Interview: Women, Heart Disease and Behavior

Without a Cure, Symptom Management Is Key

Mary C. Corretti, M.D., is associate professor of medicine, as well as director of the adult echocardiography laboratory in the Division of Cardiology at the University of Maryland Medical System in Baltimore. Her research has concentrated largely on coronary artery disease and cardiac risk factors.

Q. Why does heart disease take a greater toll on women than on men?

A. In part, it's because of differences in rates of diagnosis. Up until 20 or 30 years ago, the medical community still thought of CHD primarily as a "man's disease." The fact that men, at least in their younger years, are far more likely than women to experience angina and heart attacks helped create that illusion. It was less widely known that the "classic" signs and symptoms of heart disease are different in men and women. Hence, women facing heart disease were more likely to go unrecognized and untreated.

Another well-documented contributing factor is the less aggressive treatment of women who are at high risk of developing CHD or who have been diagnosed with CHD. Many reasons have been proposed for this - from sexual discrimination, to differences in access to medical care between elderly men and women, to the greater difficulty of performing surgical interventions on women's smaller blood vessels.

Q. Is this gender gap in diagnosis and treatment improving?

A. In my experience, definitely. Physicians have become far more aware of the ways heart disease develops and expresses itself in women. In addition, they've received encouragement to more aggressively treat women who either have, or are likely to develop, heart disease. A major impetus came in 1999, when the American Heart Association and the American College of Cardiology issued a statement calling for more aggressive CHD risk factor management in women. More women are participating in clinical trials, which have shown that interventions can be just as fruitful in them as in men.

Q. Does this mean we can look forward to shrinking disparity between male and female death rates from CHD?

A. I would like to think so, but not necessarily. The death rate from CHD is not declining as quickly in women as in men. In addition, several serious risk factors for CHD are on the rise among grown women and girls alike. For example, the Surgeon General recently reported that in the past 20 years, the percentage of overweight children has doubled and the percentage of overweight adolescents has nearly tripled.8 These indicators, coupled with American women's persistent ignorance of CHD risks and symptoms, suggests that the recently-observed decline in women's death rates from CHD may stop or even reverse itself.

Q. How would you begin raising awareness of risk factors?

A. With the patient-primary care provider relationship. An American Heart Association Task Force survey found that women between the ages of 25 and 44 generally felt they were not well informed about heart disease. Ninety percent indicated a desire to discuss heart disease or risk reduction with their physicians, but only 30 percent reported that such a discussion had taken place.(2) It has been suggested that pregnancy and the preconception period are prime opportunities for women and their physicians to review CVD risk factors and adjust behaviors. I don't see why this shouldn't happen even earlier; heart healthy habits should be taught to children and adolescents.

Q. Why is that?

A. Autopsy studies indicate that atherosclerosis can start in a woman's 20s. In fact, if she has a family history of early heart disease - that is, a parent or sibling who has suffered a heart attack or other cardiac event before age 55 - it may begin in her teens. Many of the behaviors that increase risk of CHD begin in childhood. Some of the best advice a physician can give a young woman is to never start smoking.

Q. What is a good age for an initial blood screening?

A. The National Cholesterol Education Program's latest guidelines recommend that a woman have her first blood cholesterol check at age 20, plus rechecks every five years. They also recommend checking blood levels of triglycerides and lipoproteins (HDL cholesterol and LDL cholesterol).(11)

Q. Even though her risk of actually suffering angina or a heart attack is relatively low before she reaches menopause?

A. The fact that women don't usually have heart attacks and angina until after menopause doesn't mean that they can afford to ignore, or even encourage, damage that is setting the stage beforehand.

Q. Because menopause seems to be a turning point, is it particularly important for a woman to have her risk of CHD evaluated or reevaluated at that time?

A. Every woman should have her total cholesterol, lipoprotein, triglyceride and blood sugar levels, as well as her blood pressure, assessed at menopause. Even if these have been normal during her reproductive years, they can quickly become abnormal when she reaches menopause. It's particularly helpful to catch elevated triglyceride levels and depressed HDL cholesterol levels, as these are better predictors of CHD in women than they are in men.

