You may remember this post on the anatomy of a heart attack. Yesterday, I read this in the September 2009 issue of Harvard Health Letter citing some differences in male and female symptoms and prevention of heart disease:
His and Hers Heart Disease
Mounting evidence makes a case for a gender-based approach to heart disease.It’s often been said that matters of the heart affect men and women differently. However, medical research isn’t focusing on who hails from Mars and who from Venus, but on gender distinctions in earthly anatomy and physiology and their influence on heart disease.
This is a change from the first decades of clinical research in cardiology, which all but excluded women, although the lessons learned brought advances in prevention and treatment that have benefited both sexes. It’s hard to blame medical researchers for overlooking women: maleness long ranked near the top of the list of risk factors, although it’s in danger of losing that dubious distinction. In the United States, the annual number of deaths from cardiovascular disease (heart disease and strokes) is now greater in women than in men.
So, after years of gender-based research, it’s becoming increasingly clear that gender differences should guide many aspects of heart disease prevention, diagnosis, and treatment.
Differences in Risk
Men and women share a lot of the same risk factors, but there are also some important differences:
- Smoking. A cigarette habit tops the list of lifestyle risk factors for men and women alike. But for women who take birth control pills, smoking increases the risk of heart attack and stroke even more.
- Cholesterol. Levels of “bad” LDL cholesterol above 130 mg/dL are thought to signal even greater risk for men, while levels of “good” HDL cholesterol below 50 mg/dL are seen as greater warnings for women. High triglyceride levels (over 150 mg/dL) are also a more significant risk factor for women.
- High blood pressure. Until age 45, a higher percentage of men than women have high blood pressure. During midlife women start gaining on them and by age 70, women, on average, have higher blood pressure than men do.
- Inactivity. Only about 30% of Americans report getting any regular physical activity, but men tend to be more physically active than women, with the greatest disparities in the young (ages 18 to 30) and the old (65 and older).
- Excess weight. Being heavy has long been thought to set one on the road to heart disease, but the location of the extra pounds may be more important than their number. Abdominal fat, which releases substances that interfere with insulin activity and promote the production of bad cholesterol, is more toxic than extra padding on the hips. Many health authorities consider a waist measurement of 35 inches or more for women and 40 inches or more for men a more precise indicator of heart disease risk than body mass index.
- Diabetes. For both men and women, having diabetes more than doubles the risk of developing heart disease, but diabetes more than doubles the risk of a cardiac death in women, while raising it 60% in men.
- Metabolic syndrome. Having any three of the five metabolic syndrome symptoms — abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high blood sugar or insulin resistance — is riskier for women than for men, tripling the risk of a fatal heart attack and increasing the chance of developing diabetes 10-fold. The combination of a large waist and high triglycerides is especially toxic to women.
- Psychosocial risk factors. The depth of the heart-head connection is still being plumbed, but there’s enough evidence to implicate certain factors as contributors to heart disease, such as chronic stress, depression, and lack of social support. Neither sex fares better than the other over all, but research indicates that some factors predominate in men and others in women. Stress is an equal-opportunity burden. Women are twice as likely to be depressed as men and to suffer more from emotional upheaval. In fact, the reported cases of “broken heart syndrome” — the sudden, but usually reversible, loss of heart function after an intense emotional experience — are almost exclusively in older women. Anger and hostility have long been cited as risk factors in men, but that’s probably because most studies of heart disease excluded women. It’s well documented that men are more likely to lack social support — especially after retirement — than are women.
- Inflammation. Chronic inflammation is now thought to set the stage for the deposition of atherosclerotic plaque. Women have much higher rates of conditions that often lead to persistent, low-grade inflammation. For example, lupus more than doubles the risk of heart attack and stroke for women.
Heart disease differences
Women Men Most important risk factors
- Diabetes
- Low HDL
- High triglycerides
- Waist measurement of 35 inches or more
- Inflammatory disorders
- High LDL
- High blood pressure in young men
Symptoms/disease
- “Unconventional” symptoms — fatigue, malaise, shortness of breath, nausea, depression
- First heart attack at average age 70 with higher fatality rate than men
- More likely to have microvascular disease
- Unstable angina warrants immediate attention
- First heart attack at average age 65
Diagnostic procedures
- ECG stress test less informative than nuclear test
- When angiography shows no discrete lesions, IVUS and pressure flow studies also should be performed.
