Women are more vulnerable to coronary heart disease

By
Dr Sashi Acharya M.D., Ph.D
Shiva Hospital Birgunj
shivahospital@hotmail.com

Heart disease is having an epidemic character in both the developed and developing countries, not the cancer but the heart disease is the number one and leading killer of men as well as women in most of the developed countries. One in every five British women dies from coronary heart diseases, the same way one in three American women dies of heart disease. Coronary heart disease (CHD) not only takes the life of the millions of people but also people make suffer from pain and organic disability. The cases of heart diseases are not uncommon in Nepal. The record of Tribhuvan University Teaching Hospital (TUTH) shows that over 23% of the people visiting the hospital suffer from heart diseases and 80% of the heart patients are male and 20% are female. Dr M.R. Pandey found coronary heart disease (CHD) in about 5% of 100 Government employees examined in Kathmandu valley. At NORVIC, to date there have been 25000 out patients and 5000 in patients according to the data published in the weekly magazine of "THE KATHMANDU POST"03 Feb 2002.Coronary heart disease is more deadly in women than in men.

Atherosclerosis is the main predisposing factor of coronary heart disease. In the process of atherosclerosis the fatty materials or plaques are deposited on the inner walls of the arteries leading to the hardening of the arteries and making them narrow. Coronary heart disease is caused by the fatty deposits on the walls of the coronary arteries feeding heart. Sometimes atherosclerosis can cause angina, a severe chest pain specially developed on exertion or stress. This pain is caused due to insufficient blood supply to the heart through arterosclerotic coronary arteries. When there is inadequate blood supply there is inadequate amount of oxygen and nutrients to the heart. But this process is reversible and temporary. Usually this pain is relived after rest. However, untreated angina may lead to heart attack. Heart attack is often triggered by a plaque rupture and results in the formation of a large blockage (thrombosis) in the coronary artery.



Warning Signs and Symptoms of Heart attack: The first warning sign of heart attack is severe burning and crushing chest pain behind the breast bone which may irradiates to both the hands, specially the left. It also may irradiate to the jaw and neck. In heart attack pain is very severe and is followed by sweating, nausea, anxiety and feeling of fear of death. Symptoms of heart attack may be different in women. Women tend to have less typical symptoms of heart attack. The symptoms may be just mild chest pain, indigestion, dizziness, shortness of breath and abdominal discomfort. These less typical symptoms of CHD in women prevent them from earliest recognition of the disease and thereby from earliest possible treatment. One can hardly believe that in the highly civilized country like United States about 35% heart attacks in women go unnoticed and unreported to physicians

Women are at greater risk of a fatal heart attack:
The First heart attack in women is more severe and they are more likely to have next heart attack within one year and also more likely to die after their first heart attack. There are number of factors which affect women in the course of their heart attacks. These are:
1. · Atypical (less typical) symptoms of heart attack following late recognition of the disease and delayed treatment

2.· Onset of the disease usually in the older age as compared to men. At older age, women are more likely to have diseases like diabetes, hypertension co- existed

3. · Low level of good cholesterol (HDL) - as the stronger predictor for heart attack in women than in men. In about 40% of women after menopause increase the levels of total cholesterol including bad cholesterol (LDL) thus making higher chance for coronary heart disease.

4. · Smoking- itself a great risk factor for heart attack. In women the incidence of heart attack and death is higher as compared to men among the smokers.

5. · Using of contraceptive pills and smoking at a time increases the risk for CHD in women 30 times higher as compared to the women using contraceptives alone.

6.· Diabetes Mellitus increases 3-7 times risk for CHD in women whereas in men increases 2 times.


Heart attack looks sudden but not. The risk factors open avenue for emergence of sudden heart attack.

Risk factors causing coronary heart disease:
It is now obvious that risk factor of CHD is" multiplicative rather than additive". The major risk factors are Smoking, Hypertension, Overweight and High blood cholesterol, age (Men 45 years or older; women 55 years or older), gender, family history of heart disease and diabetes mellitus.

Smoking
Smoker has twice higher risk than non-smoker for CHD. According to Public Health, Danish researchers, smoking as few as 3 to 5 cigarettes daily increases the risk of heart attacks and death. If you smoke and use the contraceptive at a time, risk for CHD is 30 times higher than the nonsmokers using contraceptive alone as cited above. In South Asia tobacco is used for smoking and chewing. They are equivalent to cigarette smoking. According to data of WHO, cigarette smoking rate in Nepal is highest (73.7%) as compared to other south Asian countries The highest rate of smoking is more explosive for CHD.

Blood Pressure
Blood pressure should be kept below 140/90mm Hg. Individuals with high blood pressure are at a greater risk for cardiovascular problems like heart attacks. More than 60% of all women over 65 have high blood pressure. Regular check up of blood pressure and regular treatment as directed by the professionals are suggested

Healthy Weight, Diet and Healthy Exercise
We all know that healthy weight and diet are very important factors to protect heart. Excessive fat and cholesterol accelerates atherosclerosis of blood vessels leading more chance for CHD. . Diet high in fruits, vegetables, grain, low fat dairy products, healthy cooking oils like canola, avocado, safflower, sunflower, fish oil and cutting down meat, egg yolk are recommended. . Healthy weight is possible only through healthy diet and healthy exercise. American College of Sports Medicine recommends regular physical exercise for at least 30 minutes daily.

