone therapy may actually cause harm. “Now were back to basics with traditional risk factors, such as high cholesterol, smoking, obesity, sedentary lifestyle, and family history of heart disease,” Dr. Wenger says.

Most men—and certainly their doctors—know about the risk factors. But the same hazards are often underappreciated by women and their physicians. Eighty percent of doctors erroneously believe that heart disease kills more men than women, according to a 2005 national study of physician awareness published in the AHA journal Circulation. In the same study, doctors were given patient profiles in which risk levels were the same but the gender of the patients differed. When asked to assess each patients health, the doctors tended to assign a lower cardiovascular risk to women than to men who had the very same risk factors—and tended to recommend less-aggressive treatments.

The upshot is that women need to be strong advocates for their own cardiovascular care, says cadiologist Goldberg. If youre having symptoms and your physician suspects only indigestion or anxiety, insist on additional testing. If a stress test or another procedure indicates problems but no blockage shows up on an angiogram, demand treatment anyway—preventive care and a follow-up plan, at least. “If your doctor isnt taking your symptoms seriously, find one who will,” Dr. Goldberg says.

Thats what Gayle Nix did. And it probably saved her life. When she was in her late 40s, the Live Oak, Fla., mom began feeling pressure in her chest, as well as pain in her back and jaw. “My doctors told me it might be indigestion or stress,” she says. “But I kept pushing for more tests.”

Even after an angiogram showed no blockage and doctors gave Nixs heart a clean bill of health, she didnt stop visiting doctors offices whenever her symptoms reappeared. Finally, she was referred to the University of Floridas Division of Cardiovascular Medicine, which happened to be conducting the WISE study—and she was diagnosed with coronary microvascular syndrome.

After a course of blood thinners and some pointers about eating right, Nixs symptoms have all but disappeared. “I got myself a treadmill, and I learned how to broil instead of frying everything like I used to,” says the now-active 62-year-old grandmother. “And I feel great.”