Heart disease is the leading cause of death in women in the United States. But if you are a pre-menopausal, asymptomatic female, don't overreact.
The most valuable tests to have to indicate your heart disease risk are the old standbys: blood pressure, cholesterol level, weight and blood sugar.
There's no question that you need to see a doctor when you're not well. But what about regular visits to the doctor for physical examinations by people who believe they are well?
Think about these facts:
- Women are at risk for heart disease and heart attacks, just like men. While they develop heart problems later in life than men, by about age 65, a woman's and man's risk is almost the same.
- Heart disease doesn't happen overnight. Your doctor can easily identify conditions that increase your risk as well as early warning signs.
- Heart disease — and even a heart attack — may or may not produce symptoms.
- Heart disease can be prevented or delayed with appropriate care and lifestyle choices.
Routine visits to your doctor are extremely useful to help reduce your risk for cardiovascular disease.
- An unhealthful cholesterol level can be identified by an exam and a blood test. Today's cholesterol lowering drugs can reduce future risk of heart disease by about 33 percent.
- By identifying high blood pressure and prescribing appropriate medication the future risk of stroke and heart attack can be reduced significantly.
- According to the American Diabetes Foundation 2 of 3 people with diabetes die from heart disease and stroke. Simple tests can identify the problem so your doctor can initiate treatment before major damage has been done.
- Early menopause, natural or surgical, can double a woman's risk for developing heart disease.
- Doctors may identify one or more of a vast number of differing health problems from observations made during a regular exam.
- Your doctor can help you stop smoking and build a plan for exercise.
If your doctor suspects you're at risk for heart disease, there are a number of traditional diagnostic tools used to look for cardiovascular disease in general and coronary artery disease in particular. Some of them are heart imaging techniques, that is, ways of creating pictures of the inside of the heart that can show the presence and extent of heart disease. These diagnostic tools include:
- Blood tests: When cells (including heart muscle cells) die, enzymes are released into the blood; blood tests can detect the presence and amount of these enzymes.
- Electrocardiogram (EKG, ECG or cardiogram): A measurement of the heart's electrical activity (which controls the heartbeat) made by an EKG machine, which is attached to the chest with wires called "electrodes."
* Portable EKG: If an EKG doesn't give conclusive results, one may get a portable EKG machine, called a Holter monitor, to wear for a day; it monitors the heart rate and notes any arrhythmias (irregularities).
- Stress EKG (stress test): an electrocardiogram made while the person is exercising (usually by jogging on a treadmill or riding a stationary bike).
* If one is unable to exercise, a drug can be injected that makes the heart react as it would during exercise.
- Echocardiogram: Sound waves are bounced off the heart to produce still and moving images of it (similar to ultrasound imaging used with pregnant women to produce images of fetuses).
* A "stress echo" is a stress test and echocardiogram done at the same time.
- Cardiac catheterization: In this more invasive test, a small tube (catheter) is inserted through a blood vessel and threaded up into the heart, to measure blood flow and pressure.
- Coronary angiogram (also called arteriogram): An X-ray of the inside of the coronary arteries to look for blockages.
* During cardiac catheterization, a contrast dye is injected into the catheter that enables blockages to be seen on the X-ray.
* The process of making an angiogram is called angiography.
Recently, a new type of imaging test, EBCT (electron beam computerized tomography or "Ultrafast CT" ), has received a lot of publicity and advertising. EBCT, often called a "heart scan," is a type of computerized tomography (popularly known as CT scan or "CAT scan"). Computerized tomography is a sophisticated imaging system that creates a series of very detailed, cross-sectional images of organs and tissues. EBCT is a variation that works much more quickly. It provides an accurate measurement of calcium deposits in the coronary arteries. These calcium deposits are reported as a "calcium score"; the higher the score, the greater the amount of calcium deposits. Scores range from 0 (no evidence of calcium deposits) to over 400 (very high amounts of calcium are present).
There does appear to be a correlation between large calcium deposits in the coronary arteries and the development of coronary artery disease. However, the correlation seems age-dependent; that is, it is stronger for younger people (up to about 50) than older (above 50). People over 50 seem to develop calcium deposits naturally, so they're not as accurate a predictor of future coronary artery disease.
Moreover, the medical profession believes certain standards must be met before a screening test (a diagnostic tool, like EBCT) can be called cost-effective. One of these is that it must provide information that will affect treatment and prognosis. So far, there are no studies showing that EBCT "heart scanning" has any significant effect on reducing deaths from coronary artery disease or improving the lives of people with it.
For example, EBCT will identify small build-ups of calcium (10 to 20 percent), but these results generally don't lead to changes in treatment, other than re-emphasizing the importance of reducing risk factors, like smoking and cholesterol. Further, the test finds only calcium deposits that have become hard (called "hard plaque"); it does not find "soft plaque" which can also cause heart attacks.
Besides being of limited value in the early detection of coronary artery disease, EBCT is unavailable in many areas, expensive and generally not covered by insurance. A team of experts from the American College of Cardiology, American Heart Association and the American College of Physicians-American Society of Internal Medicine concluded, "The proper role of EBCT is controversial and will be the subject of future ACC/AHA statements."
