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Since 1984, more women have died of cardiovascular diseases than men.

To help increase awareness about heart disease in women among health care professional and consumers, in February 2004 the American Heart Association released new evidence-based guidelines that advocate a personal approach to preventing cardiovascular disease in women. The guidelines, which represent a major collaborative effort by representatives of the American Heart Association and 11 other professional and governmental co-sponsoring organizations, are based on a detailed review of more than 7,000 studies. While some of the guidelines deal with medication-when to prescribe, how much, the best choices-many deal with lifestyle changes that study after study have shown are effective at lowering blood pressure, reducing cholesterol levels, minimizing atherosclerosis and, overall, reducing a woman's risk of developing heart disease, based on her individual cardiovascular health. View the AHA's guidelines.

Heart attack and stroke are common results of conditions that restrict or stop the blood flow to the heart or brain. At any given age, men have a greater risk of heart attack than women, but women are only half as likely as men to survive a heart attack, and more likely to have a second attack.

Coronary heart disease (CHD), also known as coronary artery disease (CAD) and ischemic heart disease, is a disease of the heart's blood vessels that, if untreated, can cause heart attacks. Like any muscle, the heart needs a constant supply of oxygen and nutrients that are carried to it by the blood in the coronary arteries. When the coronary arteries become narrowed or clogged and cannot supply enough blood to the heart, the result is CHD.

African-American women are more likely to die of CHD than Caucasian women, perhaps because they are more likely to have more risk factors, including high blood pressure (hypertension), diabetes, obesity and smoking, and are more likely to receive poorer health care than Caucasian women. For example, in 2001, the overall CHD death rate (per 100,000 population) was 176.7 for black women compared to 137.4 for white women and 138.4 for Hispanic women. Heart disease risk is also higher among Mexican Americans, Native Americans, native Hawaiians and some Asian Americans. This may be partly due to higher rates of obesity and diabetes in these groups.

Coronary heart disease starts with atherosclerosis, a process in which fatty substances build up inside the walls of blood vessels. Blood components also stick on the surface inside vessel walls making the vessels narrower and "hardened," and eventually less flexible. The buildup and narrowing proceed gradually and result in decreasing blood flow, followed by CHD symptoms.

But the buildup, or "plaque," may also break apart and suddenly produce a blood clot, limit blood flow and cause symptoms. When blood flow to the heart is reduced, chest pain, or angina, can result. If blood flow is nearly or completely blocked, a heart attack can occur and cause muscle cells in the heart to die. Because the cells cannot be replaced, the result is permanent heart damage. Each year, more than 200,000 American women suffer heart attacks, an all-too frequent outcome of CHD.

Your risk of developing heart disease increases as you grow older. Prior to menopause, estrogen is thought to provide some protection to women against heart disease. (Premenopausal women who have diabetes or who smoke are not protected by estrogen, as diabetes and smoking are major risk factors for heart disease.)

Estrogen works to keep a woman's arteries free from atherosclerotic plaque (the buildup of fatty substances, cholesterol, cellular waste and other material) partly by improving the ratio of LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol. Estrogen increases the amount of HDL cholesterol, which helps to clear the arteries of LDL cholesterol-the type of cholesterol that contributes to plaque buildup in the arteries. LDL-cholesterol is a major cause of CHD, according to the National Cholesterol Education Program (NCEP) of the National Heart, Lung, and Blood Institute (NHLBI).

However, taking supplemental estrogen in the form of menopausal hormone therapy does not reduce a woman's risk of cardiovascular events. To the contrary, research shows that certain forms slightly raise the risk of heart attack and stroke. Hormone therapy is no longer recommended as a strategy to reduce or prevent heart disease in women, according to NHLBI, because safer, more effective medications, such as cholesterol-lowering statin drugs, are now used. (For more details on menopausal hormone therapy and the Women's Health Initiative, the study that revealed risks associated with menopausal hormone therapy, visit the Women's Health Initiative.)

Risk Factors for Heart Disease
Over the last two decades, researchers have characterized many risk factors for developing cardiovascular diseases. Smoking especially accelerates the development of atherosclerosis, constricts blood vessels, accelerates blood clot formation and restricts the amount of oxygen the blood supplies to the body. Smokers who have heart attacks and strokes are more likely to die from them.

High blood pressure, high cholesterol, elevated triglycerides, obesity and lack of exercise jeopardize the function of the major heart arteries and are particularly threatening to women. Stress may also contribute to heart disease symptoms in women.

