How to Prevent a Heart Attack

Everyone's got a heart, but it's another one of those organs that's different in men and women. Here's the best advice both of you will ever get for taking care of yours.

That men and women are different is certainly not news. One popular book even suggests that we come from different planets. But recent research suggests that it's more than plumbing and light years that separate us: Our wiring is different too; in particular; that set of wires and pumps known as the cardiovascular system. When we asked leading heart doctors to tell us how you can attack-proof your heart, they nixed a one-sex-fits-all plan in favor of this "his and hers" approach. But they also asked us to remind you of one way that we're all alike: Heart disease is the leading killer of both men and women. So share this article with the heart that's dearest to you.

No more queen of denial. One out of every three women currently under 40 will eventually develop heart disease; more than 505,000 women of all ages died from it in 1996-11 times as many as died from breast cancer. Didn't know that? You're not alone.

"In the past, many doctors didn't know that heart disease was a major cause of death in women, let alone the leading one," says Marianne J. Legato, MD, Prevention advisor and a professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York City. "Although awareness and treatment have improved somewhat, especially in large cities, the death rate from a first heart attack is twice as high in women under 50 as it is for men of the same age."

The bottom line: It's up to you to ask for more tests or seek another opinion if you feel that your doctor is dismissing your concerns, risks, or symptoms.

Think "down with cholesterol." Aim for a total cholesterol of less than 150 milligrams per deciliter (mg/dl), an LDL (bad) of 130 mg/dl or less, an HDL (good) of 45 mg/dl or higher, and triglycerides of less than 150.

"For women, a low HDL is much more predictive of heart disease than a high total cholesterol," says Debra Judelson, MD, medical director of the Women's Heart Institute at the Cardiovascular Medical Group in Los Angeles. "HDL over 60 mg/dl is a positive protector against heart disease," adds Dr. Legato. It may edge your total cholesterol up, but you're still protected against heart disease if your total cholesterol/HDL ratio is 4.0 or less.

Dr. Judelson suggests that you ask your doctor to tack on one more measurement to your regular cholesterol test: lipoprotein (a), a protein strand that's attached to bad cholesterol molecules. When researchers from the Framingham Heart Study tested these levels in more than 3,000 women, they found that participants with lipoprotein (a) above 25 mg/dl doubled their risk of heart disease.

Rate your risk.
In addition to abnormal cholesterol, you're more likely to develop heart disease if you have these risk factors:

Smoking (ups the odds at least two- to fourfold-more if you take birth control pills)
Diabetes (raises your risk four to six times)
Blood pressure higher than 135/85
Family history of early heart disease
Premature (before age 38) menopause (either naturally or through removal of the ovaries) and not taking hormone replacement therapy (HRT)
Overweight
Sedentary lifestyle

Don't settle for the treadmill test, where you simply walk on a treadmill while your blood pressure and heart's electrical activity are measured. "Although it's a good starting point for men, a treadmill test is counterproductive for women because it produces so many false positives and false negatives," says Dr. Legato.

So where do you begin? With an exercise echocardiography, also known as a stress echo test. While you're on a treadmill, a machine translates sound waves into pictures that show your heart's size, shape, movement, and pumping ability.

Redesign your diet.
A low-fat diet is appropriate for most women, but certain women with a low HDL level can actually increase their risk for heart disease from cutting back on all fats. Most women (and men) will improve their health with a Mediterranean-style diet consisting of lots of fruits and vegetables, with most of the fat coming from olive oil, canola oil, olives, avocados, and nuts. Olive oil raises good HDL and lowers your risk, says Stephen Devries, MD, director of the Heart Center at the University of Illinois in Chicago. (Prevention recommends that you limit total fat to 25% of daily calories, with no more than 7% as saturated fat.)

Because diabetes increases the risk of heart disease more for women than men, you should use whole grain carbohydrates such as whole wheat bread and brown rice rather than refined ones such as white bread and white rice, says Walter Willett, MD, chairman of the department of nutrition at the Harvard School of Public Health.

In his study of more than 64,000 nurses, Dr. Willett and his colleagues found that those who ate large amounts of refined carbohydrates doubled their chances of developing type 2 diabetes, while those who consumed mostly whole grains didn't raise their risk at all.

Deal with hormones.
Doctors think that women have heart attacks later in life than men because estrogen protects them until menopause, says Dr. Legato. But lately, doctors are being a little more careful about prescribing HRT because a large study suggested that it actually increased the risk of death in women who already had heart disease when they began treatment.