High Cholesterol Level
High cholesterol level, triglyceride level and low density Lipoprotein (LDL) or Bad cholesterol accelerate atherosclerosis. Low level of high density lipoprotein (HDL) or good cholesterol- a stronger predictor of CHD and is more vulnerable to women. According to The American College of Cardiology women's HDL level should be at least 45mg/dl. Desirable cholesterol levels in healthy people and in patients with coronary heart disease is given in table below:


 Desirable Level in Healthy individuals Desirable Level in CHD patients
Total Cholesterol < 200 mg/dl " "
Triglyceride < 150 mg/dl " "
HDL Cholesterol Not less than 40 mg/dl > 40 mg/dl
LDL Cholesterol < 130 mg/dl < 100 mg/dl

As men and women get older their cholesterol levels rise. When cholesterol levels are elevated both men and women are at greater risk of coronary heart disease. Family history of heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65) is considered as one of the major risk factor.

Menopause, Diabetes and CHD in women
In 40% women above the age 55 (after menopause) increases the cholesterol level. Before menopause women are mostly protected from CHD. This is the advantage of women over men, however, after menopause the condition is different increasing the risk for coronary heart disease. Diabetes Mellitus increases 3 to 7 fold or even 10 fold chance for CHD in women whereas in men 2-3 times. Menopause and Diabetes mellitus effectively eliminate the female advantage over men. After menopause heart protective hormone estrogen level decreases. Recent studies show that hormone replacement therapy is not helpful in the treatment and prevention of CHD in women. Heart disease has been very common in our country affecting both men and women. Following is the data regarding CHD among the patients admitted in Shiva hospital Birgunj: Five hundred patients relatively concerned were selected for analysis. Randomized Selection of the patients was done on the age basis, age varying from 30 to 85 years. In this analysis the prevalence of CHD is found to be 9.8% Among the patients of CHD, 49%were male and 51% were female 57 % of the patients suffering from CHD had coexisted diseases like Diabetes Mellitus (in 5 out of 49 patients or10.2% ) and Hypertension (in 23 out of 49 patients or 46.93%).
It is important to note how common is CHD in our socio-economic context and how often CHD is coexisted with diseases like Hypertension and Diabetes Mellitus which are considered to be the risk factors of coronary heart disease. Angina and heart attacks are chronic and progressive coronary heart disease that develops over many years. Many of the risk factors could be prevented just adopting heart healthy life style and preventing cigarette smoking. Heart healthy life style includes cholesterol lowering diet, aerobic exercise and weight management making the heart patients live longer, healthier and happier. Heart-healthy life style adds years to life and life to years to the patients. Less typical symptoms of heart attacks in women make much more difficult to recognize heart attacks in time. Women and we health professionals are required to learn all the possible measures to prevent heart problems and get the earliest diagnosis and earliest possible treatment.

Bibliography:


1. Women and Coronary Heart Disease.http:/www.healthnet.org.uk/new/facts/facts 07.htm
2. http://www.nhlbi.nig.gov/health/public/heart/other/hdw-syn.txt
3. Nishtar S. preventing coronary disease in south Asia.heartfile.org/apend.htm
4. http://quit smoki…/aa 022800a.htm.
5. http://stress.about.c.../bldyh15.htm
6. Smoking Control Among Health-Care Workers-World No. Tobacco day,1993 MMWR may 21, 1993/Vol. 42/ No. 19
7. http://www.life heart.com/ patient/ angina / cad. asp
8. http//www.life heart.com/ patient/ quality of life/ nutrition. asp
9. Study of Menopausal Women with Heart Disease Finds No Benefit, Potential for Harm from Hormone Therapy and Antioxidant Vitamins(NHLBI Network@ AIR.org)
10. http://www.nhlbi.nih.gov/whi/
11. Even light smoking is harmful cutting down on cigarettes is just not good enough. http:// heartdisease.about.com/library/weekly/
12. Circulation.1999; 99:2480-2484. American Heart Association, Inc.
13. National Coalition for women with Heart Disease copyright 2002
14. www.bbc.co.uk/health/heart
15. Mayo clinic Heart Book 2nd Edition Bernard J. Gersh, M.D.
16. Annual Review of Diabetes by The American Diabetes Association, Inc.
17. Alarming Rise Among Rich and Poor: SPOTLIGHT Vol, 21:No.38,Apr 05-Apr 12, 2002
18. Cardiac disease shows a marked rise by Tashi D Thinley: THE KATHMANDU POST April 26, 2001 Baishak 13, 2058.
19. Heart 2002; 88:573- 578, 553-554.
20. Coronary Artery Disease edited by Lee B. Weitzman, M.D, FACC, FCCP: Heart center on line newsletter.
21. http://www.heartdisease.about.com/library/weekly
22. http://www.nhlbi.nih.gov/health/public/heart/ Facts about Heart Disease & Women: So You