Until recently, cardiovascular disease was considered a “man’s disease.” Virtually all major studies on heart disease and stroke recruited men as participants and reported their findings based on disease in men. Unfortunately, heart disease recommendations were made in both men and women based on this limited information. As a result, heart disease and stroke was going undiagnosed in women and, when it was diagnosed, was ineffectively treated. Evidence began to emerge that showed that cardiovascular disease is not the same in men and women. Studies were coming to light that women were developing heart disease and stroke in alarming numbers. Fortunately, over the past decade a groundswell of new research and insights about cardiovascular disease in women has appeared. Public health campaigns began to raise awareness about these devastating diseases in women and research initiatives were funded by the National Institutes of Health, the World Health Organization and other international groups to study the scope of the problem and how best to meet the needs of women throughout the world.

Despite making great strides in public awareness and health care initiatives, heart disease and stroke remains the number one killer of women worldwide. According to the World Health Organization cardiovascular disease is the cause of death for one third of all women on the planet (1)—a staggering statement. In the United States alone more than 40 million women have diseases of the heart and blood vessels and one in three American women that die this year will do so from heart disease and stroke (2). Sadly, many physicians still do not realize that more women than men die of cardiovascular disease each year (3). Worst of all, the majority of these cases can be detected and treated early thus saving the lives of countless American women. Blood tests, CT, and ultrasound studies can mean the difference between effective treatments and a silent disease that strikes with devastating consequences.

What is a Heart Attack?

All living tissues in the body need oxygen and nutrients in order to survive. They also need to get rid of carbon dioxide and waste products in a timely fashion. The substance that provides all of these services is blood. The blood vessels take blood to and from every organ and tissue in the body. Even though all blood that circulates through the body moves through the heart at some time, blood moving through the chambers of the heart is only there to get pumped along, to either the body or the lungs. Blood moving through the chambers of the heart does not deliver any nutrients nor does not remove any wastes. In order for the heart to get the oxygen and nutrients that it needs, the heart has its own blood supply. Several small arteries extend to various areas around the outside of the heart. These relatively tiny coronary arteries supply all the blood that active, muscular organ needs to survive and function.

A heart attack, or myocardial infarction, occurs when the coronary arteries are fully blocked in some way. When blood flow to the heart is interrupted, it can cause pain, feelings of nausea, and a sense of impending doom. What is worse, if blood flow to the heart is not restored in short order, the heart begins to die. Once an area of the heart is dead, it cannot do the primary job of the heart, which is to pump blood to the rest of the body. Thus the heart is forever weakened and lacks the squeezing power that it once enjoyed. In a massive heart attack, the heart is too destroyed to function and the sadly, the person dies.

How does a coronary artery to become blocked?

Most often it is due to coronary artery disease, a form of atherosclerosis. Atherosclerosis is a medical term that describes a particular and common disease of arteries. For years atherosclerosis has been described to patients as a “clogging of the arteries” evoking mental images of gunk collecting on the walls of a drain pipe. We now know that atherosclerosis actually damaging the artery—the gunk is actually destroying the pipe itself. Atherosclerosis is a disease in which fatty deposits invade the wall of the artery causing it to weaken and bulge. This atherosclerotic plaque bulges into the middle of the artery and can block blood flow. The atherosclerotic plaque can become so diseased and even rupture leading the body to “think” that artery needs to be clotted, much like a broken artery would need clotting if you cut your arm. When this clot forms in an area that is already bulging from atherosclerotic disease, blood flow to the heart stops completely. When blood flow to the heart stops, it is a heart attack.

What is a Stroke?

As was mentioned previously, every organ and tissue in the body needs a steady supply of blood to deliver oxygen and nutrients. The brain is no exception. All blood that the brain receives from the heart comes through four (yes, only four) blood vessels: two carotid arteries and two vertebral arteries. If you have ever felt your pulse in your neck, you have felt the carotid artery pumping blood to the brain. These four arteries split over and over again to supply the entire brain with life-sustaining blood.

Stroke, or brain attack, is caused when blood flow is suddenly interrupted to a part of the brain. When the brain is deprived of blood it becomes damaged and begins to die. As the brain dies, it can lead to various neurological symptoms depending on which area of the brain is without blood. Some of the more common symptoms are slurred speech, numbness, and difficulties moving, but many different symptoms are possible. If the blockage is cleared within the first few hours of a stroke, all stroke symptoms will disappear as blood flow returns to those regions of brain. If this occurs the stroke is referred to as a transient ischemic attack or TIA. If the blood flow is not restored in a reasonable amount of time, say four to six hours, the stroke symptoms can become permanent.

