Traditionally, cardiovascular disease has been thought of as a “male” disease, but cardiovascular disease is in fact the leading cause of death for women as well as for men in the United States. In 2003, all forms of cardiovascular disease claimed the lives of about 500,000 American women, according to the American Heart Association (AHA). Statistically, 2 out of every 5 female deaths in the United States is caused by cardiovascular disease, especially coronary heart disease and stroke.

Alarmingly, studies continually reveal that women lack understanding of the risks they face from heart disease and stroke. While the media tends to emphasize breast cancer, cardiovascular disease claims more than 10 times as many lives as breast cancer annually and more than 8 times as many lives as lung cancer. It is responsible for more deaths annually among women than all other causes combined. Minority women face an even greater risk. Cardiovascular disease claims a significantly higher number of black and Mexican American women than white women, possibly because of higher rates of obesity and lack of exercise in these populations. While there has been positive news in recent years -- overall rates of heart disease have declined in women, possibly due to risk factor reduction -- there is still significant room for improvement in the diagnosis and treatment of heart disease in women.

Studies are ongoing to understand the gap between the dangers of cardiovascular disease in women and its treatment. In recent years, researchers have begun to understand that women experience cardiovascular disease differently than men, especially coronary heart disease. It may have different symptoms, and onset tends to occur later in life. Because of these differences, women may be less likely to be referred for testing for heart disease. As a result, women have to be more assertive in seeking out appropriate care. Also, women have different target goals when it comes to controlling risk factors such as cholesterol levels and triglycerides. It is important that all women understand the dangers posed by cardiovascular disease and take appropriate steps to prevent it.

One of the most common symptoms of cardiovascular disease is chest pain. Research has suggested, however, that women tend to experience chest pain differently from men. In women, the chest pain may be more diffuse or resemble abdominal pain more than in men. Also, studies have found that women are more likely than men to be told that their symptoms are due to stress or an unrelated issue. In fact, some findings do indicate that some women are more prone to psychological and/or stress-related chest pain than men. However, chest pain in both men and women needs to be evaluated for the possibility of heart disease.

The list of heart disease symptoms that are often reported by women is called the “ABCs” by experts:

• Angina or chest pain. This is often felt as tightness in the chest that sometimes radiates down the left side or up to the jaw. It may be mistaken by a physician and/or patient as indigestion, a toothache or temporomandibular joint syndrome (TMJ, an aching jaw.)
  
  
• Breathlessness. This can include fairly regular shortness of breath (dyspnea), particularly when exercising, or only nighttime breathing difficulties while lying down.
  
  
• Chronic fatigue (feeling very tired or run down all the time).
  
  
• Dizziness. In some cases, women may even faint (syncope).
  
  
• Edema (swelling), particularly in the lower body (ankles and lower legs).
  
  
• Fluttering, also known as rapid heartbeats or palpitations.
  
  
• Gastric upset, nausea or indigestion-like symptoms.

Women who are concerned about their heart health are urged to seek a second opinion if they are not satisfied with the first.

Heart attacks, angina and coronary artery disease are among the many forms of cardiovascular disease – the leading cause of death among American women. The media currently stresses the dangers of breast cancer, but cardiovascular disease claims more than 10 times as many female lives as breast cancer does. To protect themselves, women are urged to learn the facts about heart disease in women, including:

• Alcohol. Some studies have shown that both women and men have better heart health when they drink moderately rather than heavily or not at all. Women’s moderate alcohol use is defined as only one drink per day. Any more alcohol in a woman can be harmful to the heart, stomach and liver, and a few studies have shown that more than two drinks a day may be linked with high blood pressure in women.
  
  
• Aspirin. Taking one low-dose aspirin of 81 milligrams appears to lower women’s risk of having a second stroke, second mini-stroke (TIA) or second heart attack. Some evidence suggests that daily aspirin may even prevent a first stroke, TIA or heart attack. However, women should talk with their physician before taking aspirin because it is not appropriate for everyone. Women are generally advised against taking aspirin if they are pregnant, trying to become pregnant or have certain medical conditions.
  
  
• Birth control pills. Not only are birth control pills designed to prevent unwanted pregnancies, but they have also been associated with significant benefits (e.g., reduced risk of colorectal cancer or ovarian cysts). Unfortunately, they have also been associated with a slightly increased risk of blood clot formation and may be inappropriate for women with a family history of stroke or other conditions. Additionally, women who smoke should avoid birth control pills.
  
  
• Cholesterol. According to the American Heart Association (AHA), over 51 percent of American women had cholesterol levels that were over 200 mg/dL in 2003. Another 18.4 percent of American women had high cholesterol (over 240) as of 2003. Men and women are at greater risk of both heart disease and stroke when cholesterol levels are elevated, but women appear to be more sensitive to low HDL levels than men. Similarly, triglycerides appear to be a better indicator of risk among elderly women than men or younger women. Both men and women at high risk of a heart attack should be treated the same for high cholesterol, especially with cholesterol-reducing medications such as statins. However, studies have shown that women are less likely to be prescribed statins than men.
  