Three-Dimensional Helical Computed Tomography (or DHCT) is another advanced variation on traditional CT scanning. Like EBCT, there are many places where it isn't available, it's expensive and generally not covered by insurance, and at present may be of limited value in the early detection of coronary artery disease.
Even if you don't think you have risk factors for heart attack, if you are a woman with diabetes, peripheral vascular disease or chronic renal disease, you need to be concerned and do something. You are at a high risk of having a heart attack — the same risk as someone who has already had a heart attack.
Some risk factors (things that increase the chance of getting a disease or developing a condition) for coronary artery disease and heart attack are beyond our control:
- Genetics: A family history of heart disease and early heart attack can increase one's risk of heart attack.
- A history of coronary artery disease, high blood pressure and other heart problems.
- Age: The heart muscle weakens with age, so that men over 45 and women over 55 are at a higher risk of having a heart attack.
- Diabetes: Uncontrolled diabetes increases the risk of developing coronary artery disease.
- Peripheral arterial disease (clogged vessels in the arms and legs): People with PAD may form blood clots, increasing their risk of death from heart attack or stroke.
- Chronic renal disease: Kidney disease can be a cause or a consequence of cardiovascular disease. It is also closely related to hypertension and diabetes.
Other risk factors, like not getting enough exercise, smoking and having too much cholesterol in the blood, are controllable. They relate to how we live, and we can always change that if we try. It's especially important for women at increased risk to live in a "heart-healthy" way.
If you are at increased risk, your doctor will probably want to do tests before recommending prevention or treatment measures. See Key Point 1 for more information on tests.
There are a number of ways to treat heart disease.
Medicines: The list of medicines now used to treat heart and cardiovascular disease would include:
- Blood pressure reducers:
* Beta blockers: Drugs that slow down the heart rate, correct arrhythmias (irregular heartbeat) and reduce blood pressure, all of which help lower the heart's workload.
* Vasodilators: Drugs that open ("dilate") the arteries, lowering blood pressure and, therefore, the heart's workload.
* Calcium-channel blockers: Another class of drugs that dilate blood vessels.
* Diuretics: Drugs that help eliminate excess fluid to aid the heart in working more efficiently.
- Blood clot reducers:
* Anticoagulant drugs: Often called "blood thinners," though they don't actually thin the blood, nor do they dissolve clots already present.
* Antiplatelet agents: Stop blood platelets (substances in blood that promote clotting) from clumping together to form clots.
* Thrombolytic drugs: Dissolve blood clots already present. To be effective thrombolytics must be given within one hour of start of symptoms.
- Cholesterol reducing medicines:
* Statins: Considered the most important and effective group of LDL-cholesterol reducing medicines. They slow cholesterol production and increase the liver's ability to remove the LDL-cholesterol already there. Because the body makes more cholesterol at night, these drugs are usually taken in the evening, at dinner or before bed. Side effects appear to be minimal and studies show that people using statins have reported 20 to 60 percent lower LDL-cholesterol levels.
* Bile acid sequestrants: Bind with bile acids in the intestines that contain cholesterol. Then they are eliminated during defecation, reducing the amount of cholesterol in the blood. Often, these drugs are prescribed in combination with statins.
* Fibrates: Lower the level of triglycerides (the main component of fat and therefore another major cause of atherosclerosis) in the blood.
* Nicotinic acid: A non-prescription cholesterol lowering substance. It's a form of niacin, the water-soluble B vitamin. When taken in high doses, well above the suggested daily amount, it can be effective in lowering LDL-cholesterol and triglyceride levels.
- Antiarrhythmic drugs that regulate the heartbeat.
- Digitalis: A drug that strengthens the heartbeat.
Percutaneous Coronary Intervention (PCI) basically refers to a procedure known as angioplasty. Angioplasty is the process of opening or widening a narrowed blood vessel. The procedure was first used in the 1970s to treat coronary artery disease. Now it is being applied to other arteries. For example, angioplasty of the carotid arteries (which carry blood to the brain) is now seen as a way to help prevent stroke.
In angioplasty, a small tube called a catheter is threaded up into the arteries to the site of the blockage. (If the catheter reaches the heart, the process is called coronary catheterization.) When the blockage is reached, a tiny balloon at the end of the catheter is inflated to open the narrowed blood vessel. (The procedure is also known as "balloon angioplasty.") After the blood vessel has been widened, the balloon and catheter are removed. The procedure may also involve using a tiny umbrella-like filter (called a "distal protection device") at the end of the catheter to catch any particles that break free from the artery and prevent them from traveling to and blocking some other blood vessel.
A more recent development is to combine a balloon angioplasty with the placement of a stent. A stent is a tiny tube made of a metallic mesh; it looks something like a wire cage or spring. It's put inside a blood vessel to keep it open and unblocked. After a blocked blood vessel has been opened by balloon angioplasty, a stent can be slid along the catheter and put in place. The most recent development in PCI is to coat the stent with medicines to help prevent further blockages; this type of stent is known as a "drug-eluting stent." Usually a balloon angioplasty and/or a stent work permanently, but sometimes the procedure has to be repeated after several years.
