Women and Heart Disease

WebMD Live Events Transcript

Other conditions may get the headlines, but doctors know heart disease is the No. 1 killer of women, according to the American Heart Association. What can you do to take your heart off your own list of worries? We welcomed Jonathan Sackner-Bernstein, MD, author of Before It Happens to You: A Breakthrough Program for Reversing or Preventing Heart Disease, on April 28, 2004

The opinions expressed herein are the guests' 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:
We are taught to check our breasts monthly. What could we do to check our heart health?

SACKNER-BERNSTEIN:
As I describe in my book, Before it Happens to You , the three facts you need to know to reduce your risk from heart disease are:

• Your blood pressure
• Your cholesterol
• Your glucose level

You should start to check these by the time you're 20 and at an ongoing basis thereafter.

MEMBER QUESTION:
What should they be?

SACKNER-BERNSTEIN:
There are two ways to answer this question. One way would be to follow the standard guidelines. The problem with the standard guidelines is that they establish levels that are cost effective for society. Instead, you should follow the evidence in the scientific literature, which defines stricter guidelines in order to minimize your risk. Those goals are:

• A blood pressure of 115/75
• An LDL cholesterol (your bad cholesterol level) of less than 100
• A glucose level of less than 100

Ideally, a woman's HDL cholesterol should be above 50, but this can be difficult to achieve.

MEMBER QUESTION:
My doctor never tells me my numbers; she just says, "You're fine."

SACKNER-BERNSTEIN:
This is a very common scenario. Your goal is to be in control of your health. Without knowing your numbers you can't be in control, and you won't know whether your health is truly optimal. In my book I describe the ways to speak with a doctor like yours in order to make the relationship work for you to optimize your health.

One of the major goals in writing my book was to provide specific examples and scripts to enable you to communicate more effectively with your doctor. For example, if your doctor is resistant to measure your cholesterol, you can simply ask, "Is there any risk to having this test?" It would be unimaginable for a doctor to say yes. Then you can follow up by saying, "Since there is no down side and scientific evidence says that my risk is minimized when my bad cholesterol is under 100, wouldn't it be to my advantage to know my cholesterol levels?"

MEMBER QUESTION:
So if I get my cholesterol level and it's high, what do I do then?

SACKNER-BERNSTEIN:
The standard approach to treating any of these abnormalities is to start with a therapeutic lifestyle change. An optimal lifestyle includes adjustment of diet and exercise routine, as well as stress management. It is unusual for a person to have the ability to drastically change their lifestyle for the duration of their life. Although it would be ideal to do so, I focus on practical steps that you can achieve whether or not you are one of the few people who can change.

Therefore, the primary focus of my book, Before It Happens to You , is to utilize the scientific data that describes the safest ways to minimize your risk. As an example, control of cholesterol can be achieved in almost all patients through the use of medicines called statins. These medicines are safer than taking antioxidant vitamins that you can buy at the health food store. Ideally, you would change your lifestyle and, when necessary, take such medicines, but even if you're like most people and can't change, you can still minimize your risk of a heart attack or stroke by optimizing your cholesterol, your blood pressure, and your glucose.

MEMBER QUESTION:
:Should women be taking aspirin for heart health?

SACKNER-BERNSTEIN:
Aspirin, used in low doses, is a standard recommendation for postmenopausal women and those at high risk for heart disease. If you were to examine the data supporting that recommendation, and compared it with the scientific evidence for other medicines used for the treatment for cholesterol and blood pressure, you would learn that although aspirin is very useful, its usefulness and safety are not nearly as impressive as these other medicines.

Specifically, by using blood pressure medicines, such as ACE inhibitors, beta-blockers, and sometimes diuretics, in addition to statins to optimize your cholesterol, you can cut your risk of a heart attack or stroke by about half, for a typical middle-age woman.

To give you a specific sense of what this means, we can consider the risk that a typical patient may face. I recently saw a 57-year-old woman with borderline blood pressure and cholesterol levels that were typical of a postmenopausal woman. When calculating her risk of a heart attack or dying from a heart attack, in the next year, it turns out that that risk is .4% of a heart attack or .4% of dying within a year of that heart attack. That means that this woman who would be told to change her lifestyle has a risk of dying within two years of one in 1000. No study has shown that changing her lifestyle will affect that risk very much.

In contrast, by reducing her blood pressure with an ACE inhibitor or beta-blocker and optimizing her cholesterol with a statin, her risk would drop about 80%.

