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                                                                                MEDICINE, Page 72

The Biggest Killer of Women: Heart Attack


By LEON JAROFF -- With reporting by Lynn Emmerman/Chicago,
Deborah Fowler/Houston and Dick Thompson/Washington


    Awaking early one morning with a tight, nauseated feeling,
Catherine McCamey, a retired Washington postal clerk, took two
antacid tablets and tried to fall back asleep. But when the
tightness in her chest turned to pain, she took a cab to the
hospital. There doctors told her that she had suffered a heart
attack and that four of her coronary arteries were blocked, and
she had to undergo bypass surgery. Two years later McCamey, now
64, remembers her bewilderment over the incident. "I was really
shocked," she says. "I thought it was mostly men who suffered
heart attacks."

    Hardly anyone associates coronary artery disease with
women. Mention the words heart attack, and people are likely to
conjure up visions of a middle-aged, slightly paunchy male
suddenly keeling over at his desk. The statistics tell a
different, startling story:

    -- About 1 million Americans, nearly half of them women,
have cardiovascular disease. Of the approximately half a
million fatal heart attacks in the U.S. every year, 247,000
occur in women.

    -- Heart attacks are the leading killer of women, claiming
six times the number of lives lost to breast cancer.

    -- Women who have a heart attack are twice as likely as
men to die within the following few weeks.

    The widespread misconception that cardiovascular disease
is essentially a man's problem stems largely from the fact that
heart attacks are rare among pre-menopausal females. Of the
quarter of a million fatal heart attacks suffered annually
among women, only 6,000 occur in those under the age of 65.
Coronary heart disease in women "doesn't take off until
menopause," says Dr. Mary-Ann Malloy, a cardiologist at Loyola
University Medical Center in Chicago, "and in the past a woman's
life expectancy didn't extend much longer than that."

    What puts women at risk after menopause? The leading
theory holds that they lose their protection against heart
attacks because of a drastic reduction in the female hormone
estrogen. That might result in the rapid buildup of plaque on
artery walls where, until menopause, very little existed. "When
estrogen levels drop, you've just lost your best friend," says
Dr. William Castelli, director of the long-running Framingham
Heart Study.

    That point was driven home dramatically to Cindy Nelson,
a Texas bookkeeper. At age 29 she had a total hysterectomy,
which prematurely deprived her of estrogen. Ten years later, she
suffered two heart attacks within a month. Says she: "I never
thought it would happen to me at 39."

    Neither did emergency room doctors, who initially
diagnosed Nelson's problem as bronchitis. Women heart patients
charge that doctors often fail to respond with the same alacrity
to their cardiac symptoms as to those of male patients. Dr.
Peter Jones of Baylor College of Medicine in Houston, agrees.
"If a young woman under 60 came into an emergency room with
chest pains," he says, "she would not be taken seriously as a
heart attack patient." Loyola's Malloy suggests that women must
be more assertive about their heart concerns. "If you have
unexplained chest pains," she says, "start with a good internist
or cardiologist and pursue it until you're satisfied."

    That pursuit proved frustrating to Phoenix author Mantosh
Singh, whose personal experience with heart disease inspired her
soon-to-be published book, Strong Women, Weak Hearts. "If we are
premenopausal," she writes, "we are not expected to have
coronary artery disease, and our diagnosis and treatment is
neglected. If we are post-menopausal, we are suffering from the
`empty nest syndrome' and need an affliction to fill our
emptiness. In either case, our illnesses are supposed to be
mostly psychosomatic: of the mind, rather than physical."

    Such charges dismay Dr. Elsa-Grace Giardina, a
cardiologist at Columbia-Presbyterian Medical Center. "I would
like to think that we treat everybody equally," she says. But
her survey of medical literature tells her otherwise. "Women
don't get thrombolytic therapy (blood-clot dissolvers like
streptokinase) as often as men, they don't get coronary
angiography or angioplasty, and they don't get bypass surgery
as often as men."

    Some of the reluctance to administer these procedures
involves age; women heart patients are generally much older than
their male counterparts. "She has it when she is 65," says
Giardina. "He has it when he's 40. She has more diabetes, more
hypertension, and she's probably taking more drugs. She's not
as clean a picture as the 40-year-old man."

    These factors often give cardiologists pause. Should they
intervene aggressively when the risks are greater? Bypass
surgery, for example, is twice as likely to cause death in women
as in men. But "with the 40-year-old man," says Giardina, "there
is no question. Gotta do it."

