Menopause and heart disease

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One of the smartest women I know brought her 80-year-old mother to see me this week. During the interview, she mentioned that she recently had developed breathlessness and an unusual discomfort in her chest. After awhile, it went away.

"It must have been gas," she said. While, indeed, the pain may have been nothing, there also is a very good chance it was an indicator of something more. Top of my mind: heart disease.

Heart disease is common in middle-aged women. For women, however, the "stereotypical" symptom of severe, crushing chest pain is a rare presentation for a heart attack. This allows for a dangerous situation, as seemingly less serious symptoms -- discomfort, a vague chest pressure, breathlessness and, on occasion, abdominal pain -- are ignored, with potentially dire consequences. Though heart disease is the No. 1 killer of women, physicians, too, can misdiagnose atypical symptoms.

Why would women be particularly prone to these atypical symptoms of heart disease?

In 1996, the National Institutes of Health initiated a study called the Women and Ischemia Syndrome Evaluation. Recently, a supplement published in the American Journal of Cardiology presented important results from this study.

In as many as 3 million women with coronary heart disease, cholesterol does not accumulate in large coronary arteries. Rather, cholesterol spreads evenly throughout the artery wall, primarily affecting smaller coronary arteries. This condition is called coronary microvascular syndrome.

Blood flow to the heart can be impaired, leading to symptoms of coronary artery disease. The problem is complicated by the fact that in as many as 40 percent of women, treadmill stress tests fail to identify a problem, and often, coronary artery angiography is negative.

These women continue to have symptoms that are ascribed to other problems, such as hiatal hernia or fibromyalgia. As a consequence, they may not be treated appropriately for heart disease, and yet they are at great risk of having a fatal heart attack.

In the journal supplement, researchers emphasize the importance of identifying women who are at great risk of having heart disease. A simple 12-point questionnaire called the Duke Activity Status Index that asks about chest discomfort, breathlessness and ability to function and exercise adequately is a relatively sensitive measure of possible heart disease.

This screening questionnaire also can help identify patients who may not be able to adequately complete a treadmill stress test. In these women, coronary artery disease should be excluded by obtaining a Persantine-Thallium Stress Test. In this test, blood flow to the heart is assessed by injection of a tiny dose of a radioisotope and persantine that has the same effect on the heart as exercise. If impaired blood flow is found but coronary artery angiography is normal, the cause is coronary microvascular syndrome.

For all these reasons, we must be aware that postmenopausal women are at high risk of having heart problems. Sadly, recent advances in reducing the incidence and death rates from heart attack have benefited men much more than women. This may in part be caused by sexual differences, but it clearly is aggravated by the false notion that heart attack is a man's disease.

The advice for women prone to heart disease is the same at any age: Live a heart-healthy lifestyle, eat right, exercise, reduce stress, treat high blood pressure, don't smoke, lower cholesterol and homocysteine (an amino acid that when elevated increases risk of heart attacks) and reduce inflammation. Each of these steps can prevent heart attacks and death.

Remember, if you are at high risk of heart disease, it likely will manifest after menopause. If you do have atypical systems such as chest discomfort, pain in the left arm, breathlessness and even indigestion, make sure your physician is aware of the Women and Ischemia Syndrome Evaluation study and understands how best to diagnose heart disease in women.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." Send e-mail to askdrdavid@msn.com.

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