Are Not Small Men:
by Nieca Goldberg
As a woman and a cardiologist, Ive written this book to help you improve the health of the most important muscle in your bodyyour heart. Knowing that heart disease has taken over the lives of 8 million women in the United States, I want to show you how taking care of yourself today will help you to have a stronger heart and a healthier life for years to come. You can prevent a heart attack from happening to youeven if it runs in your familyby following the Womens Healthy Heart Program that I present in this book. If youve had a heart attack already, this program will show how to keep it from happening again. I have designed this unique cardiac prevention and treatment program specifically for women.
Until very recently, no book like this could have been written, because all the knowledge, research, and treatments concerning heart disease were based on findings in men. For too many years, the medical establishment was ignorant of womens unique needs and physiology and looked upon women as simply small men.
But women are not small men. It is now understood that our physiology is very different from that of men, especially when it comes to heart disease. Our hearts are proportionately smaller, and when we develop the first signs and symptoms of heart disease, we are usually ten years older than men. Consequently, to be effective, heart disease prevention and treatment programs for women must be different from those for men.
If youre like most women, you probably have a Pap smear every year and, especially if youre over forty, a mammogram every year or two. Im sure youve heard all the scare stories about breast and cervical cancer, and you know that these two simple tests can reduce your risk for them. But you may not realize that heart ailments disable and kill more women than all cancers combined.
Five years ago I established the Womens Heart Program at Lenox Hill Hospital in New York City to deal with that reality. Now that baby boomer women are entering menopausethe heart disease yearsby the millions, I want to spread the word that heart disease is a womans greatest health threat.
Im not interested only in the condition of your heart; I want to help you become healthier as a whole person: healthier in your mind and entire body as well. That means you need to learn better ways to deal with stress, which takes a toll on your overall health and can set you up for heart disease as well as high blood pressure. As a woman working almost exclusively with female patients for over a decade, I know that we often tend to put off seeing to our own health needs in favor of seeing to the needs of those close to us. In this book, Ill help you figure out some ways you can make time to take care of yourself, which will help you have a stronger heart and a healthier life in general. Youll also learn to recognize unhealthy behaviors and replace them with healthy ones.
Perhaps youve already been diagnosed with heart disease, and youre feeling overwhelmed and frightened. This book is for you too. Ill tell you about the latest research on how to keep your disease under control and evenin some cases of high cholesterolreverse its course. And if youve already had a heart attack, this book is for you too because following my program step by step can make your heart healthier and reduce your risk of further heart damage.
Sometimes its hard for women to relate to heart disease unless theyre already suffering from it. Its a silent and initially a painless killer, doing its dirty work in secret and over time. Heart disease can start early in life, even before the age of twenty. In its earliest stages, you cant see it or feel itit has no symptoms.
Sometimes physicians have difficulty conceptualizing coronary artery disease in women too, even though they have been to medical school and seen the life-threatening waxy buildup of cholesterol on the insides of the coronary arteriesthe atherosclerosis that lies at the root of heart disease. When I was training during the 1980s, doctors didnt even believe women got heart disease. In fact, when I was a resident, anytime we saw a woman with chest pain, a familiar symptom of heart attack, everyone said, Oh, this is so unusual! In my first month of internship, I examined a thirty-eight-year-old woman who worked at the hospital and was suddenly having chest pain. At first no one believed me when I said that she was having a heart attack. Yet she smoked two packs of cigarettes a day, and everyone knew that smoking put men at risk for heart disease. Even though heart disease was right there in front of them, the doctors couldnt see it in a woman!
Doctors now know that heart disease is so deadly for women that their chances of dying from it are one in two. That means basically that either you or your best girlfriend is likely to die of a heart attack, stroke, or related heart problem. By contrast, the odds of getting breast cancer during the course of your life are approximately one in eight, and your chances of dying from it are one in twenty-five.
The younger a woman is, the less likely she is to have symptoms of heart disease. Until the age of fifty-five, men are much more likely than women to develop symptoms. But after menopause a womans risk goes up sharply. In fact, if you dont take steps to reduce the risk, your chances of having a heart attack after you reach sixty are as great as a mans.
In over a decades practice helping women patients, I have learned a lot, and now through this book I want to help as many women as I can to recognize the prevalence of heart disease and to teach them how to be proactive in preventing it. I want you to see how improving the health of your heart will improve the health of your entire body. I want you to be able to recognize the signs and symptoms of heart disease and to know what to do if you should become affected. I want to show you how to demand the proper treatments if and when you need them. Above all, I want to keep you from ending up like a patient I will call Teresa.
At forty-seven, Teresa was a successful hospital administrator. She was a single mom and active in her church. Although she smoked, was overweight, and was often short of breath, she believed these habits and discomforts were due to her stressful job. One evening after a delicious restaurant meal, Teresa experienced a burning sensation in the lower part of her chest. The pain became so worrisome that she called her doctor, who assured her that it was just indigestion. Take some Maalox, he advised. And Teresa, next time dont eat so much.