How does a stroke occur?

Atherosclerosis can damage blood vessels in the brain just as it does in the heart. Ruptured atherosclerotic plaques in the arteries of the brain attract platelets and clotting factors. If enough debris collects in the artery, it can interrupt blood flow and cause a stroke. This form of ischemic stroke does occur and can cause significant neurological damage.

More commonly, stroke is caused from bits of clotted blood and other materials lodge in the blood vessels of the brain. Remember that four blood vessels supply the entire brain and that each of the main arteries splits into smaller and smaller branches, like the branches of a tree. If a blood clot travels through these increasingly narrow blood vessels without dissolving, at some point it will lodge in an artery and block blood flow. When this occurs, the area of brain that is normally supplied blood by that artery is starved of blood. This area begins to die and neurological symptoms appear.

The scope of the problem

Cardiovascular diseases, such as heart attack and stroke, kill 500,000 women in the U.S. each year (4). That is the equivalent of seven jet airliners crashing every day.

Cardiovascular disease is by far the number one cause of death in women worldwide (1) and in the United States (4).

In the United States alone, 40 million women are living with cardiovascular disease every day (5).

If all forms of major cardiovascular disease were eliminated, human life expectancy would increase by seven years. By comparison, eliminating all cancer would only add three years (4).

On average in the United States, someone has a heart attack every 25 seconds, and dies of a heart attack every minute (4).

On average in the United States, someone has a stroke every 40 seconds, and dies of a stroke every three to four minutes (4).

Women accounted for over 60 percent of U.S. stroke deaths in 2004 (4).

While one in 25 women will die of breast cancer, one in three will die of heart disease and stroke (4).

One in two women will develop cardiovascular disease in their lifetime (5).

Heart attack and stroke is preventable with early diagnosis and treatment!

The high risk of death and disability can be avoided if women get routine testing for cardiovascular diseases. This means at least yearly appointments to a physician for physical exams.

Unfortunately, since heart disease and stroke are still considered by some to be “men’s diseases,” the disease is under diagnosed in women (6). Also, women tend to receive less aggressive coronary artery disease treatment than men (7). Until cardiovascular disease is detected and treated in women as it should be, women must take it upon themselves to get educated about heart disease and stroke and become advocate in their own cardiovascular health. This starts by understanding the illness and how it is both similar to and unique from cardiovascular disease in men.

Risk factors in women

In many ways the risk factors for women are the same as they are in men—but not always. If women can avoid cardiovascular risk factors until menopause, they are at significantly less risk of heart disease and stroke and live much longer than women who do not (8). As of 2006, guidelines recommend that women be screened and placed into one of three levels of risk for cardiovascular disease: High Risk, At Risk, and Optimal Risk.

A woman is considered High Risk if she has or has had any one of the following:

• Disease involving the blood vessels of the heart, brain, or periphery (like arms and legs)
• Chronic kidney disease
• Diabetes mellitus (sugar diabetes)

A woman is considered At Risk if she has or continues to do any one of the following:

• Smokes cigarettes
• Eats a poor diet (high saturated fats, low fiber, excess simple sugars, etc.)
• Is physically inactive
• Is obese, especially around the midsection
• Has a family history of cardiovascular disease
• Has poor exercise tolerance (meaning that she cannot perform modest exercise)
• Has high blood pressure
• Has abnormal blood cholesterol
• Has evidence of blood vessel disease such as increased carotid intima thickness or coronary artery calcification

Women with none of the above risk factors or risk behaviors are considered at Optimal Risk which means that their risk for cardiovascular disease is quite low.

What are your risk factors?

If you have had a heart attack and stroke and recovered, your doctor should have you on several therapies in order to prevent another cardiovascular event. Proper management in cases like this includes a daily aspirin, cholesterol medications, implementation of proper diet and exercise, as well as controlling all of the other risk factors that have led to heart attack or stroke. Peripheral vascular disease, diabetes and chronic kidney disease are risk factors that are just as important as having had a heart attack or stroke.

