Dear Dr. Pat:

I am a 58-year-old woman who has high blood pressure and elevated cholesterol. I am about 40 pounds overweight, and I don’t have the time or energy to exercise. I am really tired a lot. My mother had heart failure that began at 65 and was told that she had undergone more than one heart attack before the heart failure was discovered. Medicine for heart failure at that time was not very successful, and soon she was housebound and unable to live without oxygen and help. She had to sit up to sleep because her lungs filled up with fluid. She was in and out of the hospital before dying at 68 from a final heart attack. I understand that women don’t have the same symptoms of heart attack as men do. Should I have an evaluation to see if I have already had a heart attack?

                                                                                       Maria

Dear Maria:

Honestly, I don’t know where to start. Yes, get an evaluation by a cardiologist to see what state your heart is in. If you are lucky and have no damage yet, find out why you are so tired, fix it, and then begin to do what you need to do in order to prevent a heart attack. Lose the 40 pounds, walk vigorously every day for 20 minutes as a start, and get the blood pressure and cholesterol under control if the weight loss doesn’t cure the high blood pressure and cholesterol! We have to be our own health care advocates, Maria. And that means taking responsibility for what we can change to prevent health crises. I am optimistic that you are ready to begin to change what you can change and am hopeful that you will have no damage to your heart at this time. I have asked Dr. Timothy Dutta, a board certified cardiologist and Clinical Assistant Professor of Medicine at Weill Cornell Medical College, to discuss the latest information about the seriousness of “silent heart attacks” in women. Dr. Dutta’s expertise includes preventive cardiology, coronary artery disease, valvular heart disease, echocardiography, and stress testing. He is also a member of our Medical Advisory Board.

Best,

Dr. Pat

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Women’s High Risk for Silent Heart Attacks—Attention Must Be Paid

By Timothy C. Dutta, M.D., FACC

Everyone knows to worry about a heart attack if he or she is having chest pain. Patients are well educated to recognize this symptom, to take it seriously, and to get to the emergency room.

If only heart attacks were always so obvious.  Unfortunately, not all patients having a heart attack will have chest pain. Women may be half as likely as men to experience chest pain as a heart symptom (28 percent vs. 55 percent). Women are more likely to have shortness of breath or other vague symptoms; some will have no symptoms at all. 

How commonly could a patient have a heart attack and not know it? Cardiac MRI provides a very accurate way to show scarring of the heart muscle from prior heart attacks. Several studies using this technology over the past several years have found that silent heart attacks are far more common than expected. A study in the Journal of the American Medical Association, published in September, again shows that silent heart attacks are common, and this study confirms that they are dangerous.

The study used cardiac magnetic resonance imaging (MRI) to look for silent heart attacks in patients over the age of 67 in Iceland. The researchers found that more patients had had silent heart attacks than known heart attacks. In the group of 936 patients who were studied, 91 had known heart attacks and 157 had unknown heart attacks. Over a six-year period, the patients with a recognized heart attack had a mortality rate of 33 percent; those with a silent heart attack had a mortality rate of 28 percent; and those who had had no prior heart attack had a mortality rate of 17 percent.

The single biggest risk factor for a future heart attack is a prior one. Controversy abounds over whether we are overusing heart medications, especially statins, in patients who are at low risk. But there is no controversy that patients who have already had a heart attack need the most intensive preventive management and the closest follow-up testing. 

Women are less likely than men to have chest pain as their symptom of a heart attack; less likely to get prompt care—even less likely to get an electrocardiogram upon arriving in the ER; and more likely to be incorrectly treated for anxiety rather than a heart attack. The lesson here is that patients, especially women, and their doctors, need to be ever-vigilant about unusual, less common symptoms of heart disease, such as shortness of breath, unusual fatigue, and disrupted sleep.  Translated, that means Be your own advocate. Assume that your new symptoms are serious—until proven otherwise.