Although doctors won't have the lowdown on HRT until even bigger studies are completed in 2005, many physicians think that HRT is safe-and beneficial-if you have risk factors for heart disease but haven't developed the condition yet. Your best bet: "Discuss HRT with your doctor before meno- pause so that you'll have a plan in place once it happens," advises Dr. Judelson.

In a recent study, women cited low self-esteem as their biggest barrier to a heart-healthy lifestyle, says Lori Mosca, MD, PhD, director of preventive cardiology research and education at the University of Michigan in Ann Arbor.

And how are you going to break free? "Work on becoming more optimistic," suggests Maryann Troiani, PhD, a psychologist in Barrington, IL, and author of Spontaneous Optimism (Castlegate, 1998). "Optimism and confidence go hand in hand."

She suggests ridding your vocabulary of negative words such as "try" and "but" because they don't give you a sense of commitment to your goal. Try to talk more to cheerful people and less to unhappy ones. "We feed off of each other's emotions," she says. And walk tall rather than shuffle your feet. "If you look the part and talk the part, chances are you'll feel the part," says Dr. Troiani.

Recognize the symptoms.
"In women, the signs of a heart attack can be very different than they are in men," says Lynn Smaha, MD, president of the American Heart Association. Instead of crushing chest pain, you may have lighter chest, stomach, or abdominal pain; nausea or dizziness; shortness of breath; heart palpitations; fatigue; and weakness.

If you experience these symptoms, Dr. Judelson advises that you immediately chew a full-strength (325 mg) aspirin (it'll significantly improve your survival rate if you are indeed having a heart attack; if not, it won't hurt) and head to the ER immediately. And if the docs say that they can't find anything wrong? "Don't let them dismiss you until you've received a thorough evaluation, including an electrocardiogram," says Dr. Judelson. "I've had too many patients who were sent home with a clean bill of health from the ER who indeed had heart disease."

Stop being the king of denial. One out of every two men currently 40 and under will eventually develop heart disease; more than 450,000 men died from it in 1996-12 times more than died of prostate cancer.

"You may think that it's the other guy who will get heart disease," says Kenneth Goldberg, MD, director of the Male Health Center in Dallas. "But all my patients with heart disease thought it was going to be the other guy. At least open yourself up to the possibility that it could happen to you. And then work as hard as you can to prevent it."

Think "down with cholesterol." Shoot for a total cholesterol of less than 150 milligrams per deciliter (mg/dl), an LDL (bad) of less than 130 mg/dl, an HDL (good) of 45 mg/dl or higher, and triglycerides of less than 150.

The most important number in that equation is LDL. "In men, studies show that a high LDL increases the risk of developing heart disease more than a low HDL or high triglycerides, and treatment of LDL is most effective in reducing cardiac risk," says Debra Judelson, MD, medical director of the Women's Heart Institute at the Cardiovascular Medical Group in Los Angeles.

An abnormal cholesterol level is not the only tip-off that a heart attack may be in your future, says Stephen Devries, MD, director of the Heart Center at the University of Illinois in Chicago.

Consider these other clues:

Smoking (increases your risk at least two- to fourfold)
Diabetes (doubles your risk)
Blood pressure higher than 135/85
Family history of early heart disease
Overweight
Sedentary lifestyle

You can calculate your own cardiac risk by going to the Web site www.intmed.mcw.edu. Click on clinical calculator, then heart disease.

Take the test.
"I tell people to take charge of their health. Make sure that you are checked for risk factors and that you get the information you need to lower your individual risk," says Dr. Devries. If you have several risk factors for heart disease, your doctor might recommend a treadmill exercise test (also called a stress test) to get an even better idea of how your heart is working, he says. You simply walk on a treadmill while your blood pressure and changes in your heart's electrical activity are monitored. Based on the results of this test, your doctor may recommend other tests or encourage you to make some lifestyle (exercise and diet) changes. If your cholesterol and/or blood pressure is particularly high, he may also prescribe medication.

Trim the fat-especially the saturated kind, advises Dr. Devries. "Most men need to cut back on the fat found in a typical American diet. Meat should be considered a treat, not a part of every meal. Pasta, stir-fries, and fish should substitute for many of the meat meals. In the dairy department, try low-fat milk and cheese," says Dr. Devries.

No excuses!
When researchers at the University of Michigan in Ann Arbor asked 186 men what stood in their way of achieving a heart-healthy lifestyle, their number one answer was-you guessed it-time (Jour. of Women's Health, vol 7, no 6, 1998).