- Stress tests more reliable than in women
- Angiography more likely to be informative
Treatment
- Less likely to have bypass or angioplasty for coronary lesions
- Longer hospital stays, higher complication rate
- More likely to receive bypass surgery, angioplasty for coronary lesions
- Shorter hospital stays
- More likely to enter cardiac rehabilitation
Differences in Risk Reduction
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 alow-dose aspirin daily starting at age 45, but women are told to holdoff 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 the Disease Process
Molecular biology and high-tech imaging have revealed some differences in how heart disease develops in men and women. In both sexes, atherosclerotic plaque — collections of cholesterol, white blood cells, and connective tissue — is laid down in areas of coronary artery walls that have been damaged by inflammation. In men, plaque tends to be deposited unevenly, creating discrete lesions that bulge from vessel walls to form blockages inside the arteries. In women, plaque is put down more uniformly throughout the vessel walls. Heart attacks in men are likely to be caused by plaque rupture, producing a clot that shuts down flow in a coronary artery. In women, they’re more likely to be the result of plaque erosion, the sloughing of smaller pieces that generate a host of smaller blood clots.
Women are also more likely than men to have microvascular disease, a narrowing or stiffening of the microscopic tributaries of the coronary arteries, which nourish the heart muscle. Even when the main coronary arteries are clear, microvascular disease can restrict the heart’s oxygen supply, producing angina or other symptoms. Microvascular disease was once known as “cardiovascular syndrome X,” a giveaway that no one clearly understood how a heart with open coronary vessels could be starving for oxygen.
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 flu like malaise. And variant, or 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 numberof 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, and 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.
Harvard Health Letter – September 2009. (which you can find at your local library in the magazine or periodicals section for free)
One thing I found interesting is that stomach fat is is an important indicator of heart disease risk (vs. say body mass index):
Excess weight. Being heavy has long been thought to set one on the road to heart disease, but the location of the extra pounds may be more important than their number. Abdominal fat, which releases substances that interfere with insulin activity and promote the production of bad cholesterol, is more toxic than extra padding on the hips. Many health authorities consider a waist measurement of 35 inches or more for women and 40 inches or more for men a more precise indicator of heart disease risk than body mass index.
Dr. Oz explains a little more on causes of metabolic syndrome (aka prediabetes, linked to increased blood pressure, higher risk of coronary artery disease, and acceleration of the aging processes), and some necessary foods and supplements:
“If your waste size is more than half your height that belly fat is poisoning your liver, and as that belly fat gets large it squeezes on kidneys (so you get high blood pressure– kidneys regulate blood pressure), and it poisons the liver and you get a fatty liver (present in 20% of Americans) and it also blocks the ability of your muscle to listen to insulin, without the muscle chewing up sugar the insulin won’t work and you get diabetes”
You may have heard people debate being ‘healthy and overweight’ — but, physiologically-speaking, it does matter in how you carry that weight. This is unfortunate for those who usually gain weight in that abdominal area. Those with so-called ‘apple shapes’: abdominal region being the last place you lose fat and first place you gain it. I don’t recommend crunches for losing stomach fat. This can lead to injury especially if done the old-school way without an exercise ball, and remember: you can’t exactly ‘spot-reduce’ fat on your stomach. Also I think they are talking about ‘visceral fat’, not ab fat. Here’s how to do a quick measure:
Walking 60 minutes a day (preferably with some incline) and eventually some weight lifting resistance, thus exercising your leg muscles (your largest muscles to burn overall fat) and following a low-glycemic load diet (with 90-100% of your food being whole, non-processed foods) is the safest, most sustainable up-to-any-age approach to sloughing off unnecessary fat.
I have been following the Greger superfood diet as much as I can (I would say 70-90% effort) and am getting results that I personally find satisfying (Currently 24 years old, but I feel 18 again and my body is starting to look that way again) — these results make me want to follow it even closer. I don’t eat tofu (like he suggests so many times), but according to his studies it melts away those fat cells.
I don’t think I want phytoestrogens as a male — If I did eat soy, I would probably not eat it more than twice a week (and would focus on tempeh and USDA organic sources–not soy meal or grits and no processed meat-alternatives –anytime you process a food it generally becomes less nutritious and you just eat too much of it and feel sick), and I would be careful where it comes from (see Indonesian tofu in video above). Men’s Health wrote a rather a scathing article on the soybean and I’ll probably post that to shed some more light on the positives and unfortunate negatives of soy (one of America’s staple foods along with corn). Also, according to Dr. Greger you may also want to try 1 teaspoon of turmeric (a fat-burning antioxidant-rich, powdered root found in your spices section). Put it on your legumes with some lime juice and cilantro for a nice protein-rich breakfast. Protein satiates your hunger for longer periods than fat or carbohydrates so don’t feel so hungry come lunchtime.
I wanted to measure some of my progress so I invested in an Omron fat measurement scale. Less expensive ones are available here but if you want to measure without paying anything you can take the one in my bathroom and use on your own time — I only use mine about once every week or so. It measures visceral (abdominal) fat and a few other things:
This was the best one I could find and it uses the electrical pulse (which you can’t feel) like any other for-home-use body fat % scales. To find belly fat, you’ll want a scale that can measure “visceral fat” and mine gives a range between 0-5 (5 being the worst). The important thing is to measure the relative change each time you step on the scale, and hopefully make some encouraging, steady progress.