Peripheral vascular disease or peripheral artery disease is caused when the arteries that supply the arms and especially legs become diseased. The atherosclerotic disease that occurs in these arteries are similar to the disease that occurs in the arteries around the heart. People with peripheral artery disease often find that walking causes their legs to ache, a phenomenon known as claudication. Sure, people’s legs can ache if they have arthritis or strain muscles, but claudication is different. This particular type of pain gets worse with walking but then recovers with brief rest. Other forms of pain usually do not do that. If you suspect that you are experiencing claudication, your physician can determine whether you have peripheral artery disease.

Diabetes mellitus, or sugar diabetes, is an important risk factor in heart attack and stroke, especially in women. Women with diabetes have significantly higher mortality (death) rates from cardiovascular disease than men with diabetes (9). If you have diabetes, controlling your blood sugar is vital to minimizing the risk of heart attack and stroke. Your doctor should work with you to come up with strategies to keep your blood sugar under control. These may involve anything from diet and exercise to pills or injections.

Chronic kidney disease is more difficult to treat in many cases. If you do have chronic kidney disease or renal failure, the need to improve the risk factors that you can control becomes that much more important.

Modifiable risk factors

Seventy percent of deaths from cardiovascular disease arise from modifiable risk factors (10). That means that seven out of ten cardiovascular deaths could have been avoided with accurate diagnosis and treatment. As you probably noticed, many of the things that place women At Risk are completely within the women’s control.

Smoking cigarettes doubles a woman’s risk of stroke and increases the risk of dying from heart disease by two to three times (4). In general, the more cigarettes that you smoke, the higher the risk of death from cardiovascular disease. Many people think that they cannot quit smoking, others have tried and failed and still others do not even want to quit. If you are trying to quit, good for you! Ask your doctor about the many avenues to smoking cessation. Freedom from cigarettes can come from pills or patches, behavioral therapy to stopping cold. There are always people ready to help you quit. If you are not trying to quit smoking, why not? It cannot be because of your health.

Think your diet is heart healthy? There are many resources that you can use to plan healthy meals that are low in saturated fats, devoid of trans fats, and high in fiber, lean protein, and complex carbohydrates. Not every diet is right for every person, so ask your doctor.

Almost everyone can exercise and everybody needs to exercise in order to stay healthy. Exercise means different things to different people but the kind of exercise that is healthy for your heart and brain is the kind that gets your blood pumping and your heart moving. Your doctor can help you chart a course to physical fitness. Start slow and do not exert yourself too much on the first day. You do not want to burn out before you develop a routine. Find a type of exercise that you enjoy and that you can stick with three to five days a week. Exercise is a necessary part of life and you may be surprised how little you need to get in order to protect your heart and brain.

Testing for the presence of risk factors

By now you have realized that when that cuff slides around your arm and inflates, the doctor is checking your blood pressure. The risk of cardiovascular disease increases as blood pressure increases; the higher the pressure, the higher the risk. Blood pressure is just one of the ways the physicians check to see if your blood vessels are healthy.

If you have been to the physician’s office as an adult, you have no doubt had your cholesterol checked. Why does your doctor care? Well she knows that when blood cholesterol levels are abnormal, the risk of a heart attack and stroke goes up considerably. Certain types of cholesterol need to be kept low, like LDL and triglycerides, while others need to be kept high, like HDL. If you have abnormal cholesterol, a disorder known as dyslipidemia, your doctor will help you take steps to correct it.

Unfortunately, checking blood pressure and cholesterol is not enough—people with normal blood pressure and cholesterol still have heart attacks and strokes. Therefore, doctors also perform other tests to see how the blood vessels are doing. Unfortunately many of these are very invasive such as a cardiac catheterization or an arteriogram. These tests involve placing a needle and probe into the artery in the leg and guiding in to the heart or other blood vessel of interest. These tests are very accurate but they require anesthesia, sedation, and a certain period of recovery.

Noninvasive tests of arterial disease

Fortunately there are two tests that are non-invasive but give physicians an excellent idea of cardiovascular health. The first is a specialized CT scan and the other uses ultrasound technology, the same technology used to view fetuses in the womb.

