How to keep your heart healthy

Although the vast majority of Canadian women don't realize heart disease and stroke are enemy No. 1, Marlies Caswell wasn't one of them. Since both of her parents had heart disease (her mother died of a heart attack at 61), she made a point of eating healthily and exercising regularly.

When she turned 40, she reminded her doctor about her family history, and he decided to send her to a cardiologist once a year to get tested for any signs of heart trouble. But what she didn’t know is that one of the major tests used to detect heart disease, the stress test, doesn’t work as well in women as it does in men. No one knows why.

When Marlies turned 50, her cholesterol shot up. Her doctors told her the jump was likely the result of hormonal changes (although she hadn’t yet hit menopause), and put her on Lipitor, a cholesterol-lowering drug. She carried on without too much worry, raising her daughter and working full time as a marketing manager with a national wine and spirits company in Vancouver.

“I’d never experienced one sign anything was wrong,” she says. “Even though I’d had two parents with heart disease, I still thought I had this beat.”

The truth is in the tests
A year later, at her annual heart checkup, an astute cardiologist noted her risk factors. He sat her down, and despite a pass on her latest round of tests, asked if she would mind if they did an angiogram (a dye test that reveals blockages in major arteries). “I thought maybe they’d find a 20 per cent blockage in one artery, give me some medication, and I’d be fine,” says Marlies.

The situation was much more dire. The test showed three of her arteries were badly blocked, and a heart attack was imminent. She needed triple-bypass surgery. “When I found out they were going to operate on the most important organ in my body, I was naturally very frightened,” says Marlies. A few months later, after a successful surgery and recovery, she would count her lucky stars that the cardiologist had bothered to probe further that day.

The difference between men and women
Statistics show that women face significantly worse odds than men do when it comes to heart disease and stroke: women are 16 per cent more likely to die from a heart attack, and stroke kills 45 per cent more women than men.

To add insult to injury, only 32 per cent of women are referred to a cardiologist following a heart attack, compared to 38 per cent of men, and women are almost three and a half times less likely to receive bypass surgery.

Experts agree a number of culprits are at play – misinformation, biology, age – but they all agree on one lifesaving truth: knowledge is power. Having an action plan enables women to prevent heart disease, as well as recognize its symptoms, while ongoing research gives us hope for better diagnostic tools and treatments that will close the gender gap.

“Men and women are more similar than dissimilar when it comes to heart disease,” says Dr. Beth Abramson, a cardiologist and associate professor of medicine at the University of Toronto. That being said, one significant difference is that most women are “protected” from heart disease, possibly by their hormones, until menopause, after which their risk catches up to men’s. But experts don’t know why.

Women's heart disease risks
Women are susceptible to most of the same risk factors as men, namely high blood pressure, damage from smoking, high cholesterol, diabetes and a family history of heart disease.

However, women with diabetes are significantly more likely to develop heart disease than others, says Abramson. Again, no one knows why. Pregnancy can also induce certain conditions that increase women’s risk for heart disease down the road, such as pre-eclampsia (hypertension in pregnancy), which can double our risk of having a heart attack in the future.

What you can do
But women can reduce their risk of heart disease and stroke by as much as 80 per cent by making simple lifestyle changes. “Women just haven’t made the connection that cardiovascular disease is a women’s disease, and that there is something you can do if you start early enough,” says Jennifer Price, an advanced practice nurse specializing in cardiology at Women’s College Hospital in Toronto.

Also, women should not deceive themselves into thinking estrogen is a free pass to an unhealthy lifestyle until menopause strikes, adds Bobbe Wood, president and CEO of the Heart and Stroke Foundations in B.C. and the Yukon. “All of the choices we make throughout our lives contribute to a plus or minus sign. Either you increase your risk or you decrease your risk of heart disease or stroke,” says Wood. “And it’s never too early to start.”

More subtle symptoms
According to Price, “what makes women harder to diagnose is that their symptoms may not be as clearcut as men’s.” Indeed, science has yet to explain why 25 per cent of women won’t have any symptoms, and half of the women who have heart attack symptoms will have symptoms similar to men’s.

The common signs include crushing chest pain below the breast bone, shortness of breath and sweating. However, the other half of women who experience symptoms, such as Marlies, will complain of back pain, neck pain and fatigue, which may last for a few days, or just a few hours. Wood explains that women tend to experience vague symptoms, such as discomfort or anxiety. “Women at risk for heart disease shouldn’t hesitate to act on any symptom, no matter how minor it may seem,” says Wood.