Since your heart disease risk does increase as you age, it's important to make heart healthy lifestyle changes that may reduce your risks as soon as possible. Heart disease prevention, including exercise and diets low in saturated fat, ideally should begin in childhood. According to the American Academy of Pediatrics (APA), up to one-third of American children from age two through the teenage years, have high cholesterol and young children, even babies can have high blood pressure.

Diabetes also is a major risk factor for heart disease. Compared to women of the same age without diabetes, women with diabetes have from three to seven times the risk of heart disease and heart attack and a much greater risk of having a stroke. Diabetes doubles the risk of a second heart attack in women but not in men. In fact, diabetes poses as great a risk for having a heart attack in 10 years as heart disease itself, according to cholesterol management guidelines developed by NHLBI. For more information on these NHLBI guidelines, visit: The National Heart, Lung, and Blood Institute.

Heart Problems Commonly Experienced by Women
The following are common heart problems in women. If you experience any of the symptoms described below, contact your health care professional for an evaluation:

Angina. If not enough oxygen-carrying blood reaches the heart (a condition called ischemia), pain or discomfort in the chest, known as angina pectoris, may result. Episodes of angina occur when the heart's need for oxygen increases beyond what's available from the blood nourishing the heart. Ischemia may also occur without causing symptoms; this condition is called silent ischemia.

An episode of angina is not a heart attack. Angina pain means that some of the heart muscle is not getting enough blood temporarily, during exercise, for example, when the heart has to work harder. Episodes of angina seldom cause permanent damage to heart muscle. In contrast, the chest pain caused by a heart attack is more severe, lasts longer and does not go away with rest or with medicine that was previously effective.

Not all chest pain is heart-related. If the pain lasts for less than 30 seconds or if it goes away during a deep breath, after drinking a glass of water or by changing position, it almost certainly is not angina and should not cause concern

Physical exertion is the most common trigger of angina. Other triggers can be emotional stress, extreme cold or heat, heavy meals, alcohol and cigarette smoking. The discomfort is a pressing or squeezing pain, usually felt in the chest or sometimes in the shoulders, arms, neck, jaws or back. Indeed, angina can trick women into accepting chest pain as something slightly abnormal, but manageable. Women with angina may even be aware which activities provoke pain.

If you have angina, you're at greater risk of a heart attack compared with someone who has no symptoms or history of heart disease. When an angina pattern changes, if episodes become more frequent, last longer or occur without much exertion, for example, the risk of heart attack is much higher in the days or weeks that follow. However, a repeating but stable angina pattern does not mean a heart attack will necessarily happen.

If you have angina, you should ask your health care professional about the best way to manage it. Learning its pattern-what causes an angina attack, what it feels like, how long episodes usually last and whether medication relieves the attack, can help. Angina is usually relieved in a few minutes by resting or taking prescribed angina medicine, such as nitroglycerin.

Silent ischemia. Sometimes diseased arteries can't deliver enough blood to the heart but no symptoms occur. This is a condition called silent ischemia. An electrocardiogram (ECG or EKG), a measurement of electrical impulses produced by the heart, may indicate silent ischemia. However, unless a woman knows her risks for heart disease and decides, with the advice of her health care professional, that she needs a heart checkup, she may never know she has ischemia. Diabetics are especially at risk for this condition.

Heart attack. When the blood supply to the heart is cut off completely, the result is a heart attack. It can cause permanent damage to the heart muscle if blood flow is not restored as fast as possible. Typically, chest pain caused by a heart attack may be accompanied by indigestion, nausea, weakness and sweating. However, heart attack symptoms are varied and can be considerably milder.

Symptoms that indicate your heart is in danger may be present for months or years before a heart attack occurs. Persistent unusual symptoms-shortness of breath, nausea, great fatigue, angina/chest pain, fainting spells and gas-like discomfort-may be red flags for heart disease. Discuss such symptoms with your health care professional, even if the symptoms come and go.

If you are at high risk for a heart attack, it is a good idea to have an action plan in place, should one occur. Your plan might include the following steps:

Discuss with your health care professional, in advance, what you should do if you experience symptoms of heart attack or stroke

Make a list of all your medications and how often you take each one. Keep the list with you and give a copy to a friend or family member who would be involved with your care if you were taken to the hospital. This list would be valuable information to the emergency department staff.

Keep a small-sized copy of your EKG in your wallet.

Coronary syndrome X, or microvascular disease, is characterized by chest pain or ischemia without evidence of blockage in the large coronary arteries. Women are at higher risk than men for this condition. Syndrome X may be caused by the small blood vessels in the heart inadequately dilating. Postmenopausal women and women who have had surgical menopause are at risk for experiencing symptoms of syndrome X because their declining estrogen levels may have an impact on the small blood vessels in their hearts.

