By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.
Even though it has been the leading cause of death for both men and women in the United States for years, cardiovascular disease is often overlooked as a significant women’s health issue. This may be due to a misunderstanding by the medical community about how heart disease manifests in women.
Distressed about a possible misdiagnosis, an HMDI reader (whom we’ll call “Sally”) sent this email, demonstrating the need to cultivate greater awareness of how symptoms of heart disease in women can differ from symptoms in men.
“I’m a 66 year-old woman who has recently been diagnosed with acid reflux, or GERD… yesterday I started experiencing pain in my left arm on the underside… the pain woke me up last night and was so severe I didn’t go to my job today. I went to an emergency urgent care facility and was told that the pain in my arm and back is due to a pulled muscle… I assured the nurses and doctor that I have not done any pulling, pushing or picking up of objects that would cause such a strain and they insisted I must have done it while sleeping. Heart problems run in my family… my late mother had heart disease for years, my father died from heart failure at age 54, and my brother died from an aneurysm at age 55. I am worried my aching has been misdiagnosed…” – Sally
Heart Disease In Women Is Often Mis-diagnosed
Most medical school training does not prepare physicians to recognize symptoms of heart disease in women. Instead, physicians are taught to diagnose and treat what manifests as CVD in men as the traditional prototype for diagnosing and treating cardiovascular disease has, for years, been a middle-aged man.
Conventional cardiologists tend to focus on pharmaceutical and surgical treatments, and often overlook the emotional aspects of cardiovascular disease that women tend to be better in tune with. As with Sally, women are more likely than men to intuitively sense that they may be experiencing cardiac issues, as well as the role that emotional pain and stress play in the development of their illnesses.
Heart Disease Symptoms in Women Are Often Different than Symptoms in Men
Not only are women generally better in touch with their emotional pain and stress, but they tend to experience more subtle or vague physical symptoms of heart disease and cardiac events than men do. While men may experience a crushing pain in their chests (angina) when having a heart attack, women’s symptoms often include:
- Discomfort, pressure or pain in the chest and/or back (also called angina)
- Tingling or pain in the jaw, elbow or arm (both men and women tend to feel pain in the left elbow or arm when having a heart attack)
- Shortness of breath and/or lightheadedness with exertion
- Sudden, profound fatigue
- Tightness in the throat
- Dizziness and/or vertigo
- Indigestion (women often feel that if they could “just burp,” they would feel better)
- Nausea and/or vomiting
- Disproportionate sweating with activity
Sometimes women’s symptoms are mild enough for them to think they just have the flu, and doctors may mis-diagnose signs of heart disease in women as other, less serious conditions such as hypoglycemia, indigestion, muscle strain, or simply just anxiety or stress.
With Sally, it’s possible* that her acid reflux and the pain in her arm and back are symptoms of CVD, and she may be at great risk of a heart attack. Especially in consideration of her ominous family history, which merits her getting a cardiac workup, her intuition that she has been mis-diagnosed may be spot on. Hopefully she has received a second opinion and acute care, if needed.
*Please note that, without physically examining Sally and knowing her medical history, I cannot accurately say what her diagnosis is; any discussion of possible cardiac problems she may be having is purely speculative.
A Closer Look at Chest Pain (Angina)
Angina – chest pain often described as a “heart cramp” – is a symptom of ischemia, restricted blood flow which results in an insufficient supply of oxygen to heart and other vital tissues. Most often, ischemia is due to plaque build-up in coronary arteries (CVD) which causes a partial blockage, but can also be caused by a blood clot which completely blocks blood flow and may result in a heart attack. Without enough oxygen, the heart quickly becomes depleted of the energy it needs to continue circulating blood throughout the rest of the body; it begins to cramp and the person feels numbness and/or pain.
As angina can be a sure sign of heart disease in women (and men), it’s crucial that both women and health professionals alike be able to recognize angina symptoms in women. With men, angina is typically felt as a sharp, crushing chest pain, in the middle of the chest or on either side. Women, on the other hand, tend to experience dull or aching pain, or even just a sense of heaviness, tightness, soreness or pressure in the chest. Also, with men, angina pain usually comes on after exercise or exertion and generally improves with rest; this symptom of heart disease in women may be experienced without any obvious cause or remedy, and rest may not help.
