Last updated: Sep 15, 2008
"When it comes to CAD, treating a woman requires different skills."

Stephen Sinatra, MD, is a cardiologist at the University of Connecticut School of medicine and the author of The Sinatra Solution: Metabolic Cardiology.

Q: Public health organizations have been hammering home the idea that heart disease is the number-one killer of women. Is it really possible that women still underestimate their risk?

A: I strongly believe that women underestimate their risk. Women really fear breast cancer; that's still their number-one concern. I think that fear of breast cancer is overwhelming for a woman. The problem is that women still don't get it. They feel that heart disease is a male-oriented disease.

Q: OK, coronary artery disease is the leading killer of women, but what age group are we talking about? Don't women get it much later in life than men do?

A: The earliest heart attack I have seen in a woman was in a 17-year-old. But generally women lag 10 years behind men. The average male gets it at 55 and woman at 65, but—and a big but here—a woman's instance of coronary artery disease (CAD) skyrockets after the age of 45. Once she starts developing perimenopause, her risk goes up by 400%. And 45- to 50-year-old women are at the greatest risk of heart disease.

Q: How is CAD different in women compared to men?

A: It's an anatomical issue. A woman's heart is smaller than a man's. Also her blood vessels are smaller. Women are more difficult to treat with angioplasty and bypass surgery because of the nature and smaller caliber of their vessels. There is also a muscular difference. Women get more diastolic dysfunction than men. Women with high blood pressure have far more complications than men do because of diastolic dysfunction. Even cardiologists don't understand it. It takes more energy to fill the heart with blood than to empty it. It requires more metabolic support, and the problem with women with hypertension and CAD is that they develop more stiffening of the left ventricle than men. Women and their cardiologists need to be very cognizant of this anatomical difference.

Q: CAD is the leading cause of death among women in the U.S., but it can still be hard to catch. How can women better recognize the symptoms?

A: Women practice denial almost as much as men do. They seem to think, "It can't be heart disease. I'm a woman." The most important aspect is getting treated quickly.Women need to take notice if something dreadful is going on in their body. If she has profound shortness of breath, sudden jaw pain, or a new pain in her back, she needs to rely on her instincts. She must seek medical attention.

Q: What atypical symptoms should women watch out for?

A: The typical presenting factor in men is pain underneath the breast bone. They also tend to break out in a sweat. Women can have that too, but I've seen women sitting in the emergency room for three or four hours with jaw pain, waiting to see an oral surgeon. And, for example, if a woman carrying a heavy load suddenly develops a profound weakness and shortness of breath, this could be the result of cardiac vulnerability. If it is something that is alarming or different—some sort of atypical pain—women should rely on their instincts and call their doctor.

Q: What lifestyle changes can women make to reduce their risk?

A: The most important thing any woman can do is to keep her weight down. Overweight status is the single most significant factor in blood pressure elevation. Also, weight gain in women is much more harmful than weight gain in men.

Women also need to eat better. They have to be really disciplined on their sugar intake, because sugar is a substance that really gives a person heart disease—not so much cholesterol. Sugar is the most pro-inflammatory food that causes excess insulin response, which damages blood vessels. The best thing I can tell a woman to do is to really be conscious of her weight and use a noninflammatory diet and some mild form of exercise.

And be aware of your stress level. I've treated a lot of women with heart disease who have young children. They do the right thing and keep their weight down, they eat good diets, they exercise. They do all the right things, but what they need to focus on is stress reduction. Be aware of vital exhaustion—especially when trying to raise a family and the stress that comes along with that. Women really need to know that being a mother is a hard job and they need to have an outlet for that, even if it's just walking the dog for 20 minutes. It's like brushing your teeth: A woman needs to put some form of stress relief into her day every day.

Q: Many women we have interviewed say their doctors, even cardiologists, missed their CAD symptoms. How can women avoid a misdiagnosis?

A: That's the conspiracy that's going on. It's unbelievable. First of all, a woman's belief is, "I'm not going to get heart disease." Some male cardiologists treating a woman may think the same thing. More and more cardiologists are finally seeing the light. Heart disease is part of a woman's life.

Women need to address this psychological factor. If a woman underplays her symptoms and the cardiologist is thinking that it's muscular skeletal pain or something else, she's probably going to end up with a misdiagnosis.

Q: Some heart tests are better suited for men. Which ones should women consult their doctors about taking?

A: There are noninvasive tests out there that are great. An exercise stress test using a radioactive isotope is an outstanding test for women. However, large breasts may interfere with interpretation of the data. An exercise echo may be a better in that case. An electron-beam computed tomography (EBCT) scan—looking at hard, calcified plaque—or a 64-slice CT scan looking for soft, vulnerable plaque, are also outstanding tests that will determine silent CAD. I am a strong fan of doing blood tests that are not looking at cholesterol but inflammatory mediators, such as C-reactive protein, homocysteine, and fibrinogen.

Q: What should women look for when searching for a doctor to treat their CAD?

A: Basically a woman needs to be able to really trust her doctor. She needs to have a feeling that the doctor sees her struggle. Heart disease is different in women, and she needs to really address this gender issue with the doctor. When it comes to CAD, treating a woman requires different skills. For example, if you have a doctor seeing a woman with high blood pressure and a man with high blood pressure, that doctor shouldn't be treating the two patients in the exact same way. Many of the studies on pharmaceutical drugs were done on men, and women may react differently. Women need to search out a cardiologist that understands the nature of heart disease in women.

Q: The Centers for Disease Control and Prevention found that the death rate for CAD in women ages 35 to 54 increased between 2000 and 2002. Why is the rate up? Do you expect this to get worse?

A: I am not surprised by this at all, and I expect it to get worse. Women are vulnerable to vital exhaustion. I'm really concerned when I see a woman stretched beyond her limits, and that's why I think we're seeing that increase.

Q: What can family members do to encourage the women in their lives to take care of their hearts?

A: The best thing a family member can do is just support them in their struggle and let them have their true emotions out.

Women—and men too—need to understand that depression is associated with a doubling of ones risk of CAD. I am very concerned about women who hold their feelings in and even turn their anger on themselves. That worsens coronary artery disease. It can also precipitate coronary events like a heart attack. The best thing for both men and women is to be true to their feelings and, if sadness surfaces, allow it to.

Q: How important is social support for women, and how do women and men differ here?

A: Women do much better with social support. They hug one another. They connect with one another. Social support is absolutely vital for women and for men. In a workshop of 44 men and women, we found more adrenaline-like hormones—indicators of stress—in the urine of participants who did not express their feelings. For example, women who had their feelings out and supported one another had very little stress breakdown products in their urine and did not have any heart disease. On the other hand, men who acted like lumps of clay—who did not cry, get angry, or show emotion—had alarmingly high amounts of emotional stress breakdown products in their urine. Eighty percent of these men had far-advanced heart disease. It was the first time I realized that men who don't cry get heart disease. Women embrace social support; men need a little help.