Because this condition is a small vessel disease, it can't be seen on an angiogram (an x-ray with dye that identifies blockages in the blood vessels). Special imaging tests, such as PET scanning or MRI, may help with the diagnosis in the future. Today, however, syndrome X is usually a diagnosis of exclusion-meaning that you may be diagnosed with this condition after having tests performed that don't identify any other causes of the chest pain. Many women who experience syndrome X have no risk factors and are otherwise healthy.

Medications commonly used to treat heart conditions may help to relieve pain caused by Syndrome X. The prognosis is generally excellent, but the symptoms can be debilitating.

Cardiac arrhythmias. The normal cardiac rhythm is called "sinus rhythm" and the normal heart rate is 60-100 beats per minute. An arrhythmia occurs when the heart beats irregularly or abnormally slow (bradycardia) or fast (tachycardia). While many arrhythmias don't cause symptoms, some cause chest pain, dizziness, fainting and shortness of breath. Atherosclerosis, angina, valvular heart disease, weakened heart muscle (i.e., cardiomyopathy), blood clots, thyroid abnormalities or heart attack can cause this condition to develop.

Medications can help stabilize heart rhythms. Abstaining from caffeine, alcohol and cigarette smoking can also help. Pacemakers are often recommended to correct a slow heart rhythm.

Assessing Your Own Risk of Heart Disease

Because heart disease and its risk factors can be silent for so long, often with few symptoms until the disease is well underway, it's important to know your personal risk factors. That includes your knowing your family health history and your cholesterol and blood pressure levels. Two major studies published in the summer of 2003 found that nearly everyone who dies of heart disease, including heart attacks, had at least one or more of the conventional heart disease risk factors: smoking, diabetes, high blood pressure and high cholesterol.

A simple heart disease risk assessment tool based on the Framingham Risk Model can be found online here. It estimates your 10-year risk of having a heart attack or dying of coronary heart disease based on your answers to questions about your personal risk factors. Your risk, whether very high, high, moderate or low, determines what steps you should take to reduce that risk, including whether or not you should be put on medication.

No matter what your age, if you suspect you have heart disease or are at risk of heart disease, talk to your health care professional about having diagnostic tests such as an exercise echocardiogram or a nuclear stress test

More on Risk Factors for Heart Attack & Stroke
Cigarette smoking is the number one preventable cause of coronary heart disease.

Elevated LDL and total blood cholesterol levels. Cholesterol belongs to a family of chemicals called lipids, which also include fat and triglycerides. Cholesterol is found in cells or membranes throughout the body and is used to produce hormones, vitamin D and the bile acids that help your body digest fat. The body is able to meet all these needs by producing cholesterol in the liver. Whole-milk dairy products, eggs, animal fats and meat add cholesterol to your bloodstream.

Cholesterol travels through the bloodstream in packages of low-density lipoproteins (LDL cholesterol), high-density lipoproteins (HDL cholesterol), and very low-density lipoproteins, which transports triglycerides. LDL cholesterol is known as the "bad" cholesterol because when too much of it travels in your bloodstream, it can lead to plaque buildup, which narrows your arteries. HDL cholesterol, on the other hand, is "good" because it helps clear out the LDL cholesterol. In very basic terms, you want your LDL cholesterol level to be low, and your HDL cholesterol level to be high (see specific target ranges for blood cholesterol levels below).

Elevated triglyceride levels: triglycerides are another type of lipid, like cholesterol, that are found in blood and body tissue. Obesity, cigarette smoking, excessive alcohol use and inactivity can raise your triglyceride levels, which in turn, raise your risk for heart disease, according to the AHA.

Blood cholesterol levels are measured by a small blood sample. A complete lipoprotein profile (a blood test that measures total cholesterol, LDL cholesterol, HDL cholesterol and triglyceride levels) is recommended by NHLBI as the initial test to determine if a person's cholesterol levels are within normal ranges. This type of test, called a fasting lipid profile, is taken when a person has not eaten for a prescribed amount of time-usually between 8 to 10 hours.

Blood cholesterol is measured in milligrams per deciliter (mg/dL; a deciliter is one-tenth of a liter).

Optimal cholesterol levels for healthy women are:

Total cholesterol: less than 200 mg/dL

HDL cholesterol: above 60 mg/dL. This range is considered to be protective against heart disease, while levels less than 40 mg/dL are considered a major risk factor for developing heart disease.

LDL cholesterol: less than 100 mg/dL

Triglycerides: less than 149 mg/dL

If you have diabetes, peripheral vascular disease, kidney disease, high blood pressure or multiple cardiac risk factors, or are at risk for these conditions, your blood cholesterol level targets likely will be different. Discuss your risk factors and ideal blood cholesterol ranges with your health care professional.