  
• Diabetes. While diabetes is dangerous for everyone’s cardiac health, studies have shown that women die from diabetes-related heart disease at a much greater rate than men. Women are encouraged to work closely with their healthcare provider to develop and follow an appropriate treatment plan.
  
  
• Dieting. Women are strongly urged to choose a heart-healthy diet over unhealthy dieting strategies such as “yo-yo dieting” (alternately losing and gaining weight). Yo-yo dieting has been shown to actually increase weight over time. A heart-healthy diet means low fat, low cholesterol, low carbohydrates and small portion sizes. Aim for 1,200 calories or less daily, and remember that no more than 30 percent of daily calories should be from fat, according to the AHA. Overall, the AHA recommends that women strive for a body mass index (BMI) between 18.5 and 24.9 and a waist circumference of less than 35 inches. As with men, abdominal obesity is a particularly powerful risk factor for heart disease.
  
  
• Exercise. Research has found that women who exercise regularly have a higher chance of living longer and in better health. Women who have been physically active throughout life develop fewer physical disabilities as they age than inactive women. Women who exercise tend to have less heart disease and breast cancer. Aim for 10,000 steps (five miles) a day; buy a pedometer to count your steps.
  
  
• Heart attack. Immediately after menopause, heart attack risk among women begins to rise until it equals men's risk. Women are more likely to die after a heart attack, more likely to become disabled, more likely to have another heart attack and more likely to develop heart failure. Women are also more likely than men to have atypical, non-chest-related symptoms of heart attack. The only way to know if chest-related symptoms are due to a heart attack is to go to the emergency room and get an electrocardiogram and a blood test called cardiac troponin or creatine phosphokinase (CPK-MB). Do not leave the emergency room without them. According to the NHLBI, the typical heart attack victim now is an elderly woman of color.
  
  

• High blood pressure. Although high blood pressure is somewhat less predictive of heart disease in women than in men, it remains an important and controllable risk factor. Studies have shown that up to 80 percent of women over age 70 have elevated blood pressure. High blood pressure among women should be treated similarly to high blood pressure in men.

• Medical treatment. Some research has suggested that, for the same diseases, women often receive different medical treatment than men. For example, women are less likely to be referred for life-saving treatments and cardiac rehabilitation after a heart attack than men are. Immediately upon the diagnosis of a heart attack, all patients should be considered candidates for appropriate therapy, such as clot-busting drugs, balloon angioplasty with stent implantation, aspirin, beta blockers, ACE inhibitors and cholesterol-reducing drugs (e.g., statins).
  
  
• Menopause. Women’s risk of heart disease and stroke increases significantly after menopause until it becomes equal to that of men. Originally, researchers assumed this was because of the protective effects of estrogen, and physicians regularly prescribed hormone replacement therapy for the prevention of heart disease in post-menopausal women. However, results from the Women’s Health Initiative and similar studies have shown that hormone replacement therapy does not reduce – and appears to increase – the risk of blood clots and stroke. Although hormone replacement therapy is still prescribed for relief of the symptoms of menopause, it is no longer prescribed for the primary prevention of heart disease. The exact association between menopause and heart disease is still being studied. Women should discuss with their physician alternate ways (e.g., heart healthy diet, vitamins and minerals) to reduce their cardiac risks.
  
  
• Smoking. Female smokers are at significantly greater risk of having a heart attack and stroke than women who do not smoke. Furthermore, female smokers face very high risks of developing respiratory diseases that have no cure (e.g., chronic obstructive pulmonary disease), lung cancer and other smoking related diseases. In fact, lung cancer claims more female lives than breast cancer does.
  
  
• Stroke. Stroke affects over 3 million women every year in the United States – accounting for more deaths among women than men. In 2003, women accounted for more than 60 percent of stroke deaths. Strokes also tend to affect women at a much younger age than men, often striking women in their 40s or 50s. Among elderly women, it is a leading cause of both mental and physical disability.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about women and cardiovascular disease:

1. Am I at increased risk for developing cardiovascular disease because I am a woman?
   
   
2. Are there any lifestyle changes I can make that could reduce my risk of developing cardiovascular disease?
   
   
3. Are there any medications I can take that can reduce my chances of developing cardiovascular disease?
   
   
4. What side effects, if any, are associated with the use of these medications?
   
   
5. What symptoms do I need to be aware of if I want to spot cardiovascular disease early?
   
   
6. Do I have any underlying conditions that increase my chances of developing cardiovascular disease?
   
   
7. What steps can I take to lower my risk of developing cardiovascular disease?
   
   
8. Should I take aspirin to lower my chances of having a cardiovascular problem?
   
   
9. Can pregnancy affect my chances of developing cardiovascular disease?
   
   
10. Can hormone replacement therapy increase my risk of developing cardiovascular disease?