MEMBER QUESTION:
I heard that old-fashioned diuretics work better than some of the newer medicines. True?

SACKNER-BERNSTEIN:
Old-fashioned diuretics work well to reduce blood pressure and also to reduce the risk of stroke. Much of the press coverage from a recent NIH trial, called ALL HAT would give the impression that diuretics are better than any other blood pressure medicine. When looking at all of the data, you will see that although diuretics are terrific blood pressure medicines, ACE inhibitors and beta-blockers appear to have modest but important advantages.

Practically speaking, when you are working towards optimal blood pressure, you are likely to need more than one medicine. Selecting from these types is likely to be better than selecting the newest medicine. A major reason is that the older medicines have been studied in greater detail and used in more patients, so we understand their safety and effectiveness with greater precision.

MEMBER QUESTION:
What are the symptoms for women and heart problems? There is a family history, but I have good cholesterol and 110/70 blood pressure. Should I still worry? I am a realtor, so of course there is stress.

SACKNER-BERNSTEIN:
The fact that you are expressing this level of concern is a crucial first step to minimizing your risk. At the risk of appearing sexist, I would like to share with you my impression of the greatest risk factor that women face. Women are too concerned with everyone else around them instead of looking out for number one. Women have to realize that heart disease is a major risk and pay attention to their own risks first and then worry about husbands, friends, and other relatives.

In your case, the fact that you know your blood pressure and cholesterol are optimal, is an important step. Once you know that your glucose (sugar level) is optimal, you are on your way to knowing that your risk is minimized. However, if you have a strong family history of heart disease, you may consider additional discussions with your doctor to make sure that all your risks are addressed.

MODERATOR:
What are the symptoms of heart attack in women?

SACKNER-BERNSTEIN:
The symptoms of heart attack in women can be the same classic symptoms that men experience. These include feelings of heaviness or pressure in your chest. However, women also can experience less typical symptoms owing to some differences in the way heart attacks can start for women. Examples include shortness of breath, nausea, or pain or discomfort or full feelings in other parts of the upper body, such as the jaw, the shoulder, or even the upper abdomen. As you will see, these symptoms are pretty common for most men and women to experience.

In order to know when you have a problem, you have two options. One would be to call 911 at the onset of any of these symptoms if they are new. In most cases, that is probably too high a level of vigilance.

However, if you notice that it is a pattern that has gotten worse, over a period of days or weeks, and you are in the midst of an episode that is more severe, calling 911 may make sense.

A second approach is possible, primarily for women who exercise regularly. Regular exercise will improve your sense of well-being and also allow you to understand if a problem may be starting with your heart. Specifically, a decrease in your exercise capacity (less able to walk or exercise than your usual) is a sign that you should call your doctor because there is likely to be an abnormality in your heart or cardiovascular system.

MEMBER QUESTION:
I am a 35-year-old female and had a heart attack in January 2004. I had had oral surgery just 1.5 weeks before the attack. Two days after the oral surgery I began having intense chest pain. Is there any relation to having a wisdom and molar tooth removed and having heart trouble? Since the surgery, I can actually "feel" my teeth. The cardiologist has told me that when I experience "jaw pain" I am to take nitro, and call an ambulance. During my cath, he stopped the blood flow and immediately my jaws began to hurt. He said this is my "sign" of a heart attack. I remember telling my husband after two days after surgery that my jaws hurt so bad that my chest hurt. I was just curious as to the connection, if any?

SACKNER-BERNSTEIN:
In your case, paying attention to episodes of jaw pain is very important. Episodes of jaw pain should be treated promptly to be certain that you do not suffer another heart attack. If you are noticing ongoing symptoms or intermittent symptoms, it may mean you require additional medicine or additional procedures to open blocked arteries.

In people who have had a heart attack, the importance of optimizing cholesterol, blood pressure, and glucose, is of even greater importance. Your LDL cholesterol must be under 80 and perhaps lower; your blood pressure should gradually be reduced to under 115 over 75. You should be receiving an ACE inhibitor, even if your blood pressure is optimal, and the same is true for a beta-blocker.

With a history of a heart attack, you understand how important it is to prevent a second one. The recommendations are just as important for people who have had a heart attack treated successfully with a stent. Even though that blockage is fixed, you still are at high risk for another heart attack elsewhere in your heart.

