Coronary heart disease is the single greatest killer of American women, extinguishing more lives (approximately one death per minute) than the next seven leading causes of female mortality. That women are far more concerned about the threat from breast cancer is testimony to the effectiveness of the public information and education programs of the American Cancer Society and the National Cancer Institute -- and certainly women should continue doing regular breast exams, annual mammograms, and PAP smears. However, they should also be aware that we know far more about risk factors for heart disease than for cancer. And often we can do something about them.
Understanding coronary heart disease
The coronary arteries supply the heart muscle with blood. Coronary artery disease, the most common cause of heart problems in adults, is due to a complex and prolonged process called atherosclerosis. This word translates literally as "artery hardening." Atherosclerosis is extremely common. It appears to begin as early as childhood or adolescence and proceeds slowly during the entire lifespan.
The process starts with small deposits of cholesterol and fat in the walls of the arteries called "fatty streaks." Next, white cells from the blood invade these streaks and ingest the fat, so that clusters of "foam cells" form within the streaks, which are now called plaques. Then, some of these cells die, leaving areas of fatty debris. The cell death also provokes inflammation and scarring, causing a "cap" of fibrous scar tissue to form over the plaque. Crystals of calcium phosphate tend to deposit in the dead material, making the arteries brittle.
As the plaques grow thicker, they narrow sections of the arteries, obstructing blood flow. When more than 80 percent of an area within a coronary artery is obstructed, the person may feel chest pain during stress or exercise. Finally, when plaques break down and lose their fibrous caps, the blood comes into contact with fatty, dead material, causing a clot (thrombus) to form. Such clots may block the artery completely, causing a heart attack (myocardial infarction). Deprived of blood flow and oxygen, an area of heart muscle effectively dies, and such episodes are frequently fatal. Even if the person survives, they may be left with a scarred heart that is prone to rhythm abnormalities and reduced function (heart failure).
Evaluating risk for atherosclerosis
Fortunately, over the last 30 years or more, medical science has learned a great deal about the factors that contribute to atherosclerosis and heart attacks. There are now guidelines for classifying a woman's heart attack risk, and, based on this classification, physicians can recommend interventions to reduce the risk.
The following factors place women in the high risk category (probability of a heart attack greater than 20 percent in the next five years):
1. A previous heart attack or angina
2. Symptoms from arterial disease in arteries other than the coronaries, including:
- aortic aneurysm
- stroke (cerebrovascular disease)
- peripheral artery disease
3. Diabetes
4. Chronic kidney disease
Those in the intermediate risk category (probability of a heart attack 10-20% in the next five years) have:
- More than a minimal amount of coronary artery calcium (seen on special x-rays) without symptoms
- The metabolic syndrome (abdominal obesity, high blood sugar and insulin levels, high blood pressure, and low plasma HDL cholesterol and high triglyceride levels)
- Multiple risk factors (such as elevated LDL cholesterol with high blood pressure)
- Markedly elevated levels of a single risk factor (such as elevated LDL cholesterol or high blood pressure)
- A close relative who experienced early onset heart disease (male <55 years, female <65 years)
Those in the lower risk category (probability of a heart attack less than 10 percent in the next five years) may still have one or more risk factors, but the problems are lower level. Women classified as optimal risk have uniformly low levels for known risk factors and a heart-healthy lifestyle.
A detailed scoring sheet for determining heart disease risk category by age, range of total cholesterol, levels of HDL ("good") cholesterol, smoking history, and blood pressure is available at the National Cholesterol Education Program. Not included in this assessment are other known risk factors for heart disease, including the presence of C-reactive protein (also known as CRP, a marker of inflammation), coronary calcium (determined by X-ray scanning), glucose intolerance (high sugar and insulin levels, best determined by a glucose tolerance test), size classification of blood cholesterol particles, Lpa (a modified lipid particle in blood), and homocysteine (a product of amino acid metabolism).
Evidence suggests that women between the ages of 40 and 55 should ask their physicians to measure these factors so that they can accurately determine their risk of heart problems. Because atherosclerosis appears to accelerate after menopause, and because lipid profiles (total, LDL and HDL cholesterol and triglycerides) tend to change for the worse at menopause, it might be best to do the measurements within a few months after you stop menstruating.
Preventive measures
No matter what risk category you fall into, regular exercise and a heart-healthy diet are good measures for preventing atherosclerosis. Lipid lowering drugs (such as the "statins") and blood pressure drugs are recommended only for women in the high risk category and/or those who have certain specific conditions too complex to describe in detail here. It is a good idea to discuss possible interventions, including hormone therapy (HT) with your physician once you determine your risk factors.
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