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As founder and director of Columbia's Center for Women's Health, Dr. Giardina believes that even with increased media attention, myths and misunderstandings still persist about women and heart disease. Here, Dr. Giardina talks about why it is so important to continue to be vigilant about spreading the word.

Cardiovascular disease is the leading cause of death among American women. It is more lethal in women than men and less aggressively treated in women. Moreover, the profound effects of reducing mortality in heart disease over the past 30 years have had little impact on women.

I find it troubling that few women understand cardiac risk or the benefits of improving lifestyle as a way of reducing heart disease. Sadly, more than half of American women are unaware that the nation's No. 1 killer of women is cardiovascular disease and stroke. Although we have made great strides in correcting the information gap compared with a decade ago, we still have a long way to go. I believe education and motivation to modify risky heart-healthy behavior will be key to improving morbidity and mortality from heart disease and stroke in the United States.

What accounts for the misperceptions about women and heart disease? The discordance between the perception and reality of heart disease for women is complex. One concern is the myth that heart disease is primarily a man's disease. According to the 2001 U.S. vital statistics, this is hardly the case: 361,000 women died of heart disease that year compared with 339,000 men. Stroke accounted for more deaths among women - 100,000 compared with 63,000 among men. Still, women most fear they will die from cancer, particularly breast cancer, and I have heard female patients say they would rather die from heart disease than cancer. The reality is that as the baby boom generation matures - 57 million women will be over the age of 65 by 2010 and 61 million by 2020 - the preference for heart disease over cancer will win out.

"The real goal should be to prevent a heart attack from ever occurring. The way to do this is by recognizing the multifactorial risk factors that contribute to heart disease and stroke."

Another contributing factor relates to the fact that the majority of women, but not all, diagnosed with heart disease tend to be 65 years old or older. Very troubling, however, is that following a myocardial infarction, women under age 50 are twice as likely to die compared with their male counterparts.

Additionally, there is concern that some women presenting with a heart attack are simply not aware of symptoms or do not have the classical complaints, such as chest pain. Rather, they may present with vague and nonspecific symptoms such as shortness of breath, nausea, fatigue, or left-arm pain. Physicians and patients need to be aware of the unique presentation for some women to make the most appropriate diagnosis and proceed in a timely fashion with the correct treatment interventions.

The real goal should be to prevent a heart attack from ever occurring. The way to do this is by recognizing the multifactorial risk factors that contribute to heart disease and stroke. Typically they include family history (a father who died from a heart attack before age 55 or a mother before age 65); smoking; hyperlipidemia; hypertension; and diabetes. More and more, we have come to recognize that obesity and physical inactivity play roles as well. Knowledge alone, however, does not transform risk factors. Almost 65 percent of patients with elevated LDL cholesterol (the bad cholesterol) do not meet the recommended values, even though they may be taking medications and are being followed by a physician.

At our Center for Women's Health, my colleague, Dr. Julia Cassetta, instructor in clinical medicine, conducted a survey among more than 200 healthy patients and found that education was the most significant predictor of total physical activity. Even though more than 75 percent of the subjects had a college education, only 53 percent met the Surgeon General's goal of 20 to 30 minutes of activity most days of the week. The disappointing level of physical activity, even among educated women with access to health care, underscores the need to target age-appropriate exercise programs toward all women and to close the gap between better and poorer educated women. All patients must maintain an interactive dialog with physicians to recognize problems and find ways to reduce risk.

Robust evidence indicates that disease prevention works. Randomized trials provide strong support for the use of beta-blockers and aspirin to prevent coronary events and ischemic stroke in women with coronary disease or a history of ischemic stroke or transient ischemia attack. The Heart Outcomes Prevention Evaluation trial showed that the angiotensin converting enzyme inhibitor, ramipril, prevents coronary events in women at high risk. Randomized trials show that blood pressure control prevents stroke and coronary heart disease in women with hypertension.

Aspirin use has a favorable risk: benefit ratio for primary prevention in high-risk women, but the evidence for it in low-risk women is not nearly so clear. A new study, designed to look at benefits of aspirin as well as vitamin E, an antioxidant, for primary prevention has just been completed and we await the results. However, there is already evidence that antioxidant supplements do not appear to be effective. Randomized trials support screening treatment of dyslipidemia to prevent first events in women with average serum cholesterol levels, and some lipid lowering drugs may prevent stroke.

We had enormous hope that hormonal replacement therapy might be a panacea for women at risk for heart disease. The Women's Health Initiative established by the NIH in 1991 focused on strategies for preventing heart disease, stroke, breast cancer, and osteoporosis in a study comparing placebo with conjugated equine estrogen and progesterone. This large trial of 16,608 healthy postmenopausal women (50-79 years) scheduled to run until 2005 (planned duration, 8.5 years), was stopped after an average follow-up of 5.2 years. The decision to stop the trial was based on the finding of 26 percent increased breast cancer risk, 29 percent increased heart attack risk and 41 percent increased stroke risk. We are now acutely aware that hormonal replacement therapy is not a suitable option for preventing heart disease in postmenopausal women and may increase risk.

Several organizations that we work with are making huge efforts to get the word out. Sister to Sister, a national advocacy group led by Irene Pollin, a member of the Advisory Committee of the Center for Women's Health; the American Heart Association through its Red Dress campaign; and our own Affairs of the Heart at Columbia's Heart Institute are all grounded in the common goal to boost education and advocate for preventive screenings.

We must all do our part to decrease the No. 1 killer of women. We can set individual goals to realize our own risks - smoking; hyperlipidemia; hypertension; diabetes; overweight; physical inactivity - and recognize and respond to risk reduction by modifying behavior and/or using medications. Throughout the ages, women have lived longer than men. These days, however, the goal is not only to live long, but also to live well and free of chronic disease.

Dr. Giardina is professor of clinical medicine at P&S and director of the Center for Women's Health. To find out more about heart disease in women, visit http://ci.columbia.edu/1181.


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