MEMBER QUESTION:
I used laxatives for a long period of time and was once told I had sustained damage to my heart because of overusage ... now I am experiencing a lot of heaviness in my chest, difficulty breathing at times, dizziness, and sweating with nausea ... my regular doctor looks at me funny when I ask them to check for heart problems because I am only 38 ... should I seek help from another doctor or take her word for it that I'm not experiencing heart problems?

SACKNER-BERNSTEIN:
The link between laxatives and heart disease is not one that is proven. Chronic laxative use can affect intestinal function, but not heart function.

For people who have symptoms including shortness of breath or fatigue, an echocardiogram is a standard recommendation to be certain that the symptoms are not caused by structural heart abnormalities. You could tell your doctor that you have learned that a standard recommendation, when heart failure is suspected, is to perform an echocardiogram. Symptoms of shortness of breath with activity could raise the suspicion of heart failure, even though it is unlikely. There is no risk from an echocardiogram. I suggest you push your doctor to consider it.

MEMBER QUESTION:
But what do you do if your doctor won't take you seriously because of age? My family has a very strong history of heart disease on both sides, yet my doctor refuses to work with me to do anything to check on my heart. I'm going to be 37 soon. He just says I'm too young.

SACKNER-BERNSTEIN:
If a patient has a family history of heart disease, all first-degree relatives should be screened aggressively. Screening includes blood pressure, cholesterol, and glucose measurements, and frequently echocardiograms or stress tests. As I say in my book, Before it Happens to You , screening should start at the age of 20 in everyone, and certainly, at least 10 years younger than the age when your first-degree relative was first diagnosed with heart disease. To understand the attitude and perspective that you need to have you can read my book or download a summary for free at www.beforeithappens.com

MEMBER QUESTION:
I am 40 this year with a family history of heart disease. Should I consider a statin drug now?

SACKNER-BERNSTEIN:
The answer depends upon the results of a fasting lipid profile. If your LDL cholesterol is higher than 100, you should consider a statin, even at 40. Although statins are prescription medicines, you should understand that their safety is far superior to many over-the-counter medicines many of the vitamins sold at your local pharmacy or health food store, and certainly amongst the safest of all prescription medicines. Although all medicines have risks, as I outline in my book, the safety of these medicines is such that you are safer taking them than not taking them.

MEMBER QUESTION:
Even with the medicines, don't you still have to eat a low-cholesterol diet and exercise?

SACKNER-BERNSTEIN:
You can definitely eat your way around the effectiveness of a statin. They should not be considered steak insurance.

However, it is also unfair for a doctor to constantly reprimand a person for not following a perfect lifestyle. Most doctors don't. So while it is to your advantage to lead a healthy lifestyle, making sure your risks are minimized is possible even if you can't change your lifestyle.

MEMBER QUESTION:
My mother had a heart attack in 1994 following her second stroke. Her BP was uncontrollable at the time, reading 260 over 140-150. She has survived, and has not had another. But she now has unstable angina, and she takes Warfarin every day. She has changed her diet, exercises as much as she can, and she has controlled stroke, BP, and cholesterol levels in this way. With the unstable angina, what is her chance of getting another heart attack? Can you predict her prognosis?

SACKNER-BERNSTEIN:
For someone like your mother, the risk of another heart attack is very high. It's not possible for me to tell you the prognosis, but I can tell you ways to improve her prognosis. Those steps would start with making sure her blood pressure is perfect, her LDL cholesterol is under 80, her HDL is above 50, and a measurement from a blood test of glucose control, called HgA1C, is 6% or less. In addition, one of her medicines must be an ACE inhibitor and even if her cholesterol seems optimal, she should probably take a statin anyway. To understand the rationale behind all these recommendations, start with my book summary download and there is more information in the book itself.

MODERATOR:
Is there anything else we should do to reduce our risk of heart attack?

SACKNER-BERNSTEIN:
If there were one thing I could do as a doctor, it would be to eliminate tobacco use. If you smoke or you live with someone who smokes, work with your doctor or anyone else you can find to help you change. In the interim, while you are working towards this goal, be particularly aggressive to optimize your blood pressure, cholesterol, and glucose. Following the Before it Happens to You plan, will minimize your risk and keep you alive and well long enough to figure out how to quit.

MODERATOR:
We are out of time. Dr. Sackner-Berstein, thank you for sharing your expertise with us today. Members, for more information please read Before It Happens to You: A Breakthrough Program for Reversing or Preventing Heart Disease. You can read an excerpt of the book at www.beforeithappens.com.

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