The following day Teresa went to work, but the burning never stopped. When she finished work at the end of the day, she paged one of my colleagues, a cardiologist. He recognized from her symptoms that she needed to get to the coronary care unit. There she was given medications. I spoke with Teresa the next morning; her blood tests showed that she had not had a heart attack. But it was clear to me that she was at high risk and that anxiety alone was not the cause of her symptoms. In the past few months, she said, four doctors had told her to take a vacation or sign up for a yoga class to relieve her symptoms. I ordered a stress test to evaluate her heart, which, given Teresas health history, should have been done days or even months earlier. (In a stress test, as the patient walks on a treadmill at a slightly increasing speed and elevation, her heart is monitored and its rhythm is recorded.)
Later that day, while Teresa was on the treadmill for her stress test, she got the burning feeling again, and the test had to be stopped. This is usually an indication that the patient has an obstruction in her coronary arteries, the blood vessels that supply the heart. Yet when I reported my findings to Teresas doctor, he couldnt believe she had heart disease. After all, shes a woman, he said to me. But Teresa did have heart disease; her stress test as well as other cardiac tests showed that one of the major arteries supplying her heart muscle had a near-total blockage. That was what had made her short of breath, a common symptom of heart disease in women. Teresas specific heart disease was coronary artery disease, one of the first steps on the road to a heart attack.
Had her doctors been negligent? Maybe notlike many doctors, they simply didnt recognize Teresas specifically female signs of heart attack. Except for her weight and smoking habit, Teresa had always been relatively healthy. She had never experienced the classic warning signs of heart disease; nor had her heart attack appeared to be a classic (that is, male) heart attack.
Women Have Different Symptoms from Men
Teresa didnt experience the classic signs and symptoms of heart disease, precisely because she is a woman. The guidelines upon which her doctor relied had been developed from clinical experience only with men. In short, Teresas doctors treated her as a small man. And because her heart disease did not conform to the male norm, it wasnt recognized for what it was.
Heart disease has too often been characterized by the stereotypical image of the middle-aged businessman turning red or pale, sweating, and clutching his chest. But for women, the picture is often very different. For women, the symptoms of heart disease or an incipient heart attack may resemble indigestion (as in Teresas case), or backache, or a vague feeling of malaise. Twelve years ago, during my cardiology fellowship, different women who had had heart attacks told me this same story over and over: I noticed that I felt breathless even during my usual activities. Occasionally Id feel a pressure in my upper abdomen, and there would be numbness in my jaw. Id get a strange numbness in my arm.
For other women, heart disease first shows up as unusual fatigue, dizziness, or palpitations. One patient, a relatively young woman in her mid-forties, experienced back pain whenever she walked up the hills in her Bronx neighborhood. Not until she went to a hospital in the middle of having a heart attack did she learn that her back pain had actually been the sign of that impending heart attack.
Because fatigue, shortness of breath, back pain, and the like were not known to be classic signs of heart attack, no doctors thought to test or treat these women for heart disease. Even today many women go from doctor to doctor knowing that something is wrong but being told that the problem is just their nerves, fatigue, indigestion, or stress. But these problems are female symptoms of heart disease. Attention must be paid!
How did this life-threatening situation come about, and what can women do about it? Above all, we have to educate ourselves about the risks and learn how to protect ourselves and get the best care, if and when we need to see a doctor. This book is my attempt to help you with that education.
Prevention, diagnosis, and treatment of heart disease in women have all lagged behind that in men for a very long time. Until recently, as I mentioned, all clinical research on heart disease was based on studies conducted only on men: the commonly accepted symptoms, the risk factor evaluations, the types and dosages of medications, the surgical treatments, and the rehabilitation recommendations were all based on what was found to be true for men. As a medical student, I was taught that all medical care is based on what was normal for a 165-pound man. This particularly annoyed me, since I am a five-foot-one-and-a-half-inch, hundred-pound woman. How could a drug dosage for someone who weighed sixty-five pounds more than I did be correct for me? How could that drug act the same in my smaller female body? For too long, most researchers have assumed that womens reactions were exactly like those of men, except on a smaller scale.
My firsthand clinical and research experience underscores the important fact that womens heart disease is in fact very different from mens. I first became interested in this issue in 1990, when I began my own career as a full-time academic cardiologist at SUNYs Health Science Center in Brooklyn, where I ran the Heart Exercise and Imaging Laboratory. There I could not help but notice that fewer women than men were even referred for stress testing. Perhaps the reason was that stress tests tend to produce a higher rate of false positives for women than for menthat is, they more often indicate the presence of heart disease when none is actually present. As a result, many doctors avoided referring women for stress tests at all, even when it was the best option for helping them diagnose what was wrong. Later, improved techniques for stress-testing women, such as stress echocardiography (the use of ultrasound to visualize the heart during exercise), became available, yet even then women were still greatly under referred. Today more women are referred for stress-testing than ever before, but they are less likely to be referred for follow-up tests if the results confirm a problem.1 This is particularly true for minority women, who often have to insist on further testing to uncover the particular form of heart disease they have.
Copyright 2002 by Nieca Goldberg, M.D.
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