Dr. Patricia Yarberry Allen likes to work as a collaborative physician. Noting that February is American Heart Month, she consults this week with Timothy Dutta, M.D., FACC, on heart health—in particular, the ways in which each patient can calculate her individual risk of heart attack—and work on ways to prevent that attack.
Dear Dr. Pat:
I am a 58-year-old woman and I work at a boring, sedentary job as a data entry clerk in an insurance company. I am single and live alone. I go to an exercise class at Curves, which is fun but not too aerobic, once a week, and I walk about 10 miles a week, back and forth to the train station from my house and work. I never smoked.
I go to church every Sunday and sing in the choir. I go out with friends and with the people from my church and choir at least twice a week. I have a balanced life and very little stress. I take cooking classes for fun and belong to a group that makes dinner for the others in the group once a month.
I have reached the stage of my life where I know I am not going to have a partner, and I am at peace with it. But, since I live alone and my brothers and sisters and their children all live far away, I have begun to think more about my health. No one in my family had any strokes or heart attacks; they seemed to just die of some kind of old-age dementia or heart failure in their nineties.
I read all the time that heart disease is the No. 1 killer of women. What does that mean, exactly? Is it heart attacks or something else? Does it mean women in their fifties or mostly women in their nineties? I never smoked and I am 5 feet 1 inch in height and 130 pounds. My blood pressure is normal and I have never had any illnesses or surgery. My cholesterol is 240 with a high good cholesterol, so my GP said I was fine. He said the usual “Lose ten pounds and cut out the fat- and cholesterol-containing foods from your diet.”
What tests should I have done, and when should I have them done? If I can avoid heart disease, I sure would like to.
I really like the idea that we have these months dedicated to awareness of a disorder or an illness. This spotlight allows health care practitioners to check on the latest recommendations and advances in the field and to use the month as a time to inform their patients of ways to either avoid a disorder, or get it diagnosed, in order to have improved quality of life.
This is what your question really is about. You live alone, you have friends, but you know that it will be harder for you to manage if you become frail without an intimate support system (family or a partner) close by. You have been blessed with good health and a good family history as well. In addition you seem to be without significant stress in your life. You have a broad social network and you have a spiritual practice; these have been shown to decrease stress and create a more peaceful life as well.
Both health care professionals and patients are interested in your basic questions. And, as you may be aware, the recommendations seem to be changing all the time for preventive care, based on cost and insurance companies’ refusal to reimburse for many evaluations once considered necessary. While some of the evidence-based changes in recommendations may be appropriate, less screening will cause illnesses and deaths that could have been prevented. I try to work with each patient as an individual, and I schedule tests based on her special profile, not that of an actuarial table.
I have asked Dr. Timothy Dutta, the Women’s Voices for Change Medical Advisory Board’s cardiologist, to answer your questions.
Dr. Dutta Responds:
Heart attacks are caused by vascular disease, which also causes strokes and aneurysms. Thirty-five percent of American women over the age of 35 die of a heart attack. Tremendous advances have been made in the last 50 years in our understanding, diagnosis, and treatment of vascular disease, and we have been able to help Americans live longer, but vascular disease remains the No.1 killer of women.
Everyone wants to know the answer to the question that you asked: What is my personal risk for developing some form of cardiovascular disease? How does this affect the choices for intervention and treatment that I might consider?
Recommendations for tests and treatment for heart disease depend on risk. Patients who are at high risk should obviously be treated, while patients at the lowest risk should not. Your young age and relatively good health place you in a group of patients who are at lower risk for heart attack. Patients like you have some risk and some room for improvement with your cholesterol and lifestyle. Is further testing warranted? Should you take a statin?
A very useful tool that helps doctors and patients answer this question is the Framingham Risk Calculator. It is easy to use. Simply enter basic information from simple tests into the calculation. Maggie, your personal risk of a heart attack is 3 percent over the next 10 years.
You may be surprised how low that number is. It is a good number, but it does mean that about 1 in 30 women like you will have a heart attack. Given that we have effective preventive treatment, is there more you can do?
Probably the most useful test beyond the Framingham Calculation is using coronary artery calcium scoring. This test is done in a CT scanner without using X-ray dye. Admittedly, the test uses radiation, but the radiation is less than that of other CT studies.
The test shows calcification from atherosclerosis in the coronary arteries to the heart and then compares the score relative to that of other men or women of the same age. This test can help refine risk in the patient with borderline risk factors. When a patient’s risk is otherwise not clear, calcium scoring can give clarity. The test is not likely to be covered by insurance, and may cost up to $400 out of pocket, but consider the cash price of Lipitor for one year: more than $1,000. The test might spare you from that prescription if your risk is lower than expected. And the test may not need to be repeated for many years, if at all.
The five major risk factors for a heart attack are high blood pressure, high cholesterol, diabetes, smoking, and family history. We can’t change our genes, but the other four risk factors can be treated with lifestyle changes and medications.
It seems as if your risk is low enough that further efforts with diet and exercise are the next step. Take an honest assessment of your eating and exercise habits. This will help you make improvements to reduce your risk. One-fourth of American women are obese, and more than one-half are sedentary.
Don’t be discouraged by believing that you can benefit only from drastic changes. The more exercise, the better, but even 20 minutes of vigorous exercise three times a week can reduce your mortality by 27 percent, and adding 30 minutes of moderate activity (walking) on the remaining days can reduce mortality by 50 percent. Many patients have a large number in mind when they set goals for weight loss, but starting with a weight loss of just 10 percent is enough to reap a benefit and is more likely to be achieved.
For the one-sixth of American women who smoke, quitting smoking is a challenge, but will also lead to huge benefits to your health.
A comprehensive history and physical with your doctor may uncover symptoms and other risk factors for heart disease beyond the Framingham risk factors. Regular follow-ups to measure your weight, blood pressure, cholesterol, and blood sugar will make sure that your risk is not increasing.