All forms of PCI are considered "invasive" procedures, because they involve entering the body, but "non-surgical" because no major incisions are involved.
Besides PCI, there is another non-surgical way of treating coronary artery disease called atherectomy. In this procedure, the doctor opens the affected artery and, depending on the type of blockage, uses one of several techniques and instruments to physically remove the blockage.
Surgical Options: The best known is popularly called "bypass surgery," technically called "coronary artery bypass grafting" (CABG or "cabbage"). As its name implies, its purpose is to allow blood to bypass or go around a blocked artery. During the procedure, blood vessels from other parts of the body (usually arteries from the chest and arm and veins from the leg) are grafted into place to create a detour around the blockage in the coronary artery. This process is also known as revascularization.
Other surgical options depend, of course, on the nature and severity of the coronary artery disease and problems it has caused. For example, coronary artery disease can lead to an irregular heartbeat (arrhythmia), which is often treated by implanting a pacemaker in a person's chest. A pacemaker is a tiny device that sends electrical signals to the heart to restore its regular rhythm. In the most serious situations, when coronary artery disease has led to a severe, very damaging heart attack, a heart transplant may be needed.
The Benefits of Prevention
In women at intermediate or high risk of cardiovascular disease, you need to pay special attention to your heart attack risk. In fact, prevention can't hurt, and all women can benefit from it. Maintaining a healthy weight, blood pressure and cholesterol, exercising daily and avoiding tobabcco will protect your heart – no matter your risk level.
Such risk factors as not getting enough exercise, smoking, and having too much cholesterol in the blood are controllable. They relate to how we live, and we can always change that if we try. In other words, the easiest and most effective way to prevent coronary artery disease (CAD) is to live in a "heart-healthy" way. That means:
- Start and maintain a program of regular physical exercise
* The choices are virtually endless, from taking a simple (but not too slow) walk to swimming to team sports to exercises classes with a professional trainer.
- Stop smoking.
- Stop drinking alcohol heavily.
- Keep your blood pressure under control.
* If you need blood pressure lowering medicine, get it and use it.
- Keep your cholesterol under control.
* If you need cholesterol lowering medicine, get it and use it.
* Eat a heart-healthy diet, which includes:
# Fruits and vegetables.
# More fish, less meat.
# "Good" oils, like olive oil and canola oil.
# Antioxidants are nutrients and other substances that protect cells in the body from the damage caused by "oxygen free radicals" (molecules that seek to become oxidized, a process that harms body tissues and has been linked to many diseases, including stroke, heart disease, and cancer); antioxidants are found naturally in food but are also available as dietary supplements (antioxidates found in food work far better than pill supplements).
# Important antioxidants include:
# Vitamins A, C, E and beta-carotene (found in carrots).
# Lycopene (found in tomatoes).
# Flavonoids (found in ginkgo biloba, black cherries, blackberries, bilberries and blueberries).
# Quericetin — a specialized flavonoid found in apples, onions, tea and red wine.
# Coenzyme Q10 — a vitamin-like substance found in soy, whole grains, mackerel and chicken.
# Folates – foods rich in folic acid, like:
# Green vegetables.
# Strawberries, oranges, raspberries.
# Nuts and seeds.
Most of the ingredients of a "heart healthy" diet have been known for a while. They're based on long-running heart health studies, like the Framingham study, which has followed a population in Massachusetts for 46 years. Recently a group of European doctors used these studies to support the idea of the "Polymeal" diet, their term for a "natural alternative" to the Polypill (discussed below).
The Polymeal daily diet calls for:
- Fruit and vegetables (400 grams (g) per day; 1 apple = 150 g.).
- Fish (114 g four times a week; 3 oz. = 85 g.).
- A garlic clove.
- A small dose of dark chocolate (no more than 100 grams per day; 1 oz. = 28 g.).
- A small glass of wine (150 milliliters per day).
Clinical trials have shown that all these ingredients help reduce either "cardiovascular disease events" (like heart attacks) or risk factors for cardiovascular disease. That doesn't mean you should instantly start eating only what's in the Polymeal diet. Nor does it mean you should start drinking wine if you're a non-drinker. But it does remind us, once again, that a heart healthy diet, along with regular exercise, is the best prevention against cardiovascular disease.
The name "Polymeal" was invented, in part, as a tongue-in-cheek response to another recent European cardiac health recommendation by a different group of scientists, the Polypill. Just as the Polymeal consists of ingredients known to be part of a heart healthy diet, the Polypill consists of a mixture of drugs known to be effective in treating various kinds of heart and cardiovascular disease.
The Polypill, first proposed in June 2003, would be a "cocktail" of six of these drugs, including a statin, three beta blockers, aspirin and folic acid to reduce homocysteine levels in the blood. (Homocysteine is an amino acid made by the body; high levels of it in the blood are associated with atherosclerosis.) But the Polypill is not yet commercially available; it is still a concept under investigation.
This article is reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, N.Y.), West 175 and the University of Rochester Medical Center.