His Heart, Her Heart: How to Keep Both Healthy -- Paula Johnson, MD -- 02/19/03

WebMD Live Events Transcript

We've been told that men and women are from two different planets, but how about their hearts? Are the symptoms of heart disease different in men and women? Do the same diagnostic tests apply to both sexes? And what about the effects of HRT on heart health? Our members asked these questions and more when we welcomed Paula Johnson, MD, to WebMD Live.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live, Dr. Johnson. Let's dive right into the questions.

Member: Is it true that heart disease is the No. 1 killer of women?

Johnson: Yes, it is true. Heart disease is the No. 1 killer of women and does surpass all cancers.

Moderator: Why doesn't it get the attention that cancers do?

Johnson: One reason is because heart disease does strike women at an older age and therefore the impact has been less recognized. In addition, in the last 15 to 20 years it's only been that the magnitude of heart disease has been understood. In addition, there has been far less advocacy around heart disease compared to cancer, especially breast cancer for women.

Member: Is it the No. 1 killer in men as well?

Johnson: It is. It's the No. 1 killer in men and it's the No. 1 killer in all racial and ethnic groups in the United States.

Moderator: And it's preventable!

Johnson: It may not be totally preventable but it's preventable to a very significant degree.

Member: Is there a difference between the heart of a man and a woman?

Johnson: Great question. We are learning more and more about differences in how heart disease develops in women versus men. The way a heart attack occurs in a woman may be different from a man. We have data from studies where they look at hearts and arteries going to the heart. But what we don't know is whether should we treat heart disease differently in men and women based on these findings.

Member: Is it true that men form collateral vessels around blockages easier than women?

Johnson: No. I have not been aware that's the case. What may be true is that women may have a total blockage of their coronary artery as their first event compared with men who may more gradually build up plaque, which would then lead to the development of collaterals. This may be more of a function of the way heart disease develops in men compared with women. This is an area being actively studied.

Member: Do you consider low-dose HRT not a high risk factor in those who have no heart disease?

Johnson: We don't have enough information to give a well-informed answer to that question. Lower doses of HRT are now being studied. What we do know is that for women without heart disease standard doses of HRT in the form of PremPro do result in a slightly higher risk of heart attack and other cardiovascular disease.

Member: Are there heart risks for women taking formulated natural bio-identical hormones (i.e., natural hormone replacement -- NHR)?

Johnson: We don't have studies to address all the different preparations of estrogen. The answer right now is that we don't know, unfortunately.

Member: Can a healthy perimenopausal woman take HRT (estrogen/progestin) for more than five years (to help ease hot flashes, etc.) without necessarily harming her heart? The WHI study found being on HRT for more than five years was harmful, but some women's health organizations are saying that it's safe for women to take HRT for more than five years (provided she speak to her doctor first.). I'm confused.

Moderator: The data from the Women's Health Initiative showed that there was an increased risk of heart attack within the first year after taking the medication. Risk continued to be elevated throughout the study period, but the greatest risk is in the first year. The current recommendation is that you not take HRT to protect your heart, and there will be a small but significant increase in risk to your heart if you continue to take HRT.

Member: What would you recommend for a woman approaching menopause who has heart disease?

Johnson: I recommend that you understand all of your risk factors, which include:

  • Your family history
  • Whether or not you smoke
  • Whether you are overweight
  • Lipids, or cholesterol
  • If you have diabetes and/or high blood pressure
  • If you exercise regularly

Then I would launch on a program to modify those risks as aggressively as possible.

Member: Do PVCs and rapid heart rate indicate heart disease? I have both and after an EKG the doctor said not to worry.

Johnson: For most people PVCs, or premature ventricular contractions, are not dangerous. For some people who have heart disease that may not be recognized, PVCs may indicate that there is a problem. It's when PVCs occur together, which is called ventricular tachycardia, that there is an indication of potential significant heart disease. A rapid heart rate by itself can often not signal any significant heart disease, but this is a matter of degree. If your heart rate is consistently very fast, this also could be an indicator of underlying heart disease. You should discuss this further with your physician.

Member: Is Plavix good to prevent the first heart attack and if so why is it so infrequently prescribed?

Johnson: We don't have good information as to whether Plavix prevents the first heart attack. What we do know is aspirin is helpful in men in preventing the first heart attack. We don't have the definitive data for women. These studies are now being performed. It has been shown in numerous studies that aspirin is protective against a second or third heart attack in both women and men.

Moderator: Do you feel women are represented well enough these days in research studies?

Johnson: We are seeing a greater and greater number of studies directed only at women or with a significant number of women, especially in the last 10 years.

Member: I've heard that people with strong support networks recover from heart attacks more quickly, but I've also heard women have more second heart attacks because they "worry" about their support people. Which is more accurate?