"In the short term, staying late at the office-instead of hitting the gym or making your doctor's appointment-may seem like it's the best thing to do for your career and family," says Dr. Goldberg. "But you can't climb the corporate ladder or be there for your family from a hospital bed. You need to prioritize your time by putting your health first and foremost."

Recognize the symptoms.
A third of the men who responded to a Men's Health magazine survey said that they wouldn't seek care if they experienced severe chest pain and shortness of breath. Duh!

If you're having the following symptoms, chew a full-strength (325 mg) aspirin (it'll help break up clots associated with your attack) and get to the hospital ASAP: Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest that lasts more than a few minutes or that quickly fades in and out. The pain may spread to the shoulders, neck, or arms, and it may be accompanied by lightheadedness, sweating, nausea, or shortness of breath.

"Remember: The longer you delay getting to the hospital, the more likely that the attack will be fatal," cautions Dr. Goldberg.

You Both Need This Advice
These heart-healthy strategies are like T-shirts from The Gap -- they'll work for men and women. So to give your ticker maximum protection, add these unisex approaches to your gender-specific plan.

Butt out.
Within 2 years after you quit smoking, your level of heart disease is about the same as someone who has never lit up, says Lori Mosca, MD, PhD, director of preventive cardiology research and education at the University of Michigan in Ann Arbor. Tried to quit a million times, but failed? Talk to your doctor about nicotine replacement products or the prescription drug Zyban.

Walk this way.
A Harvard University study showed that women who walked at a 3-mph or faster pace at least 3 hours a week reduced their risk of heart disease by 40%. Another study in men found that those who walked less than 1/4 mile a day had twice the heart disease risk of those who walked at least 11/2 miles a day.

Chill out.
Chronic stress may raise the level of homocysteine, an amino acid that may increase the risk of heart disease in men and women, says Catherine Stoney, PhD, a psychologist at Ohio State University in Columbus. Of course, you can't totally eliminate stress from your life, but Dr. Stoney recommends exercise and relaxation techniques such as yoga to help cope with those stresses. In addition, you can lower your homocysteine levels with at least 400 micrograms (mcg) of folic acid daily from your diet or a supplement. Good sources of this B vitamin include fortified cereals, orange juice, green leafy vegetables, and beans.

In people with heart disease, a vitamin E supplement seems to reduce the risk of death by 40 to 60%. Many doctors recommend 400 international units (IU) daily. One caveat: Be sure to check with your doctor before starting on this supplement because it may interact with some of the medications you are taking.

Four Surprising Heart-Smart Snacks
Scientists used to think of them as junk food. Now research shows that eating moderate portions of these snacks may actually help your heart when eaten as part of a healthy diet, says Penny Kris-Etherton, PhD, RD, a professor of nutrition at Penn State University in State College.

Dark chocolate. "An ounce of dark chocolate contains 10 times more antioxidants than a strawberry," says Dr. Kris-Etherton. "In addition, my preliminary research shows that a diet containing about an ounce of chocolate a day increases good cholesterol and prevents bad cholesterol from oxidizing, a process that may lead to heart disease."

Nuts. Because they're rich in healthy fats, vitamin E, and phytochemicals, eating a handful of nuts-peanuts, almonds, even cashews-more than twice a week appears to lower your risk of heart disease. Prevention's Millennium Diet (Jan 2000, p. 122) recommends 2 tablespoons of chopped nuts five times a week.

Guacamole. Dip in- avocados are a great source of heart-healthy monounsaturated fat, says Dr. Kris-Etherton.

Shrimp. Yes, it's high in cholesterol. "But the omega-3 fatty acids and other nutrients that you get from shrimp still make it a good, very low cal snack," says Dr. Kris-Etherton.

Think your doctor isn't doing all he can to help you prevent heart disease? Well, you may be right.

A survey of more than 30,000 office visits and 1,521 physicians throughout the US found that cardiologists are nearly twice as likely to offer heart disease prevention services such as cholesterol testing as general internists (Jour. of the Amer. College of Cardiology, Nov 1998).

We asked Richard Lewis, MD, professor of cardiology at Ohio State University in Columbus, when to ask your primary care physician for a referral to a heart specialist. Here are the scenarios he listed:

You have major risk factors for heart disease such as a strong family history, diabetes, abnormal cholesterol, and high blood pressure
You are experiencing symptoms of heart disease such as shortness of breath, palpitations, or chest pain
You have an existing heart problem and want a specialist to comanage your treatment
You are considering taking a cholesterol-lowering medication and want a consultation beforehand