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By John Ambrose, M.D.
Cardiovascular disease remains the leading cause of death in the United States with annual mortality rates exceeding that of cancer. While conditions such as breast cancer receive widespread media attention, cardiovascular disease is actually eight times deadlier for women than breast cancer. The designation of cardiovascular disease comprises several different disease conditions. The most common manifestations of cardiovascular disease include: hypertension or high blood pressure, which can be asymptomatic for many years and if poorly managed can contribute to heart attack, stroke or heart failure; stroke, which is caused by either a blood clot in an artery supplying blood to the brain or a cerebral hemorrhage caused by leakage of blood from these same vessels; and last, heart failure, which is another manifestation of cardiovascular disease resulting in the inability of the heart to effectively pump blood to the rest of the body. However, there is one heart-killer missing from this list that accounts for over 50% of all deaths related to cardiovascular disease: ischemic heart disease, also known as coronary artery disease. Here, the differences in risk and symptoms, and prevention and therapy methods for both men and women will be discussed.
Ischemic or coronary heart disease can lead to angina, heart attack, heart failure or sudden cardiac death, and is the most prevalent of all heart diseases. In 2006 alone, this type of heart disease represented in excess of 400,000 deaths/year in the USA according to American Heart Association statistics. Coronary artery disease is a condition where there is a buildup of plaque in the coronary arteries, which supply blood flow to the heart. A slow build up of plaque over time can lead to progressive narrowing which causes the symptoms of angina. Angina or heart pain generally occurs when the demands for blood supply to the heart are increased such as would occur with exercise but the supply is limited because of the narrowing. Typical symptoms include discomfort in the chest, neck, shoulders or lower jaw brought on by exertion or other forms of stress and relieved promptly by rest or nitroglycerine. With a heart attack, a blood clot acutely forms in one of the arteries that contains plaque and abruptly stops all blood flow causing the muscle of the heart to die. Sudden coronary death is usually due to a fatal arrhythmia or irregularity of the heartbeat that prevents the heart from pumping. This can occur during an acute heart attack or in patients in whom there has been severe damage to the heart muscle related to prior heart attacks or other causes.
Those at highest risk for ischemic heart disease are said to have risk factors for its development. These risk factors include older age, a history of hypertension, elevated cholesterol, diabetes or active cigarette smoking. A family history of heart disease is also important and this means that a mother, father, brother or sister have some premature manifestation of coronary artery disease which might include a history of heart attack, angina or heart pain or the need for a stent (artificial tube) or bypass surgery. In general, women become symptomatic with ischemic heart disease later in life than men do and it is most common after menopause. However, there are exceptions, particularly in those with several of the risk factors mentioned above. Unfortunately, today it is not uncommon for men and women in their 30’s and 40’s to experience symptoms of ischemic heart disease. Nearly all are smokers and most are either diabetic, obese, have elevated cholesterol and/or a positive family history.
Men with Ischemic Heart Disease
In men, the first presentation of heart disease is often acute myocardial infarction (heart attack) and/or sudden death. The symptomatic presentation of a man with a heart attack is usually typical in that they present with squeezing pressure, pain or tightness in the chest radiating to the left arm, neck or into the jaw associated with sweating and often a sense of doom. The discomfort usually begins at rest and can last for up to several hours. Men, in comparison to women, are more likely to undergo acute interventional care for an acute heart attack. In this scenario, an angiogram and a stent would be placed into the coronary artery to open up the blocked artery.
Men who experience angina or heart pain as the first manifestation of ischemic heart disease, also tend to experience pain, pressure or tightness in the chest which is brought on by exertion and relieved by rest. However, even in men, the symptoms of angina can be mistaken for other conditions including indigestion. Because of cigarette smoking and unfortunately because of the increased use of illicit drugs such as cocaine and methamphetamines, cardiologists are seeing more and more younger patients in their twenties and thirties presenting with ischemic heart disease. Both cocaine and methamphetamine use are notorious for causing cardiac pain and acute myocardial infarction (heart attack).