Other Symptoms of Heart Disease in Women
Angina in women might even be mistaken for heartburn (women commonly feel a need to “just burp” to feel better), and women may not know they have angina, and are therefore at risk for a heart attack, until the condition is dire. Gastrointestinal distress is often one of the most commonly disregarded signs of CVD. Another symptom of heart disease in women is pain or pressure radiating into the jaw or neck; a woman could easily seek help at the dentist’s office instead of going to the hospital with such symptoms.
For men and women alike, shortness of breath and sudden fatigue are often early warning signs that the heart isn’t getting enough oxygenated blood. However, while the onset of these symptoms is usually sudden in men, women tend to experience chronic breathlessness, or may awaken in the middle of the night with difficulty catching their breath. Women’s fatigue may be unexplained or generalized.
One possible explanation for these differences is that women may be more in tune with changes in their bodies that indicate heart disease, while, for men, heart attacks are unfortunately often the initial symptoms recognized. The other side of the coin is that women may also be more prone to dismiss their pain and discomfort, having learned to bear the physical effects of menstruation, pregnancy and childbirth; they may not seek medical attention until the situation becomes dire.
Menopause, Heart Disease, and Cardiac Events
Women’s risk of having cardiac events significantly increases after they go through menopause. This is because of the gradual loss of heart-protective estrogen. As women age, they tend to experience a greater increase in cholesterol levels, high blood pressure, weight gain, and hormonal imbalance.
Younger women, although less commonly, have heart attacks too. They are usually “vitally exhausted,” from working, caring for or raising children or other family members, or possibly enduring rough emotional situations like divorce or death of loved ones. Feeling burned out, overloaded, and stressed are indications of potential cardiac problems, even for people who appear healthy on the surface. Excessive stress not only depletes the immune system and can lead to the inflammation which causes cardiovascular disease, but it causes blood to thicken and blood pressure to rise. While estrogen protects younger women against unhealthy cholesterol levels, it will not, on its own, prevent heart attacks. Stress management is key to preventing heart attacks in all ages of women, as well as men.
Statistically, men tend to experience cardiac events about a decade earlier than women, but they generally have a better chance at recovery. Also, men usually report symptoms that appear as “mechanical difficulties” or changes in physical function in their bodies, rather than as problems of the heart, or of their emotional lives. Signs of heart disease in women may not be recognizable, and may be mistaken for general malaise. One-third of all coronary-related events in women are actually “silent” heart attacks, where symptoms remain unrecognized and treatment is delayed or neglected.
How to Protect Against Heart Disease and Cardiac Events
Even though a woman’s risk of cardiovascular disease increases after menopause, there are many lifestyle patterns she can establish which can reduce her vulnerability to CVD, heart attacks and other acute events (most of these suggestions apply to men as well):
1. Eat a heart-healthy, anti-inflammatory diet
Women of all ages should consume plenty of fresh, organically-grown vegetables and fruits as well as wild-caught fish packed with omega-3s. As sugary foods contribute to inflammation, try to avoid foods consisting of simple sugars (e.g. white breads, pastries, cookies, pastas, candies, etc.) as much as possible. Remember that taking a bite or two of these goodies won’t catalyze the excess insulin response and inflammation that consuming larger quantities of them on a regular basis will. In the same light, avoid excess alcohol consumption. Opting for monounsaturated fats (from sources like olives, avocado, and nuts) over saturated, trans- and hydrogenated fats (animal fats, margarine, and cookies) will also help. Avoiding excess salt intake can help keep blood pressure down; be sure to read labels for hidden sodium and try to ingest less than 2.5 grams per day. See My PAMM Diet for more information.
2. Exercise regularly and moderately
Women who participate in regular, moderate exercise can keep their insulin levels at bay and avoid metabolic syndrome and/or diabetes, improve their circulation and blood pressure, reduce their risk of osteoarthritis and cancer, diffuse emotional stress, and beat depression. Walking with a human or animal friend every day, or every few days, for 30 to 60 minutes is certainly enough. Research shows that exercise is particulary important for post menopausal women.