Where there is atherosclerosis, there is calcium. As blood vessels are injured by the development of atherosclerotic plaques, they accumulate calcium within them. This is bad for blood vessels but good for radiologists trying to diagnose disease. The calcium shows up on a CT scan, much like the calcium in bone shows up on an X-ray. Newer CT scanners like spiral or helical CTs are allowing the heart to be seen in incredible detail. By measuring the calcium in the coronary arteries, the radiologist can deduce a calcium score, the higher the score, the greater the risk for coronary artery disease and heart attack. Unfortunately the technique does involve the use of radiation, which some people would rather not have.

Just as there is calcium in plaques, atherosclerosis also causes other characteristic changes in the arteries of the body. You will recall that atherosclerosis is actually a disease in the wall of the artery rather than simply a “clogging of the pipes.” As atherosclerosis gets worse, it invades part of the wall of the blood vessel. The blood vessel wall that it invades is between the intima and media (Figure). The intima is what touches the blood in the wall of the artery and the media makes up the muscles within the artery wall. As atherosclerosis advances, the space between the intima and media gets bigger.

Diagram by Stijn A.I. Ghesquiere; Maastricht, November 2005.

One of the newest and most patient friendly techniques to detect disease of the arteries uses the same gentle energy that is used to see babies before they are born: ultrasound. By using inaudible sound waves, doctors can look at the carotid artery in vivid detail. By measuring the thickness of the various layers of the carotid artery, physicians have a completely noninvasive tool for identifying cardiovascular disease without the use of radiation. It turns out that this thickness is an important clue to cardiovascular disease. Researchers reported in the New England Journal of Medicine that “increases in the thickness of the intima and media of the carotid artery, as measured noninvasively by ultrasonography, are directly associated with an increased risk of myocardial infarction and stroke in adults without a history of cardiovascular disease (11).” Doctors around the world have found this same link (12). This means that using ultrasound to measure the intima-media thickness of the carotid artery (CIMT) can be used to diagnose heart disease and stroke in people that have no other signs of the disease.

Moreover, when CIMT is combined with ultrasound evaluation of arteries in the leg, the measurement of a woman’s cardiovascular risk becomes even more precise. This new test, called the CIPA scan, will not only detect cardiovascular disease in its early stages, but it can give a measurement of a woman’s “vascular age.” When compared to her true age, the vascular age gives a woman a sense of how healthy her blood vessels really are.

The CIPA scan is a very powerful tool for detecting the presence of heart disease and stroke. The CIPA scan can detect disease that may not yet be present in blood tests. When you consider that the CIPA scan is fast (less than an hour), does not use any radiation, and is completely painless this test is destined to become one of the central weapons in the fight against cardiovascular disease in women.

Works Cited

1. The World Health Report 2004. World Health Organization. Geneva : s.n., 2004.

2. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. American Heart Association Expert Panel/Writing Group. 11, 2007, Circulation, Vol. 155, pp. 1481-1501.

3. National study of physician awareness and adherence to cardiovascular disease prevention guidelines in the United States. Mosca L, Linfante AH, Benjamin EJ, et al. 2005, Circulation, Vol. 111, pp. 499 –510.

4. Heart Disease and Stroke Statistics – 2009 Update. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. 3, 2009, Circulation, Vol. 199, pp. 480-6.

5. Heart disease and stroke statistics—2006 update. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. 2006, Circulation, Vol. 113, pp. e85–e151.

6. Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon. Weisz D, Gusmano MK, Rodwin VG. 1, 2004, Gend Med, Vol. 1, pp. 29-40.

7. Gender differences in the presentation and management of acute coronary syndromes: a national sample of 1365 admissions. Doyle F, De La Harpe D, McGee H, et al. 4, 2005, Eur J Cardiovasc Prev Rehabil, Vol. 12, pp. 376-9.

8. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, et al. 6, 2006, Circulation, Vol. 113, pp. 791-8.

9. A comprehensive view of sex-specific issues related to cardiovascular disease. Pilote, L, Dasgupta, K, Guru, V, et al. 6, 2007, CMAJ, Vol. 176, pp. S1-S44.

10. The burden and costs of chronic diseases in low-income and middle-income countries. Abegunde DO, Mathers CD, Adam T, et al. 9603, 2007, Lancet , Vol. 370 , pp. 1929-38.

11. Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group. O’Leary, DH, et al. 1, 1999, N Engl J Med, Vol. 340, pp. 14-22.

12. Intima media thickness as a surrogate marker for generalised atherosclerosis. Bots, ML and Grobbee, DE. 2002, Cardiovasc Drugs Ther, Vol. 16, pp. 341-51.