Dear Dr. Andersen,

I have a strong family history of coronary artery disease even though no one in my family has diabetes or obesity. Everyone who had this problem was fit and did not smoke. Maternal grandfather died in his 50’s of a sudden heart attack. His sister died of heart failure in her 60’s after having survived two heart attacks in her 50’s. My mother and her sister had high cholesterol but no other risk factors; both died young after their symptoms were thought to be due to indigestion. They were in their late mid 50’s.

My generation–siblings and cousins–are entering our 40’s and are quite frankly terrified of our fate. We are a group of healthy women and want a fair shot at surviving what we know to be the number one killer of women.

Would you review the symptoms of a heart attack that women may have that are different from those that men have? Should we be on a cholesterol lowering drug or aspirin daily? None of us has really high cholesterol but we all have total numbers around 200 with higher levels of the bad cholesterol than the good. Our triglyceride levels are normal. We don’t have high blood pressure or any other medical conditions. What diagnostic tests should we have and how often?

I read that there is a test called troponin that can help doctors in emergency rooms differentiate between heart attacks and other conditions. Is this a valuable test yet? Is it widely available?

Should we wear those bracelets that people with allergies wear, “Warning: Might be having a heart attack?”. The only stress we have is this one and we know it isn’t good for us.

Thanks for your writing about heart disease. Your readers appreciate it.

Best,

Norma

Dear Norma,

Your family history of heart disease – more specifically, coronary artery disease – is indeed impressive. I am most saddened that your mother and sister had high cholesterol and symptoms from their heart disease, but were misdiagnosed and died too young. Indeed it is our youngest female patients who have the greatest death discrepancy rates compared to the youngest men and we do not know why – but underdiagnosis, less aggressive treatment and, perhaps most importantly, lack of education about prevention all contribute to this. Death rates due to heart disease have declined over the past few decades in this country, but we now know that the incidence of heart disease in our youngest adults, age 29-39 has been increasing since 2000, and is increasing faster in young women.

The most common symptom of a heart attack is chest pain, but 43 percent   of women having heart attacks do not have chest pain. A troponin test is a blood test that can be measured fairly quickly in any emergency room in this country to confirm the diagnosis of heart attack, but ideally, we want make the diagnosis before waiting for a blood test to come back. Symptoms in women are more often atypical and can be jaw pain, shortness of breath, weakness or indigestion — as in your mother and sister. We doctors need to be suspecting the diagnosis of heart disease more often in women — and even in young women — and treating them more aggressively. You don’t need a bracelet, because unless you are in cardiac arrest (which every health practitioner will recognize) you will be able to speak for yourself — and you need to speak for yourself. You need to be your own health advocate. If you are not feeling right, get evaluated and demand that your heart gets fully evaluated.

T here is no one “tell-all” screening test. You could have a normal stress test on one day and die of a heart attack the next, from a plaque rupture that we do not know how to predict. You can get a 64 slice CT angiogram (be exposed to radiation and dye and take a chance your life insurance rates will increase) but this will only tell you how much plaque you have, not necessarily what to do about it — unless it is so critical you need an intervention, such as surgery or stenting.

Nonetheless, Norma, there is also a tremendous amount you can do to reduce your risk of developing and dying from this disease.

First of all – you are what you eat. The plaque that clogs our arteries (and leads to strokes and heart attacks) comes from dietary fat and cholesterol.

• Avoid or significantly cut down on animal fats, like fatty red meats, butter, and cream —although polyunsaturated fats, as from vegetables and fish, are actually good for you.
• Also avoid excess salt, which can increase your blood pressure.
• Eat whole foods rather than processed foods.
• If you are overweight, or more specifically have excess fat in your waistline (over 35 inches for women, 40 in men) you should also reduce your intake of calorie-packed, nutritiously deficient white carbohydrates like rice, pasta, potatoes and bread. The fat around your waist is metabolically active; it can make your blood pressure higher, cholesterol levels worse, and increase your chance of developing diabetes – all of which contribute to heart disease.

The second most important thing you can do for your heart health is be physically active. Physical activity is the fountain of youth; the more you do, the better. Just walking briskly, for 20 minutes three times, a week has been shown to reduce premature death rates by 50 percent   or more in both men and women.

Get your blood pressure checked; if it is high, get it treated. Physical activity and a low salt diet, rich in fruits and vegetables, will lower blood pressure; but if it remains elevated ( > 140/85 mmHg) a medication may be needed.

Have cholesterol goals. Your total cholesterol may not be high, but what is the breakdown? Given your dramatic family history, I would encourage you and your family members to aim for a level of LDL (the bad cholesterol) of less than 100 and an HDL (the good cholesterol) of at least 50. I would, indeed, strongly consider taking a statin medication (e.g. Lipitor, Zocor, or Crestor) to help achieve this. If your HDL is very low, medication such as niacin has proven to be extremely helpful – not just by increasing your HDL, but by making the HDL that you have more effective.

Statin medication has also been shown to reduce the risk of heart disease in healthy men and women with acceptable cholesterol levels, but with an elevated marker of inflammation – high sensitivity C-reactive protein (hs-CRP). This can be easily measured in the blood. Niacin is also helpful in lowering Lp(a) – a molecule in the blood known to accelerate heart disease. This is elevated in some families, and should also be measured in you and your family members.

And an aspirin a day has been shown to reduce the risk of a first heart attack in high risk men over the age of forty, and reduce the risk of a first stroke in women over 65; it’s also been recommended for use in very high-risk women under the age of 65, so you may wish to consider this as well.

Norma, we haven’t figured it all out yet. Clearly, there are risk factors for heart disease which we have yet to discover. You may be a very happy family, but stress impacts all of us, and working to reduce your stress – on a daily basis – is important. Attempting to get a good night’s sleep is undervalued, and I believe crucial for good heart health.

Sometimes the first symptom of heart disease is sudden death: That is why prevention is so important. Norma, if you can focus and attempt to work on all I’ve written about, you can change the natural history of this disease in you and your family.

Please know, we are working very hard to better understand this disease. I have a very busy and wonderful practice — I love my patients; but I am now dedicating part of my career and my life to patient and doctor education about prevention and treatment of this disease – particularly in women. I will be so happy to keep you posted.

Good luck, Norma. You are empowered — there is a lot you can do. Everything that is good for your heart is good for you.

Most sincerely,

Holly S. Andersen, M.D.