Johnson: It is true that women who have support networks do tend to do better in recovering. The role of stress is still being studied in whether or not it leads to a second heart attack. The current thinking is that the more you can reduce stress the better off you will be. And part of reducing stress may be having good support networks.

Member: How valuable are treadmill stress tests? Is there something better?

Johnson: Treadmill stress tests are valuable for women. It's a good test to perform initially to see whether physical stress leads to a lack of blood flow to the heart. For some patients, especially women, there is an increased rate of false positive results. Therefore, for some women it may be better to have a stress test with additional imaging, such as an echocardiogram, or using a specific substance to allow pictures of your heart to be taken. When a stress test is recommended to you, it's a good idea to ask your physician which type of test is best for you.

Member: I am in a study at UNC for diabetics relating to heart disease. After heart scans done in the study last summer I had bypass surgery. What are the chances that I will have a heart attack now? I am 51 and have quit smoking.

Johnson: Diabetes is a very potent risk factor for heart disease for women in particular and although altering your risk factors is an extremely positive thing to do there is no way to predict whether you will eventually have a heart attack. What we can say is that you will decrease your risk of having a heart attack or developing heart failure by stopping smoking, controlling your blood pressure, controlling your diabetes, and doing the things we know are good for your heart.

Member: Is a catheterization risky for someone with small vessels and severe, diffuse plaque?

Johnson: A cardiac catheterization is a common test, but even so, it is considered invasive. If you have diffuse plaque the catheter must pass through large arteries with the plaque in order to get to your heart. There is a risk that a small piece of this plaque could break off and cause either a problem in your extremities or a stroke. All that said, most who have coronary disease also have diffuse plaque. And poor outcomes from cardiac catheterization are not common.

Member: Could drinking less than two glasses of water a day instead of eight-plus glasses of water a day for many, many years lend to high blood pressure and to possible heart disease? And if so can this be remedied by starting to drink eight-plus glasses of water a day in order to bring a possible high blood pressure problem down to a range of at least 130/80?

Johnson: There has been no correlation between lack of water intake and development of high blood pressure. It is, however, important to remain hydrated with water.

Member: Is it true that women are less likely to be eligible for clot-busting drugs during a heart attack than men? If so, why?

Johnson: Women tend to be older when they experience their first heart attack and may have other illnesses that make them less eligible for clot-busting drugs, such as a history of bleeding from the gastrointestinal tract or history of stroke. There are data to suggest women may be under treated with regard to these drugs. These data has been widely circulated in the medical community and awareness of this discrepancy has increased over the past several years.

Member: My mother use to take blood pressure medication. After she took them she started taking other drugs. She wasn't the same after that; her memory was affected, as were her walking and her heart, which was already enlarged, but didn't cause any problems. She was 82 1/2 when she started taking medication. She would have been 85 if she didn't die last year. Could medication sometimes shorten life?

Johnson: Treating high blood pressure is critically important for women and men of all ages. Medications sometimes need to be adjusted for elderly patients and especially elderly women, given they tend to be smaller than men. Blood pressure medication does not cause premature death.

Member: Are so-called "silent" heart attacks more common in women than men?

Johnson: Silent heart attacks are not more common in women but are more common in diabetic patients. So if you are diabetic it is very important to have routine medical care and to discuss your risk of heart disease with your physician.

Member: If you could make one policy change for all physicians dealing with heart patients, what would it be?

Johnson: I would make the delivery of preventative services something that is reimbursed adequately. At this point in our healthcare system there is little incentive to provide true preventative care to patients. And I feel that given the amount of information we have on the benefits of lifestyle modification in helping to ward off heart disease, our system should support what we have learned from science. We talk a lot about wellness and prevention but we don't truly have a system that shows the true value of it.

Member: Are women who have had gestational diabetes at any greater risk for heart disease than women without diabetes?

Johnson: It looks like women who have had gestational diabetes are at higher risk for developing diabetes in the future. They are also at higher risk for heart disease as well. Get checked regularly for the development of diabetes in the future. Also be aware of other risk factors, and do what you can to modify them.

Member: If a person has absolutely no will power, and heart disease and diabetes runs in family, do you believe in intestinal bypass surgery? How dangerous is it? I'm a 52-year-old female who now weighs 283 and was over 300. I only weighed 115 to 125 until my 20s.

Johnson: My feeling is that for some patients who have exhausted all other options, including programs that attempt significant behavior modification, that this surgery may be a reasonable intervention. We don't know the very long-term outcome from the surgery. I would say that if you were over 300 pounds and decreased your weight to 283 that you were able to lose weight, and potentially doing more of that ... is worth a try.

Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Johnson?

Johnson: I think that for women, understanding the risks for heart disease is critically important and feeling empowered to modify those risks will lead to a healthier female population.

Moderator: Thanks to Paula Johnson, MD, the executive director of the Connors Center for Women's Health and Gender Biology and chief of the Division of Women's Health at Brigham and Women's Hospital, for being our guest.

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