Also, if a woman has not yet been told how to recognize the symptoms of heart disease, she should be given that potentially life-saving information [see "Symptoms of Heart Attack and Angina in Women," page 6]. Women are notoriously good about knowing when others need help; they need to learn more about when to seek help for themselves.

Q. What if a woman opts to take replacement hormones at menopause?

A. She still requires screening and education. Until recently, it was believed that the increase in CHD risk after menopause was primarily due to postmenopausal drops in estrogen production and that taking replacement estrogen after menopause would protect a woman's cardiovascular system. We now know that estrogen is only one part of the picture. Moreover, recent research has cast doubt on the ability of hormone replacement therapy (HRT) to lower postmenopausal heart disease risk.(9) The research results are coming in, but it's clear that hormones are not a "magic bullet" against heart disease. Nothing is.

Q. You mentioned the need to treat CHD risk factors "aggressively." What does that mean?

A. We have learned that the right treatment - a combination of behavior modification and, where indicated, medication and surgical intervention - has tremendous power to reduce a woman's risk of developing heart disease or stem its advance.

Q. Does that not imply a sweeping program intended to produce rapid behavioral change on all fronts?

A. It is generally unrealistic - in fact, a setup for failure - to expect a woman to radically revamp numerous behaviors and many key aspects of her lifestyle all at once. I find the best approach is to start tackling as many risk factors as the woman can handle, at the most rapid rate she can tolerate. I work with her to set a series of realistic goals and marshal necessary supports, including other specialists. Over time, we hit as many bases as hard as possible. I start with the modifications that will bring the quickest results for a given patient. The results reduce risk, provide encouragement and set the stage for more progress.

Q. Given the CHD risk associated with obesity, is any diet that produces weight loss beneficial?

A. Because diet has a very important impact on the development of atherosclerosis, any diet to lower CHD risk needs to be heart healthy. This is a very active area of cardiovascular research. It is currently recommended that a heart healthy diet is one that is balanced; is low in saturated fat, cholesterol and sodium; is rich in fruits, vegetables and grains; and contains fish, lean poultry and lean meat. The so-called "Mediterranean diet" fits this description. (See"Fishing for Heart Health: The Mediterranean Diet, page 5.)

Q. You mentioned exercise. How important is that?

A. For the vast majority of women at risk of CHD, who get far too little regular exercise, increasing physical activity is one of the best places to start. That's true even if they aren't overweight. Research concludes that as little as 30 minutes of moderate activity a day - such as brisk walking, bicycling, or raking leaves - will help protect heart health.

Q. What about women who have already experienced angina or a heart attack?

A. I always encourage these women to join a cardiac rehabilitation program or other comprehensive risk reduction program. Participation in a cardiac rehabilitation program has been shown to decrease a woman's chances of dying from CHD.(12) In my own practice, I have seen that it can make a world of difference. My experience is that women who participate in cardiac rehab tend to be more compliant with their self-care regimens. They're also more likely to make a positive adjustment to their new circumstances. That's important because women who suffer from depression after the onset of heart disease tend not to do as well medically.

Q. Where does the future of women's heart disease research lead?

A. We still have much to learn about women and CHD, including the best ways to identify women at risk of angina or a heart attack. Several noninvasive procedures - including electron beam CT scanning to diagnose atherosclerosis and testing for abnormal levels of such substances as C-reactive protein and fibrinogen - are under investigation.

The biggest challenge at hand, however, is using the information we already have. It's never too early for a woman and her primary care provider to start talking about, identifying and taking action against risk factors for heart disease. The payoff could be longer, healthier, more productive lives for literally millions of American women.