    She also senses biases related to worth: "A 60-year-old
man is president of IBM; a woman of 60 is not. A 60-year-old
man may want to go back to full-time work, and many 60-year-old
women are not considered as important in life."

    Aggravating the problem is the fact that most major
studies of cardiovascular disease have largely excluded female
subjects. As a result, Loyola's Malloy complains, there are
"loads of data on men and none on women. That only increased the
impression that this was a man's disease." It also resulted in
therapies and procedures appropriate for men but not necessarily
beneficial to women. A landmark study showed, for instance, that
a small daily dose of aspirin helps prevent heart attacks in
men, but no one knows if the same is true for women.

    Other problems abound. When electrocardiograms (EKGs) are
used to test for heart disease, women more often show some
abnormalities. Consequently, many doctors are apt to ignore a
slight irregularity in women's EKGs, explains Dr. Gerald Pohost,
"unless it is crystal clear the woman has heart disease."
Pohost, director of the division of cardiovascular disease at
the University of Alabama Medical Center, thinks that the high
rate of EKG errors may result partly from the placement of
electrodes on a woman's chest -- more difficult to do because
of the female anatomy.

    Female breasts, he says, may also influence irregularities
on thallium stress tests; simply put, the breast tissue gets in
the way of the imaging technique. Doctors at Beth Israel
Medical Center in New York City have apparently circumvented
that problem by using the PET (positron-emission tomography)
scan, which they say is highly accurate in detecting even minor
heart damage in women.

    At director Dr. Bernadine Healy's instigation, the
NATIONAL INSTITUTES OF HEALTH is preparing to launch the Women's
Health Initiative, a $500 million, 14-year study of 140,000
postmenopausal women. The study will explore the effects of
diet, smoking and other factors on women's risk of developing
heart disease, stroke, osteoporosis, and breast and colon
cancers. The study will also evaluate the effects of hormone
replacement therapy: providing women with supplemental estrogen
or with estrogen plus progestin after menopause.

    Some studies have already suggested that these supplements
reduce the risk of heart disease by as much as 30% to 50%, but
cardiologists and their patients sometimes shy away from them;
larger doses, like those used in early birth-control pills, are
known to increase the risk of endometrial and breast cancer.
Still, many doctors, considering the even greater risk of
coronary-artery disease in the absence of estrogen, now endorse
the supplementary therapy. One strong advocate is Framingham's
Castelli, who calls the evidence of its efficacy in protecting
against both heart disease and osteoporosis "overwhelming."

    For all the hubbub about estrogen, its workings are still
somewhat mysterious. "We attribute the rise in heart disease to
menopause, in which the estrogen supply is diminished," says
Columbia's Giardina. "Yet we really don't know how estrogen
works." The hormone is known to promote higher levels of HDL,
the "good cholesterol" that helps keep arteries clear. Yet
estrogen increases HDL by only 10% or 15%, and Giardina suspects
that is not enough to account for the dramatic difference in
heart disease rates between men and premenopausal women.

    Part of the answer may lie in a report published two
months ago in Circulation, an American Heart Association
journal. In a study of some 1,900 men ages 42 to 60, Finnish
researchers determined that the risk of heart attack was greater
among men with high blood levels of iron than in those with
lower readings. For each 1% increase in the amount of ferritin
(a protein that binds iron), the risk of heart attack increased
by 4%. The reason, many doctors suspect, is that iron may
interact with LDL, "the bad cholesterol," in a way that promotes
the formation of plaque on arterial walls.

    Healy finds the Finnish study "very provocative." It
suggests that at least part of estrogen's protection is
indirect: by triggering the monthly menstrual flow, which
carries away iron, it reduces levels of the metal in the
bloodstream and lessens the threat of heart attack. When periods
cease after menopause, the reasoning goes, iron begins to
accumulate and the risk rises.

    Besides taking estrogen supplements, "women themselves can
do a lot to reduce their risk of heart disease," says Dr.
Millicent Higgins, associate director of epidemiology and
biometry at the National Heart, Lung and Blood Institute. She
recommends that women have their blood pressure checked and
treated if it is found to be high, eat diets low in fat,
exercise, lose excess weight and stop smoking. But most
important of all, she says, is that "women need to be aware that
they can have heart attacks."