The Biggest Killer of Women: Heart Attack

By LEON JAROFF

AWAKING EARLY ONE MORNING WITH A tight, nauseated feeling, Catherine McCamey, a retired Washington postal clerk, took two antacid tablets and tried to fall back asleep. But when the tightness in her chest turned to pain, she took a cab to the hospital. There doctors told her that she had suffered a heart attack and that four of her coronary arteries were blocked, and she had to undergo bypass surgery. Two years later McCamey, now 64, remembers her bewilderment over the incident. "I was really shocked," she says. "I thought it was mostly men who suffered heart attacks."

Hardly anyone associates coronary artery disease with women. Mention the words heart attack, and people are likely to conjure up visions of a middle- aged, slightly paunchy male suddenly keeling over at his desk. The statistics tell a different, startling story:

-- About 1 million Americans, nearly half of them women, have cardiovascular disease. Of the approximately half a million fatal heart attacks in the U.S. every year, 247,000 occur in women.

-- Heart attacks are the leading killer of women, claiming six times the number of lives lost to breast cancer.

-- Women who have a heart attack are twice as likely as men to die within the following few weeks.

The widespread misconception that cardiovascular disease is essentially a man's problem stems largely from the fact that heart attacks are rare among pre-menopausal females. Of the quarter of a million fatal heart attacks suffered annually among women, only 6,000 occur in those under the age of 65. Coronary heart disease in women "doesn't take off until menopause," says Dr. Mary-Ann Malloy, a cardiologist at Loyola University Medical Center in Chicago, "and in the past a woman's life expectancy didn't extend much longer than that."

What puts women at risk after menopause? The leading theory holds that they lose their protection against heart attacks because of a drastic reduction in the female hormone estrogen. That might result in the rapid buildup of plaque on artery walls where, until menopause, very little existed. "When estrogen levels drop, you've just lost your best friend," says Dr. William Castelli, director of the long-running Framingham Heart Study.

That point was driven home dramatically to Cindy Nelson, a Texas bookkeeper. At age 29 she had a total hysterectomy, which prematurely deprived her of estrogen. Ten years later, she suffered two heart attacks within a month. Says she: "I never thought it would happen to me at 39."

Neither did emergency room doctors, who initially diagnosed Nelson's problem as bronchitis. Women heart patients charge that doctors often fail to respond with the same alacrity to their cardiac symptoms as to those of male patients. Dr. Peter Jones of Baylor College of Medicine in Houston, agrees. "If a young woman under 60 came into an emergency room with chest pains," he says, "she would not be taken seriously as a heart attack patient." Loyola's Malloy suggests that women must be more assertive about their heart concerns. "If you have unexplained chest pains," she says, "start with a good internist or cardiologist and pursue it until you're satisfied."

That pursuit proved frustrating to Phoenix author Mantosh Singh, whose personal experience with heart disease inspired her soon-to-be published book, Strong Women, Weak Hearts. "If we are premenopausal," she writes, "we are not expected to have coronary artery disease, and our diagnosis and treatment is neglected. If we are post-menopausal, we are suffering from the 'empty nest syndrome' and need an affliction to fill our emptiness. In either case, our illnesses are supposed to be mostly psychosomatic: of the mind, rather than physical."

Such charges dismay Dr. Elsa-Grace Giardina, a cardiologist at Columbia- Presbyterian Medical Center. "I would like to think that we treat everybody equally," she says. But her survey of medical literature tells her otherwise. "Women don't get thrombolytic therapy (blood-clot dissolvers like streptokinase) as often as men, they don't get coronary angiography or angioplasty, and they don't get bypass surgery as often as men."

Some of the reluctance to administer these procedures involves age; women heart patients are generally much older than their male counterparts. "She has it when she is 65," says Giardina. "He has it when he's 40. She has more diabetes, more hypertension, and she's probably taking more drugs. She's not as clean a picture as the 40-year-old man."

These factors often give cardiologists pause. Should they intervene aggressively when the risks are greater? Bypass surgery, for example, is twice as likely to cause death in women as in men. But "with the 40-year-old man," says Giardina, "there is no question. Gotta do it."

She also senses biases related to worth: "A 60-year-old man is president of IBM; a woman of 60 is not. A 60-year-old man may want to go back to full-time work, and many 60-year-old women are not considered as important in life."

