In this article:
Key Points
- Heart disease tops other leading causes of death among women, including cancer, chronic lung disease, pneumonia, influenza, and accidents.
- In the United States, about 6.8 million people have angina; 4.2 million—well over half—are women.
- In 2003, a large Federal study called the Women's Health Initiative (WHI) found that, contrary to previous beliefs, hormone replacement therapy does not seem to protect the heart and, in fact may even increase the risk of coronary artery disease.
- Researchers have concluded that there is no overall benefit to taking estrogen alone, and recommend that it not be taken for chronic disease prevention in postmenopausal women.
Think heart disease is a man's problem? Think again—most of all if you're a
woman past menopause.
While deaths from heart disease have been on a downward trend for men, they have been on the upswing for women.1 Many women have urged their husbands to quit smoking and to get off the couch, only to find they may be diagnosed with heart disease.
Over 13 million Americans have coronary artery disease, (sometimes also referred to as coronary heart disease). Heart disease is the single largest killer of both men and women. This year alone, of the 64.4 million Americans who have cardiovascular disease, including high blood pressure, an estimated 565,000 will have a first heart attack and 300,000 will have a repeat attack.1
A woman's health problem
Who gets heart disease, and when, is in part a question of gender. Many women think they're more likely to die from cancer, especially breast cancer, than from heart disease but they are wrong. Heart disease tops other leading causes of death among women, such as cancer, chronic lung disease, pneumonia, influenza, and accidents, says the American Heart Association (AHA). In fact, in every year for the past 20 years, heart disease has claimed the lives of more women than men in terms of total deaths.1
Among non-white women, heart disease can be a greater worry. African-American women who haven't reached menopause are two to three times more likely to have risk factors for heart disease than white women who haven't reached menopause, according to the results of a study in Preventive Cardiology in 2000.2
Researchers at Oregon Health Sciences University in Portland compared heart disease risk factors in 100 African-American and 100 white women between the ages of 18 and 45 years, in good health and of similar financial status. The African-American group had higher blood pressure, more obesity, and ate more saturated fat and cholesterol. These are all factors that could help explain why African Americans are more prone to heart disease. Learn more in Heart Disease, Race, and Ethnicity.
Almost twice as many women get angina as men. In the United States, about 6.8 million people have angina; 4.2 million—well over half—are women. Each year, roughly 400,000 new angina cases are diagnosed, many of them in women.1
Heart disease later — but more serious
Women do have one major edge over men: Heart disease tends to start about 10 years later in women. And for more serious events, such as heart attack and sudden death, women lag behind men by 20 years. The lifetime risk of getting coronary artery disease after 40 years of age is 49% for men and 32% for women.1
But while men have a greater overall risk and get heart attacks earlier in life, the gender gap narrows as women age into their senior years. Women then begin to catch up with men in rates of heart disease and heart attack.1
Coronary artery disease is two to three times more likely to strike a woman after she reaches menopause than it is to strike a woman of the same age who has not reached menopause. What's worse, women who have a heart attack are more likely to die early. The American Heart Association says 38% of women will die within one year after a heart attack, compared with 25% of men.1
Researchers suggest that women die at a higher rate because they have heart attacks at older ages than men and are more likely to be sicker, or because they receive less aggressive treatment. But the reasons may be even more complex. Some doctors suspect that gender plays a role in the causes and types of heart attacks.
One study looked at 1,044 men and women who had heart attacks.3
All were treated with angioplasty, a
therapy that opens clogged arteries. Even when men and women received the same treatment after being in the hospital for a heart attack, women were still 2.5 times more likely to die. This was true even after the researchers considered the fact that some women were older and had more diabetes and high blood pressure than the men.
For years, heart disease research has been done mostly on men. These findings prompted one female heart doctor to comment that when it comes to heart disease, men and women have different physiology and symptoms that beg for a "gender-specific" approach to research, prevention, and treatment.4
For example, diabetes is emerging as a much stronger risk factor for heart disease in women than in men. The protective advantage women have before menopause is lost when women have diabetes. The dramatic increase in the occurrence of CAD in women with diabetes compared with men is potentially due to a number of factors. Compared with men, women can have higher rates of depression, lower financial status, poorer blood sugar control, more severe increases in blood pressure and blood fats such as cholesterol, and more body fat around the stomach area ("apple"-shaped) than the hips ("pear"-shaped).5
Another study has shown that women with heart disease have more risk of having another heart attack or stroke as their blood pressure continues to climb, even if only in small amounts. Every time the systolic blood pressure (the bigger, top number) goes up by 10 millimeters of mercury (mm/Hg), a woman’s risk of another heart problem can go up by as much as 9%, making a strong link between increases in systolic blood pressure and future heart problems.6 It is very important for women, as well as men, to keep their blood pressure in the proper range. See Heart Basics–Blood Pressure for more information.
