His and hers heart disease, Part 2

Women and men share most risk factors for heart disease — including high cholesterol, inactivity, obesity, high blood pressure, and smoking — but there are some gender differences in its development, symptoms, and prognosis.

Men and women who want to live a heart-healthy life together can devise a single diet and exercise program that will suit them both. But their paths diverge at pill time and cocktail hour.

Aspirin. Baby aspirin should have a place on a man's medicine shelf 10 years before a woman's. Men at risk for heart attack are advised to take a low-dose aspirin daily starting at age 45, but women are told to hold off until they're 55, and then to take it for the purpose of preventing strokes. For both genders, the protective effects of aspirin have to be weighed against the gastrointestinal risks.

Alcohol. While two drinks a day may keep a man's cardiologist away, they may hasten a woman's journey to the ER. Women are limited to a single drink because their bodies hang on to alcohol longer: lower levels of the liver enzymes that break down alcohol keep concentrations in a woman's blood higher for longer periods. As a result, alcohol abuse has more serious effects on women's hearts than on men's, as evidenced by studies of patients with alcoholic cardiomyopathy — a weakening of the heart muscle.

Differences in symptoms

When the coronary arteries are obstructed or constricted so that the heart muscle isn't receiving the oxygen it needs to do its work, the body feels the results. Both men and women may experience angina, the classic sign of coronary artery disease characterized by chest pain, a cold sweat, nausea, and other symptoms.

But women are more likely than men to have less dramatic symptoms, such as general fatigue and a flulike malaise. And variant angina — also known as Prinzmetal's angina —  which results from coronary artery spasm and is likely to strike in the wee hours during deep sleep, is more common in women than in men. 

Differences in diagnosis

When someone shows up at a medical facility with cardiac symptoms, a number of tests can be used to determine the source, beginning with resting electrocardiography (ECG), followed by stress testing, in which a person walks on a treadmill while being monitored by ECG.

However, ECG stress tests are more likely to miss cardiovascular disease in women than in men. Nuclear stress tests, in which an image indicating blood flow to the heart is made before and immediately after exercise, cost more, but they're more reliable than ECGs in women.

Coronary angiography — an X-ray that outlines blockages in coronary arteries — is considered the gold standard for identifying the location of blockages in people with positive stress tests. But all that glitters isn't gold for women. Because they're less likely than men to have discrete, bulging lesions and more likely to experience microvascular disease, their angiograms may show no obstructions. Women may need two additional tests, which can be performed during angiography:

• Intravascular ultrasound (IVUS) involves threading a tiny transducer into a coronary artery to capture a cross-sectional image of the artery walls. It can find arteries that have been narrowed more uniformly by atherosclerotic plaque.
• Coronary flow reserve studies, in which a catheter measures the change in coronary blood flow in response to increased demand, can indicate whether the microscopic vessels in the heart wall are delivering an adequate blood supply.

Differences in treatment

For women who have uniformly narrowed coronary arteries or microvascular disease, lifestyle changes and medications are the only treatment options. For women and men with obstructive coronary lesions, angioplasty with stenting and coronary bypass surgery are equally likely to succeed in opening their arteries, but women are less likely than men to be offered these procedures.

When women do have bypass surgery or get angioplasty, they tend to be a decade older than men undergoing similar procedures. Perhaps as a result, they require longer hospital stays, have higher death rates in the weeks following the procedure, and are less likely to be referred to coronary rehabilitation centers.

The bottom line

Heart disease is still the No. 1 killer of us all, although death rates have declined by 25% since the late 1990s. Heart disease has become less deadly for a variety of reasons:

• better control of risk factors like cholesterol and blood pressure
• faster diagnosis,
• improvements in emergency care
• advances in medications and procedures

If there's a message for men, it's that it's all there for the taking. Diagnostic and therapeutic protocols are made for you. Whether you've had a heart attack or are trying to prevent one, your greatest challenge is to adhere to a healthful diet, exercise often, have regular check-ups, and take your medication as prescribed.

The message for women: A healthy lifestyle is key, especially if you have an inflammatory disorder or an expanding waistline. If you're depressed, get help. And if you feel unusually tired, achy, or short of breath, don't write it off as nothing — or blame it on aging. Check with your doctor to make sure it isn't heart disease. If you're diagnosed with heart disease, you may have to be a little more aggressive in getting the care you need. Seek out one of the women's heart centers that are springing up in hospitals across the nation.

Read "His and hers heart disease, Part 1"