Women's Risk Factors for Heart Disease

A woman's risk factors for heart disease fall into two categories, controllable and uncontrollable.(1)(13)

The controllable risk factors are:

High blood pressure
High blood cholesterol
Smoking
Obesity/Overweight
Physical inactivity
Diabetes

Age over 55 (related to menopause)
Family history of early heart disease

While stress has been linked to increased risk of heart disease, there is not universal agreement that it operates independently of the risk factors listed above.(14)

Behavioral change and lifestyle modification are the first line of defense in reducing risk factors for CHD. Even where medication or a surgical intervention is appropriate, behavioral change is required to achieve and maintain the best effect.

Interview #2: : Anger and Heart Disease in Women: Conquering a Heartbreaking Emotion

Stephen Sinatra, M.D. is a board-certified cardiologist and certified psychotherapist and is head of the New England Heart Center in Manchester, CT, director of medical education at the Manchester Memorial Hospital and assistant clinical professor of medicine at the University of Connecticut School of Medicine. The author of four books and the editor of a monthly newsletter on heart health, Dr. Sinatra has a particular interest in the crucial role of emotion in heart disease.

Q. There have been many studies suggesting that certain emotions are linked to a higher rate of heart disease and, where heart disease exists, to a greater likelihood of death or recurrence. Do you believe that there is a cause-effect relationship at work, that these emotions are harmful?

A. Yes, research has documented that our emotions manifest themselves as behaviors and physiological changes that can make us more vulnerable to heart disease.

Q. Is anger one of those emotions?

A. Definitely. I consider it a major psychological risk factor for heart disease.

Q. How does anger endanger the heart?

A. Anger triggers the release of stress-related hormones and other substances that produce profound cardiovascular changes. Blood vessels narrow, increasing their resistance to blood flow. The heart rate rises and blood pressure shoots up. When anger is allowed to fester, it's like trying to drive a car with the emergency brake on; something has to give. Chronic anger becomes part of the body's biology, affecting both the heart and the blood vessels. Situational anger may set off a cascade of events that lead to the partial or total blockage of a critical blood vessel in the heart, which can trigger angina or a heart attack.

Here's a classic example of the power of anger: One of my patients told me that shoveling snow didn't provoke his angina - but angry confrontations with his 16-year-old son did!

When not dealt with "cleanly," anger also leads to maladaptive behaviors. Many of these, such as smoking and overeating, are risk factors for heart disease as well. When turned inward, anger can transform itself into depression; the results of the Nurses' Health Study showed that depression increases a woman's risk of heart disease.

Q. Is the incidence of what you might call "toxic anger" any different in women than it is in men?

A. Each and every one of us, male and female, has anger at some time. How harmful it is depends on how we experience and manage it. I can't offer scientific proof, but I have seen that women are more likely to suppress their anger, because expression of anger is less socially acceptable in women than it is in men. Suppressed anger - like other unexpressed emotions - tends to fester, so it is more likely to cause cardiac damage.

Q. So women's anger isn't inherently more dangerous than men's, but their tendency to suppress it can make it that way?

A. Yes. Suppressed anger is especially problematic in women who internalize it so efficiently that they can't even see they're angry. The same is true in women who know they're internalizing their anger but think they're doing the right thing, engaging in a beneficial behavior by being "good soldiers."

These women don't see themselves as having an anger problem. They need help to see they're putting themselves at risk before they can even begin to work on their anger.

Q. Is there any evidence that overcoming an anger problem reduces cardiac risk?

A. Yes, very good evidence. There are some excellent individual studies. An overview of 20 clinical trials published in the late 1990s looked at the impact of various psychosocial treatments for distressing emotions, including anger, in cardiac patients. Those who received treatment had less psychological distress - along with better blood pressure, heart rates and blood cholesterol levels. They were also less likely to die or have another episode of heart disease within two years.(16)

It's interesting to note that most of the studies failing to show a positive effect of psychosocial treatment on clinical outcomes also fail to demonstrate a reduction in psychological distress.(16) That underscores the fact that effective psychosocial interventions help both mind and body.

Q. What accounts for the improvements?

A. The angry individuals learn to "own" their issues and deal with them in more productive ways. They have less physiological response to stimuli, making them less prone to anger-induced angina, irregular heartbeat and heart attack. At the same time, they develop an improved outlook, with an increased tendency to adopt other health- promoting behaviors. Anger can be an exceedingly difficult piece of the puzzle to work through, but also exceedingly worthwhile.