An underlying biological difference in heart disease could explain why, in some cases, it is harder to diagnose and treat in women. For example, research sponsored by the United States National Heart, Lung and Blood Institute has shown that doctors are more likely to look for major blockages in angiograms, whereas in many women there are two areas of dysfunction – one in the cells that line the coronary arteries, and another in the tiny vessels that branch within the heart – that may go undetected.

This female-specific vascular disorder was discovered by newer tests, such as ultrasounds of the blood vessels. The hope is that new screening capabilities and treatments will soon be more available to catch this heart condition unique to women.

Gender-specific research
The good news is that medicine is making up for lost time. A wealth of new research projects are underway through the Genesis Project, headed by Dr. Louise Pilote, a cardiovascular epidemiologist and professor of medicine at McGill University in Montreal.

In one of the major Genesis studies, for example, researchers will be trying to arrive at definitive differentiations between men’s and women’s heart-disease symptoms. This enormous five-year undertaking aims to compensate for the fact that, to date, less than 20 per cent of heart research participants have been women.

“When we apply the results of these studies to women, we really don’t have enough information to conclude with statistical power that the results will be the same in women.” For example, she says, this explains why cholesterol-lowering drugs are not as effective in women as they are in men.

For the most part, experts believe the medical community is beginning to treat women differently. They temper some of the scary statistics by suggesting women’s death rate due to heart attack may be higher because of age-related complications, since we tend to have our first incidences of the disease seven to 10 years later than men. But Pilote points out that women may be receiving less treatment, either because we miss the signs and therefore the window of opportunity for certain procedures or medications – a serious concern – or because there are simply fewer treatment options for us.

Marlies says women are ultimately in the best position to inform themselves. “I’m constantly making my daughter, now 28, aware of the risks she may face.”

Know your risks!
Most Canadian women have at least one risk factor for heart disease or stroke, according to Bobbe Wood, president and CEO of the Heart and Stroke Foundations in B.C. and the Yukon.

Uncontrollable risk factors:
Increasing age: Men tend to have heart attacks younger, but women’s risk catches up with age.
Heredity: If you have a male or female parent or sibling who had heart disease before the age of 55, you are at an increased risk.
Previous heart attack or stroke: Forty-three per cent of women age 40 and older who survive a first heart attack will be at an increased risk to have another one within five years.
Ethnicity: First Nations, Inuit, Métis, South Asian, and African men and women are at an increased risk.

Controllable risk factors:
- Smoking (and exposure to secondhand smoke)
- High cholesterol
- High blood pressure
- Physical inactivity
- Obesity or being overweight
- Diabetes (type 1 or type 2)

Women’s risk factors
Menopause: Estrogen’s positive effect changes with menopause. It can increase bad cholesterol levels. Menopause may lead to increased blood pressure and more body fat around the waist, have harmful effects on the way blood clots, and may affect the way our bodies handle sugar.

Birth control pills: In a small proportion of women, oral contraceptives increase the risk of high blood pressure and blood clots (the risk is greater if you smoke, already have high blood pressure, are over 35 or have other risk factors for heart disease).

Pregnancy: Conditions during pregnancy that put women at a higher risk of heart disease include pre-eclampsia and gestational diabetes.

Could it be an attack?
Don’t hesitate to get medical help if you experience any of these symptoms and are at risk for heart disease. You have a one- to three-hour window before treatment options become limited, says Dr. Louise Pilote, a cardiovascular epidemiologist and professor of medicine at McGill University in Montreal.

Five warning signs:
1. Nausea, indigestion or vomiting
2. Sweating and/or cool, clammy skin
3. Difficulty breathing
4. Chest pain or discomfort*
5. Pain in the arm, neck, jaw or back*
Sudden discomfort or pain in these areas that does not go away with rest may indicate a heart attack. For women, chest pain may not be the first sign. Watch for unusual tiredness, trouble sleeping, problems breathing, indigestion and anxiety up to a month or so before a heart attack.

*May feel like burning, squeezing, heaviness, tightness or pressure.

Take action
Quit smoking.
“Quitting smoking is the most important thing you can do to cut your risk,” says Jennifer Price, an advanced practice nurse specializing in cardiology at Women’s College Hospital in Toronto. Smoking contributes to atherosclerosis (hardening of the arteries), doubling the risk of developing heart disease and certain types of stroke. The good news: after one year of quitting smoking, your risk of heart attack is half that of a smoker. Check out methods to quit smoking at the Lung Association’s website, lung.ca.

Get your cholesterol checked
If you have any risk factors for heart disease, you should get your cholesterol tested annually. You may be able to control your levels with diet changes.