To tackle the issues of heart health that face female patients, an expert panel and writing group has been formed to develop guidelines that can help healthcare professionals prevent heart disease in adult women.7 Some of the recommendations for women include:
- Taking aspirin if a woman is at high risk of having heart disease. However, not enough research has been done to know whether women who have a low or intermediate risk of heart disease should also take aspirin. Always ask your doctor first before using aspirin for heart disease.
- Encouraging women at high risk for heart disease to eat more fish (which contain omega-3 fatty acids) as part of a heart-healthy diet. Eating fish (like salmon, flounder, or catfish) may help decrease the risk of cardiovascular disease. Women who do not eat fish can eat foods such as walnuts or soybean oil, which are also good sources of omega-3 fatty acids. Be aware, however, that these foods may not provide as much benefit to the heart as fish oil. You can learn more in Dietary Supplements and Nutrition Matters. Be sure to always ask your doctor before using any nutritional supplement.
The panel concluded that more diverse groups of women need to be enrolled in clinical trials looking at heart disease. The group noted that not enough studies included elderly women who were older than 80 years or age, or women of varying races and/or ethnicities.7
Higher rates of angina, including Syndrome X
In some women, reduced blood flow to the heart causes chronic angina, marked by pain, pressure, or discomfort in the chest. Some women also feel varying levels of pain or discomfort in the teeth, jaw, shoulder, back, or arm. Women may also be less likely than men to suffer the well-known chest symptoms of chronic angina that cause them to suddenly clutch their chest during an attack. Instead, some women may have more shortness of breath, tiredness, and physical weakness than men, or they may have more pain or discomfort coming from their back rather than the chest. These "atypical" symptoms are important signals that a woman may have chronic angina and, if they occur, should be discussed with a doctor.
A bout of angina is not necessarily a sign that you are having a heart attack, but it is almost always a sign of heart disease. Angina may worsen over time, and angina pain or discomfort that doesn't go away in a few minutes may signal a heart attack. Read more in When Angina Gets Worse.
An angiogram is a type of X-ray that highlights heart arteries to see whether they are partly blocked. In patients with Syndrome X, the arteries appear normal and unblocked, but patients still experience angina attacks, sometimes without physical exercise. Researchers believe the pain is caused by the failure of small arteries that supply blood to the heart to function well. These tiny vessels appear to tighten, which lessens blood flow to the heart. When the heart doesn't receive enough oxygen, chronic angina pain or discomfort results. For more information, see Other Types of Angina.
Because Syndrome X is most common in women who are undergoing or are past menopause, hormones may play a role. Fortunately, many drugs to treat angina may also manage Syndrome X. Learn more in Angina Medications.
Hormone Replacement Therapy: No evidence of heart protection
For many decades, doctors and women alike have accepted the belief that hormone replacement therapy (HRT) during and after menopause can help prevent heart disease. By replacing low levels of estrogen, the medical community reasoned, a woman could continue to benefit from the hormone's protective effects.
Many were very surprised when a large Federal study called the Women's Health Initiative (WHI) sounded this warning in the summer of 2003: HRT appeared to offer no protection for the heart and, in fact may even increase the risk of coronary artery disease. The study's final results, published in the New England Journal of Medicine, recommended that (under their doctor's direction) women should not continue using HRT to prevent heart disease, nor should they start.8
In the WHI study, researchers followed up 16,608 healthy postmenopausal women in the United States. One group took a combination HRT regimen of estrogen and progestin, while a control group took placebo, or dummy, pills for comparison.
In the group taking HRT, researchers found a 24% overall increase in the risk of coronary artery disease, compared with women taking the placebo pills. This translated into six more heart attacks per year for every 10,000 women using HRT—a slight jump in numbers. The risk of heart attack was greatest in the first year after starting HRT. In contrast, researchers found no significant increase in risk for other heart problems, including angina and congestive heart failure.
Originally, the 15-year WHI study on HRT and heart disease had been scheduled to end in 2005. But researchers halted the study three years early, in the summer of 2002, because they became aware that the risks of HRT outweighed the benefits. They discovered that besides heart attacks, women taking HRT also had a greater chance of developing breast cancer, blood clots, or stroke. These risks were considered too great to offset the HRT-related benefits of a reduced risk of hip fractures and colorectal cancer.