Q. Knowing this, do you always look for potentially dangerous anger in a patient with heart disease?

A. Yes, but I'll confess that it's easy to spot the patients most likely to suffer from anger-related heart problems: they're anxious, hostile, very easily frustrated, hard to get close to.

Q. What is the most productive approach for such a patient?

A. A cardiac rehabilitation program plus an appropriate psychosocial intervention. That combination produces the best outcomes, including a lower recurrence of heart attack and angina.

Q. Don't cardiac rehabilitation programs provide emotional help?

A. The typical cardiac rehabilitation program includes some low-level stress management - meditation, guided imagery, relaxation response and so on. The exercise component tends to have a beneficial effect on emotions. But there isn't always a psychotherapeutic component; that requires staff members with special facilitation skills. There isn't the high-level psychotherapeutic intervention that many people require.

Q. What types of psychosocial interventions do you recommend for your patients?

A. That depends on the individual's needs and situation. Sometimes I work psychotherapeutically with one of my patients, individually or in a group. Other times I make a referral to a therapist, social worker or counselor. If a patient is not willing to enter into such a relationship, I suggest ways for the patient to work with his or her own anger.

Q. What would you tell a woman who reads this interview and wants to know if her anger puts her at risk of heart disease?

A. I would tell her to ask herself the following six questions. Her answers should tell her if she has anger that needs to be addressed.

1. Do I ever give a "look that could kill"?
2. Do I ever strike out verbally or physically?
3. Do I sometimes flare my nostrils or hold my breath when I am upset?
4. Do I ever become hostile and impatient to the point of interrupting others?
5. Do I feel that it would not be feminine to show my anger?
6. Do I "stuff" my negative feelings, blame myself, or become depressed?

The so-called "Mediterranean diet" has gained increasing favor among health care professionals for the prevention and treatment of both heart disease and other chronic medical conditions. Population studies have repeatedly linked consumption of this diet to lower incidence of, and mortality from, heart disease.

Modeled after the traditional cuisine of Mediterranean regions such as Crete and Southern Italy, the diet is characterized by: (17,18)

An abundance of plant foods, especially fruits, dark-green vegetables, breads, grains, beans, nuts and seeds.
Low to moderate daily intake of cheese and yogurt.*
A few weekly servings of fish, preferably cold water (salmon, halibut, etc.) and prepared without breading or frying.
A few weekly servings of poultry.*

Zero to four eggs weekly.

Red meat only a few times a month.*

Olive oil as the primary source of fat, instead of animal fat, other vegetable oils, mayonnaise or margarine.

A reliance on fresh or minimally processed food.

Sweets in moderation, with fresh fruit being the typical dessert.

Wine at mealtimes is a staple of classic Mediterranean cuisine. However, overconsumption can be detrimental to a woman's health - so women who drink wine are generally advised to drink at most one glass per day, with a meal.

While the total fat content of the Mediterranean diet (about 25 to 30 percent of calories from fat) is only slightly lower than that of a moderate American diet, there are major differences in the type of fat. The Mediterranean diet contains less saturated fat and polyunsaturated fat and more monounsaturated fat and omega-3 fatty acids, than American fare. Omega-3s may have a positive effect on heart health because of their anti-inflammatory properties.(13)

It's still uncertain whether the diet, or some other aspect of life on the Mediterranean, accounts for the lower risk of heart disease in that region.(17) However, evidence in support of the diet's benefits is emerging. Among the 69,017 American women who provided diet information as part of the Nurses' Health Study, those whose intake was most like the Mediterranean diet at the start of the study were least likely to develop CHD in the following 12 years.(19) Other studies have linked improved blood chemistry and lower recurrence of heart disease to consumption of a Mediterranean-style diet.(20,21)

Symptoms of Heart Attack and Angina in Women

Women are less likely than men to believe that they're having a heart attack, and more likely to delay in seeking emergency treatment.(15) Yet rapid treatment may mean the difference between a good recovery and death or debility.