Women with Ischemic Heart Disease
As mentioned earlier, women present later than men by about ten years due partly to the fact that estrogen appears to be protective. However, this protection wears off after menopause. Women with ischemic heart disease present initially more often with angina (heart pain) than with myocardial infarction (heart attack). Unfortunately, when they present with myocardial infarction, their mortality rates tend to be higher than men. This, in part, is related to the fact that their symptoms tend to be more atypical and often go unrecognized as a manifestation of heart disease. Some of these symptoms, but not all, can be explained by the fact that the very elderly (those greater than 75 years of age), whether male or female, commonly have atypical presentations of ischemic heart disease (and women generally present with symptoms later in life than men do).
Instead of typical pain or pressure in the chest, the person may experience just generalized weakness, shortness of breath, prolonged nausea or indigestion, upper shoulder, arm or neck discomfort that is brought on by exertion or stress and goes away with rest. In the case of a heart attack, these symptoms are prolonged, lasting several hours and occur at rest. However, it should be remembered that not all discomfort in the chest, neck or in the upper back is due to ischemic heart disease. The opposite is usually true. Only about 10% of patients seen in emergency rooms presenting with chest pain are found to have ischemic heart disease as the cause. Another group of patients who frequently have atypical or unusual presentations of ischemic heart disease are diabetics. In some cases, diabetics can even have a heart attack and be completely asymptomatic.
Prevention
Prevention of ischemic heart disease can be divided into primary versus secondary prevention. Primary prevention deals with individuals who are at risk but as of yet do not have symptomatic manifestations of ischemic heart disease. On the other hand, secondary prevention deals with individuals who already have symptomatic disease and in this group, one is trying to prevent future adverse events. Secondary prevention is done by a physician and often it will be a cardiologist. He or she will treat the patient with appropriate medications including aspirin, cholesterol lowering medications, and medications for hypertension, as well as encouraging general lifestyle changes. If the patient has had a stent or a prior heart attack, additional medication is prescribed.
For those at risk but without any symptoms, prevention is essential. There are several risk factors that can be modified with proper lifestyle changes including diet, exercise and smoking cessation. Several of these risk factors such as high blood pressure and elevated cholesterol generally require nutrition and lifestyle changes, and drug therapy. Obesity increases the risk for diabetes, high blood pressure or elevated cholesterol. A proper diet and exercise regimen are essential and good habits are best developed at an early age. Cigarette smoking is a very serious problem and it is one of the most difficult habits to break because nicotine is so addictive. While motivated patients with the help of newer drugs can in some instances quit smoking, the easiest method is never to start in the first place!
Patients need to be self-motivated if they want to remain healthy and lessen their chances of symptomatic heart disease. All adult patients should know what their cholesterol count is, including what their levels of good (HDL) and bad (LDL) cholesterol are. Knowing your blood pressure and your blood glucose is also essential. An appropriate lifestyle, consisting of a healthy diet and regular exercise is the first step to a healthy, disease free life.
The key to prevention, however, is to start at a very early age. As a corollary, even the very elderly can benefit from measures to reduce elevated blood pressure, stop smoking etc. In addition to your lifestyle, periodic checkups by health care professionals can prevent problems in the future by identifying potential risk factors that can be managed with the appropriate therapies. Individuals with symptoms that suggest ischemic heart disease as outlined in this article should seek professional help from their health care professionals who can best evaluate and manage these symptoms. Because symptoms in women may not initially be recognized as a manifestation of ischemic heart disease, it is always wise if one is unsure, to check with your physician if any of the atypical presentations mentioned above occur regularly. Lastly, anyone with either prolonged chest discomfort or other symptoms, particularly if occurring at rest, should seek immediate attention by calling 911.
About the Author: Dr. John Ambrose is the chief of cardiology at UCSF Fresno and a professor of medicine at UCSF. He is a nationally and internationally recognized authority on coronary artery disease with over 225 publications in scientific journals mainly dealing with ischemic heart disease.
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