3. Supplement your diet with targeted nutritional supports
To prevent free radical damage, support cellular metabolism and repair, and offset the effects of emotional and physical stress, supplementation can help increase women’s resistance to disease. In addition to being on a core multivitamin/multimineral nutritional program, women can benefit from daily doses of CoQ10 (60-100 mg), fish or squid oil (1-2 g), vitamin C (1,000+ mg), and magnesium (400-800 mg). Other antioxidants of choice include vitamins E, B vitamins / folic acid, and carotenoids (flavonoids and OPCs such as pycnogenol). L-carnitine and alpha lipoic acid also top my list of nutritional supplements for women.
4. Effectively Manage Stress
Stress reduction is one of the key elements in health preservation. Since a woman may prioritize the needs of others over her own, it is important that she nurture herself, as well, to avoid burnout. Regularly practicing mind-body techniques like sitting or walking meditation, yoga or Tai Chi, can help balance her autonomic nervous system, as can engaging in enjoyable activities. Creative and/or social activities like art-making, dancing, connecting with friends and family, cooking / baking, gardening, or journaling can help a woman stimulate the production of oxytocin, a stress-reduction hormone. Treating herself to a massage, facial, manicure, haircut, etc. can also help her manage stress.
5. Find a doctor who will “partner” with you in your health
Finding a physician a woman trusts – one she can speak honestly with and that honors her feelings and “inner life” – can help her become a “partner” in her own health. Knowing about preventative measures and women-friendly options can help her make the best decisions for her when at the doctor’s office.
- Know what tests to ask for: A middle-aged woman should ask for a cholesterol particle size test. This test ensures more comprehensive cholesterol readings than standard lipid testing, as it measures plaque-producing Lp(a), which tends to rise in menopausal women. Ask also to have levels of biochemicals that can help predict CVD checked: C-reactive protein(CRP), homocysteine, and fibrinogen.
- Refuse to take a statin. Unless she displays evidence of inflammation, CVD, or has had a prior cardiac procedure or event, a woman should not take a statin to lower her cholesterol. Statins deplete her body of CoQ10 and can increase Lp(a). Overprescription of statins has resulted from pharmaceutical influence, not proven health benefits in otherwise healthy people with higher cholesterol numbers.
- Avoid synthetic hormones when possible; the preferred choice is natural, plant-based hormone replacements. While conventional therapies can cause cardiovascular damage, natural substitutes won’t result in such serious side effects, as their chemical structures mimic those already in the body.
What to Do If Diagnosed with Cardiovascular Disease
The good news is that CVD is reversible! When diagnosed with heart disease, a woman should:
- Get beyond the shock and grief and start making preventative lifestyle changes that will support her health. Although important for her to express emotions of fear, sadness, and anger, she also needs to take some action to start reversing her condition.
- Develop a good support system. Find someone she can genuinely express her feelings with and reach out to others for support and guidance. Seek out and embrace love in life.
- Join a cardiac rehabilitation program at her local hospital where she can receive counseling about how to take care of her heart. Cardiac rehab programs offer nutritional counseling, supervised exercise prescriptions, and peer support to help her get back on track with her health.
- Adopt and maintain positive perspective. Seeing her health condition as an opportunity to learn how to better care for her body, spirit, and soul can help her better engage in her healing process.
- Try a new activity. Upon getting clearance from her physician or rehab nurse, a woman with heart disease can start making time to do things she’s always wanted to. CVD can actually bring “second chances” in life.
References and Resources:
- Sinatra, ST. Heart Sense for Women (The Penguin Group, 2000).
- Sinatra ST. “Six Heart Facts Every Woman Should Know.” Drsinatra.com, accessed April 27, 2012.
- “Dr. Sinatra on Women, Stress and Heart Disease.” Health.com, accessed April 27, 2012.
- Sinatra ST. “Why More Women are Dying of Heart Attacks – Even in the Hospital.” Blog.drsinatra.com, February 24, 2012.
- Gray, John. Why Mars and Venus Collide: Improving Relationships by Understanding How Men and Women Cope Differently With Stress. New York. John Gray Publications 2008.
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