Any of these symptoms may indicate a heart attack or angina:(15,13)

Pain or discomfort in the center of the chest. This is the most common symptom in both men and women. However, women often experience a dull, aching discomfort beneath the breastbone, instead of the sharp, crushing pain men tend to feel.

Pain or discomfort in other areas of the upper body. Women are more likely to feel this in the back, neck, jaw or stomach, while men more often experience pain and numbness in the left arm. The stomach pain that signals a heart attack or angina in a woman may be easily mistaken for indigestion and fullness, and is often accompanied by a feeling that burping would relieve the discomfort.

Other symptoms such as shortness of breath, breaking out in a cold sweat, nausea or light-headedness. All of these are more common in women than in men.

A woman's angina symptoms may come and go with no obvious cause and not improve with rest; a man's angina usually strikes after exercise or exertion and improves with rest.

A woman often experiences chronic, low-grade symptoms, such as chronic breathlessness or waking in the night with difficulty catching her breath; a man tends to experience sudden dramatic symptoms.

The Research

1. National Institutes of Health. (August 1998). Heart disease and women: Are you at risk? Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute.

2. Jones, P. H., Kinlay, S., & Mosca, L. J. (Eds.). (2001). CVD in women: An update on risk factor management. New York Medical College CME Notes, 1(3), 2-13.

3. Parker-Pope, T. (2001, June 1). Risk of heart attack is greater for women than they realize. The Wall Street Journal, p. B1.

4. Heart disease remains top killer, statistics show. (2002, January 1). The Washington Post, p. A11.

5. Wenger, N. K. (2000). Lipid management and control of other coronary risk factors in the postmenopausal woman. Journal of Women's Health and Gender Based Medicine, 9 (3), 235-243.

6. American Heart Association. Facts about women and cardiovascular diseases. women.americanheart.org

7. National Heart, Lung, and Blood Institute. Facts about heart disease and women: Are you at risk? www.nhlbi.nih.gov

8. U.S. Department of Health and Human Services. (2001). The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.

9. Mosca, L., Collins, P., Herrington, D. M., Medelsohn, M. E., Pasternak, R. C., Robertson, R. M., et al. (2001). Hormone replacement therapy and cardiovascular disease: A statement for healthcare professionals from the American Heart Association. Circulation, 104, 499-503.

10. American Heart Association science advisory: Hormone replacement therapy and cardiovascular disease. www.americanheart.org

11. National Heart Lung and Blood Institute. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult treatment panel III). www.nhlbi.nih.gov

12. Jones, C.A., Valle, M., & Manring, S. (2001). Using survival analysis to explore female cardiac rehabilitation program adherence. Journal of Applied Nursing Research, 14 (4), 179-186.

13. Sinatra, S.T., Sinatra, J., & Lieberman, R. J. (2000). Heart sense for women. Washington, DC: LifeLine Press.

14. National Heart, Lung, and Blood Institute. Facts about coronary heart disease. www.nhlbi.nih.gov

15. National Heart, Lung, and Blood Institute. Women and Heart Attack. www.nhlbi.nih.gov

16. Krantz, D.S., Sheps, D.S., Carney, R.M., & Natelson, B.H. (2001). Effects of mental stress in patients with coronary artery disease: Evidence and clinical implications. Journal of the American Medical Association, 283(14), 1800-1802.

17. The Mediterranean diet. nutrition.about.com

18. Royal College of Physicians, London, England. 2000 Consensus statement: Dietary fat, the Mediterranean diet and lifelong good health. www.chd-taskforce.de

19. Fung, T.T., Willett, W.C., Stampfer, M.J., Manson, J.E. & Hu, F.B. (2001). Dietary patterns and the risk of coronary heart disease in women. Archives of Internal Medicine, 161(15), 1857-62.

20. Research points to "Mediterranean" diet to help prevent repeat heart attack. www.cnn.com

21. Michaels, S. Heart-healthy eating, the Mediterranean way. mediterraneanonline.com

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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