In 2003, researchers reported a similar cancer finding in the British medical journal The Lancet.9 They studied more than one million women in the United Kingdom and found a higher rate of breast cancer, and death from breast cancer, among current users of HRT, compared with women who did not take hormones. Women who took estrogen alone also faced an increased risk of breast cancer, although not as high as for women taking HRT. (Typically, HRT consists of estrogen and progestin, with progestin added to help prevent estrogen from causing uterine cancer. However, women who have had their uteruses removed can take estrogen alone.) Fortunately, the cancer risk declined gradually after women stopped hormone use, according to the study. This study is the largest to examine the effect of hormones on breast cancer.
An article in the Journal of the American Medical Association has revealed that doctors are heeding the results of the WHI— within only one month after the release of the findings from the WHI study, prescriptions for HRT had dropped significantly.10
In contrast to HRT, some questions on estrogen-alone hormone therapy remain unanswered. Although the WHI stopped the HRT part of its trial, the group decided to continue the estrogen-only replacement therapy part until 2005.
However, this study was stopped a year before it was supposed to end, too. Just like the first arm of the trial, the estrogen-only trial was halted because estrogen alone did not appear to prevent heart disease. Although the hormone seemed to decrease the risk of bone fractures, it also appeared to increase the risk of stroke. Some women taking the hormone did seem to have lower rates of breast cancer, but this outcome needs more research. In the end, the researchers concluded that there was no overall benefit to taking estrogen, and recommended that it not be taken for chronic disease prevention in postmenopausal women.11
Meanwhile, millions of women are adjusting to the monumental news. Many have stopped taking HRT with their doctor's permission, while others continue for a variety of reasons, such as to get relief from intolerable menopausal symptoms such as sleeplessness, night sweats, or hot flashes.
If you're going through menopause or are postmenopausal, talk to your doctor about your options for preventing heart disease, now that HRT is no longer recommended. Lifestyle changes may help, for example, quitting smoking, exercising regularly, and following a low-fat, low-cholesterol diet.
Ask your doctor whether you might benefit from drugs to control high blood
pressure or high cholesterol. In a June 2002 issue of Circulation: Journal
of the American Heart Association, investigators reported that among
postmenopausal women taking HRT, those who took statins reduced their risk
of heart disease by 21%, compared with those who did not take statins.12
Women who already have heart disease may also benefit from other
medications, such as aspirin and drugs for angina (these include
beta-blockers,
calcium channel blockers,
and nitrates). Read
Angina Medications for more information.
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Sources
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American Heart Association. 2004 Heart and Stroke Statistical Update.
http://www.americanheart.org/downloadable/heart
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Gerhard, GT "Premenopausal black women are uniquely at risk for coronary
heart disease compared to white women." Preventive Cardiology 2000;
3:105-117.
PubMed
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"Women with Heart Attacks Who Undergo Angioplasty Twice as Likely to Die As
Men." Montefiore News and Events, 2000.
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"When It Comes to Matters of the Heart, Gender Makes a Difference."
Montefiore News and Events, 2001.
http://www.montefiore.org/newsreleases/2000/02/heart_
health_and_gender/. Accessed October 18, 2005.
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"Coronary Heart Disease in Women with Diabetes.” Diabetes and Cardiovascular Disease Review, Issue 5, 2003.
http://www.diabetes.org/uedocuments/Issue5.women.
diabetes.cvd.pdf Accessed July 23, 2004.
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Mason PJ, Manson JE, Sesso HD. Blood pressure and risk of secondary cardiovascular events in women: the Women's Antioxidant Cardiovascular Study (WACS). Circulation 2004;109:1623-9. PubMed
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Mosca L, Appel LJ, Benjamin EJ. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004;109:672-93.
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PubMed
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Million Women Study Collaborators. "Breast Cancer and Hormone Replacement
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Hersh AL, Stefanick ML, Stafford RS. National use of postmenopausal hormone therapy: annual trends and response to recent evidence. Journal of the American Medical Association 2004;291:47-53.
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Anderson GL, Limacher M, Assaf AR. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. Journal of the American Medical Association. 2004;291:1701-12.
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Herrington, DM, et al. "Statin Therapy, Cardiovascular Events, and Total Mortality in the Heart and Estrogen-Progestin Replacement Study (HERS). Circulation, 2002: 105:2962-2967.
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