Get your blood pressure checked, too
High blood pressure (the measure of the pressure of blood against the walls of your blood vessels) affects one in five Canadians. High blood pressure damages the walls, resulting in weakness or scarring that promotes the buildup of plaque, which blocks arteries. Controlling your blood pressure by managing your weight, eating a low-sodium healthy diet and getting regular exercise can reduce your risk of stroke by up to 40 per cent and your risk of heart disease by up to 50 per cent.

Eat five daily servings of fruit and vegetables
Of course, you need to reduce your consumption of saturated and trans fats, and processed and salty foods as well.

Zen out
“People think it’s stress that kills us,” says Dr. Beth Abramson, a cardiologist and associate professor of medicine at the University of Toronto, “but it’s how we deal with stress.” Find healthy ways to cope with stress, such as exercising, instead of reaching for fatty comfort foods. If you’re really overburdened, consult with a life coach or talk to loved ones about sharing some of the load.

Measure your waist
If your waist is more than 35 inches around, you could be at an increased risk of heart disease. Obesity begets high blood pressure and diabetes, which beget heart disease.

Schedule exercise into your calendar
Exercise 120 to 150 minutes per week and you’ll reduce your risk of heart disease by 30 per cent, according to Bob Reid, associate director of prevention and rehabilitation at the University of Ottawa Heart Institute. Check out easy ways to increase your heart rate below.

Exercise for a healthy heart
Here’s motivation: Research shows that inactive women are at twice the risk of developing heart disease as active women. Aerobic exercise combined with strength training is the best kind of exercise to protect your heart, says Reid.

Try to choose activities that work out your upper body, too, he adds, such as cross-country skiing, tennis and swimming. “Even well-paced walking goes a long way to improving cardiovascular health. One of the biggest issues women have is that they put everyone else’s health before theirs,” says Reid. “Break up your overall expenditure through the day into bouts that are 10 minutes long if you need to.”

- Since research shows women tend to benefit from social support during exercise, consider joining a group – or starting one of your own!

- Don’t rule out high-intensity activity. Research shows women aren’t as engaged in strenuous activity, such as playing on sports teams, as men.

- Look for ways to incorporate exercise into your commute, for example, cycling to work.

- Strive to work out at 60 to 80 per cent of your maximum heart rate. Calculate your rate by subtracting your age from 210, which gives you your maximum. Work out at 60 to 80 per cent of that. And you don’t need a fancy heart rate monitor, says Reid. Simply count the number of beats in 10 seconds by holding two fingers on your wrist while exercising. Multiply that by six to get your heart rate.

Cholesterol’s role
Cholesterol is a big concern for women. After menopause (at, on average, age 51), levels tend to rise, says Dr. Beth Abramson, a cardiologist and associate professor of medicine at the University of Toronto. In fact, almost half of all Canadian women between the ages of 18 and 74 have high cholesterol levels; a whopping 80 per cent of women aged 65 to 74 have unhealthy levels.

Cholesterol is a fat in our blood that our bodies use to make cell membranes, vitamin D and hormones. Low-density lipoprotein (LDL) is dubbed “bad” cholesterol because it promotes plaque buildup. High-density lipoprotein (HDL) is “good” cholesterol – it helps get rid of LDL. Some people can control cholesterol with lifestyle changes, but it may also be necessary to take medication.

Strategies:
- Reduce daily fat intake to 20 to 35 per cent (for a woman this is between 45 and 75 grams of fat a day)
- Cook with healthy fats, such as polyunsaturated and monounsaturated oils (such as olive oil)
- Avoid unhealthy fats, including saturated and trans fats
- Quit smoking (it increases your LDL)
- Be active most days of the week

Choose more often:
- Vegetable oils
- Nuts and seeds
- Fish
- Fruit and vegetables
- Whole grains

Eat less often:
- Egg yolks
- Partially hydrogenated vegetable oil
- Hard margarines
- Fast/processed foods
- High-fat dairy products (cream and cheese)

What are heart disease and stroke?
Heart disease covers many conditions. The most common, coronary artery disease, involves blood vessels in the heart that become blocked with a combination of fatty materials, calcium and scar tissue (called plaque), preventing oxygenated blood from reaching the heart.

A stroke is an interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels in the brain (hemorrhagic stroke). About 80 per cent of strokes are ischemic, and the buildup of plaque narrowing the arteries that supply blood to the brain is involved in most incidences.

Learn more about your heart health under Disease Prevention in our Health and Nutrition section.

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