Because elevated LDL cholesterol has been determined to be a major cause of CHD, more aggressive strategies have been recommended by both NHLBI and the AHA to treat and manage this condition. NCEP/NHLBI released updated guidelines in August 2004 endorsed by the AHA that target lower LDL cholesterol thresholds at which to begin treatment. The guidelines also recommend more intensive treatment options for health care professionals to consider for individuals at very high, high and moderately high risk for a heart attack. (For more information, visit the "Cholesterol" topic at www.nhlbi.nih.gov.)

Your health care professional may also order "expanded" cholesterol testing, such as the Vertical Auto Profile (VAP) and Berkeley tests. These tests identify the levels of certain types of LDL cholesterol and may provide more accurate reading of your overall risk of cardiovascular disease. For instance, while a standard lipid profile provides an LDL level, an expanded profile further characterizes the type of LDL, including LDL particle number and size. In addition, markers indirectly related to lipids but associated with cardiovascular risk, like homocysteine and high sensitivity C-reactive protein (CRP) are sometimes measured. It is possible to have a standard lipid profile showing all numbers in the target range, but still have an LDL particle number or homocysteine level associated with excess risk for cardiovascular disease. Doing expanded testing might enable your health care provider to better target your therapy to reduce your individual risk.

Although these special tests are commonly used, they haven't yet been shown to lead to changes in the way high cholesterol levels are treated to reduce the overall number of cardiovascular events, like heart attacks. So they have not yet been included in national diagnostic or treatment guidelines for high cholesterol and triglycerides. They do, however, provide additional detail about traditional lipids while assessing non-traditional markers of cardiovascular risk.

High blood pressure (hypertension). When the heart is working too hard to pump blood through the body, the intensity can damage the walls of the arteries of the heart and body.

A blood pressure reading records a systolic blood pressure-the highest pressure measured when the heart contracts with each beat, and a diastolic blood pressure-the lowest pressure measured in the arteries when the heart relaxes between beats. Optimal blood pressure is less than 120/80mm hg, read "120 over 80." Hypertension-high blood pressure-is defined as systolic pressure greater than or equal to 140 mm hg or diastolic pressure greater than or equal to 90 mm hg.

There is another category called "prehypertension" you should be aware of. This designation is made when the systolic pressure is 120 to139, or diastolic pressure is 80 to 89, and means you have a significant risk of developing high blood pressure, or hypertension.

Homocysteine. Homocysteine is an amino acid normally present in the body. Recent studies suggest that high blood levels of this substance may increase a person's chances of developing heart disease, stroke and reduced blood flow to the hands and feet. It is believed that high levels of homocysteine may damage the arteries, make the blood more likely to clot, and/or make blood vessels less flexible.

Research also shows that the level of homocysteine in the blood is affected by the consumption of three vitamins-folic acid and vitamins B6 and B12. People who consume less than the recommended daily amounts of these vitamins are more likely to have high homocysteine levels. Recommended daily amounts are as follows: 400 micrograms of folic acid, 2 milligrams of B6 and 6 micrograms of B12. However, we do not yet know whether B vitamin treatment reduces vascular risk.

C-Reactive protein (CRP): a high level of CRP in your blood may mean that the walls of the arteries in your heart are inflamed, which may raise your heart disease risk. The American Heart Association and the U.S. Centers for Disease Control and Prevention issued new guidelines for the blood test in January 2003. The guidelines recommend limiting the use of the CRP test as a discretionary tool for evaluating people of moderate risk, and not as a means of screening the entire adult population, as insufficient scientific evidence supports widespread use at this time.

A blood test called the high sensitivity C-reactive protein blood test (hs-CRP) is now widely available. Most studies show that in healthy people, the higher the hs-CRP levels, the higher the risk of developing a future heart attack. In fact, scientific studies have found that the risk for heart attack in people in the upper third of hs-CRP levels is twice that of those with hs-CRP levels in the lower third. Recent studies also found an association between sudden cardiac death, peripheral arterial disease and hs-CRP.

According to the American Heart Association, a growing number of studies have examined whether hs-CRP can predict recurrent cardiovascular disease and stroke and death in different settings. High levels of hs-CRP consistently predict new coronary events in patients with unstable angina and acute myocardial infarction (heart attack). Higher hs-CRP levels also are associated with lower survival rate of these people. Many studies suggested that after adjusting for other prognostic factors, hs-CRP was still useful as a risk predictor.

It is not yet known whether specific interventions will benefit patients who have high hs-CRP, however aspirin therapy and cholesterol-lowering drugs might be helpful in these individuals.

courtesy of healthywomen.org