Aggravating the problem is the fact that most major studies of cardiovascular disease have largely excluded female subjects. As a result, Loyola's Malloy complains, there are "loads of data on men and none on women. That only increased the impression that this was a man's disease." It also resulted in therapies and procedures appropriate for men but not necessarily beneficial to women. A landmark study showed, for instance, that a small daily dose of aspirin helps prevent heart attacks in men, but no one knows if the same is true for women.

Other problems abound. When electrocardiograms (EKGs) are used to test for heart disease, women more often show some abnormalities. Consequently, many doctors are apt to ignore a slight irregularity in women's EKGs, explains Dr. Gerald Pohost, "unless it is crystal clear the woman has heart disease." Pohost, director of the division of cardiovascular disease at the University of Alabama Medical Center, thinks that the high rate of EKG errors may result partly from the placement of electrodes on a woman's chest -- more difficult to do because of the female anatomy.

Female breasts, he says, may also influence irregularities on thallium stress tests; simply put, the breast tissue gets in the way of the imaging technique. Doctors at Beth Israel Medical Center in New York City have apparently circumvented that problem by using the PET (positron-emission tomography) scan, which they say is highly accurate in detecting even minor heart damage in women.

At director Dr. Bernadine Healy's instigation, the NATIONAL INSTITUTES OF HEALTH is preparing to launch the Women's Health Initiative, a $500 million, 14-year study of 140,000 postmenopausal women. The study will explore the effects of diet, smoking and other factors on women's risk of developing heart disease, stroke, osteoporosis, and breast and colon cancers. The study will also evaluate the effects of hormone replacement therapy: providing women with supplemental estrogen or with estrogen plus progestin after menopause.

Some studies have already suggested that these supplements reduce the risk of heart disease by as much as 30% to 50%, but cardiologists and their patients sometimes shy away from them; larger doses, like those used in early birth-control pills, are known to increase the risk of endometrial and breast cancer. Still, many doctors, considering the even greater risk of coronary- artery disease in the absence of estrogen, now endorse the supplementary therapy. One strong advocate is Framingham's Castelli, who calls the evidence of its efficacy in protecting against both heart disease and osteoporosis "overwhelming."

For all the hubbub about estrogen, its workings are still somewhat mysterious. "We attribute the rise in heart disease to menopause, in which the estrogen supply is diminished," says Columbia's Giardina. "Yet we really don't know how estrogen works." The hormone is known to promote higher levels of HDL, the "good cholesterol" that helps keep arteries clear. Yet estrogen increases HDL by only 10% or 15%, and Giardina suspects that is not enough to account for the dramatic difference in heart disease rates between men and premenopausal women.

Part of the answer may lie in a report published two months ago in Circulation, an American Heart Association journal. In a study of some 1,900 men ages 42 to 60, Finnish researchers determined that the risk of heart attack was greater among men with high blood levels of iron than in those with lower readings. For each 1% increase in the amount of ferritin (a protein that binds iron), the risk of heart attack increased by 4%. The reason, many doctors suspect, is that iron may interact with LDL, "the bad cholesterol," in a way that promotes the formation of plaque on arterial walls.

Healy finds the Finnish study "very provocative." It suggests that at least part of estrogen's protection is indirect: by triggering the monthly menstrual flow, which carries away iron, it reduces levels of the metal in the bloodstream and lessens the threat of heart attack. When periods cease after menopause, the reasoning goes, iron begins to accumulate and the risk rises.

Besides taking estrogen supplements, "women themselves can do a lot to reduce their risk of heart disease," says Dr. Millicent Higgins, associate director of epidemiology and biometry at the National Heart, Lung and Blood Institute. She recommends that women have their blood pressure checked and treated if it is found to be high, eat diets low in fat, exercise, lose excess weight and stop smoking. But most important of all, she says, is that "women need to be aware that they can have heart attacks."

CHART: NOT AVAILABLE

CREDIT: [TMFONT 1 d #666666 d {Source: American Heart Association, based on the Framingham Heart Study}]CAPTION: RISING RISK

Heart attacks in the U.S. in thousands*

CHART: NOT AVAILABLE

CREDIT: [TMFONT 1 d #666666 d {Source: National Center for Health Statistics}]CAPTION: RISING RISK

Leading causes of death*

With reporting by Lynn Emmerman/Chicago, Deborah Fowler/Houston and Dick Thompson/Washington