Coronary artery disease (CAD) is the leading cause of death in women in the developed world. CAD refers to narrowing of one or more of the arteries sitting on the heart muscle. If blood flow to one of these arteries is suddenly reduced to a blocked artery caused by a blood clot, or by rupture of an existing narrowing, this leads to a heart attack. Women with risk factors for heart disease are at increased risk for heart attack, directionally similar to men. CAD causes approximately four times as many deaths in women compared to breast cancer. Compared to men, women are at higher risk for bleeding after invasive cardiac procedures. They are also more likely to develop autoimmune diseases and fibromuscular dysplasia (a condition that causes focal narrowing and enlargement of medium-sized arteries in the body), potentially predisposing to heart attack in the absence of traditional atherosclerotic-type blockage of heart arteries, especially among younger women. Furthermore, while women typically have the same rate of CAD onset 10 years later than men this cardioprotective effect is reduced in women with polycystic ovary syndrome, cigarette smoking and women entering menopause (including premature menopause). Also, specifically to women, hypertensive disorders of pregnancy (such as preeclampsia), gestational diabetes and preterm delivery are also recognized as factors which increase lifetime risk of heart attack.
Taking this sobering information into account, the following things will help every woman reduce their risk of heart attack:
1. Be aware that your symptoms of a heart attack may not follow the textbook.
Chest pain is the most common symptom of heart attack in both men and women. However, compared to men, women are more likely to have a heart attack without chest pain, and their symptoms may vary widely and may simply consist of weakness, fatigue, nausea, breathing difficulties or pain in neck, jaw, or back.
2. Be aware that your risk of heart attack increases after menopause, but hormone replacement therapy does not lower that risk.
Premenopausal women have lower risk of heart attack compared to men, but this protection narrows after menopause. This increased heart attack risk is partially because women entering menopause are mostly older than premenopausal women, and advancing age is usually associated with an increase in percent body fat. In women going through menopause, the loss of oestrogen may increase circulating lipids and lipoproteins. Taken together with age-related increase in body fat, women undergoing menopause are at increased risk for insulin resistance, hypertension, and increased cholesterol, all increasing heart attack risk. In some cases, hormone replacement therapy primarily used to treat menopausal symptoms may increase the risk of heart attack among menopausal women. If menopausal hormone therapy is used in menopausal women, it should be at the lowest effective dose, administered early (within 5 years) of menopause, and should not be prescribed for the primary purpose of preventing heart disease.
3. Recognise and treat polycystic ovary syndrome.
Polycystic ovarian syndrome (PCOS) often occurs in premenopausal women who are overweight or obese and is clinically characterized by androgen excess. This may be suspected in women with hirsutism, menstrual irregularities or infertility. PCOS increases heart attack risk, largely because of accompanying metabolic problems like insulin resistance, glucose intolerance, diabetes mellitus, hypertension, deranged lipid profile (increased triglycerides and decreased good cholesterol, HDL) and metabolic syndrome. As with other patients at elevated heart disease risk, women with PCOS should be aggressively treated with lifestyle factors including optimal nutrition and increased physical activity. Early use of medications may also be needed, such as statins and metformin therapy that lower triglycerides, and improve insulin resistance with improvement in menstrual regularity, hirsutism, acne, and spontaneous ovulation.
4. Know your weight and waist.
Your body mass index, a calculation based on your weight and height, should ideally range between 19 and 25 to minimise risk of heart attack. In addition, your waist circumference should be less than 80 cm. Excess abdominal fat is a risk factor of heart disease, diabetes, non-alcoholic fatty liver disease and other cardiometabolic condiitons.
5. Eat heart healthy.
Your diet is typically the biggest influence on weight and waist circumference. However, even at a healthy BMI and waist circumference, an unhealthy diet can increase your risk of heart attack. There is no single diet that is perfect for all patients, but as outlined here, a Pesco-Mediterranean diet is a good place to start. Minimise refined carbohydrates, processed meats and foods high in sodium and trans fats. Use moderation when consuming unprocessed red meats, poultry, eggs, and milk. Have a high intake of fruits, nuts, fish, vegetables, vegetable oils, minimally processed whole grains and legumes. Remember to make long term adjustments that you can sustain – fad diets or short term solutions don’t last.
6. Limit your alcohol intake.
While some studies have previously shown that a small amount of red wine can reduce the risk of heart attack, that’s no reason to start drinking if you don’t already due to the net clinical harm that alcohol causes for a range of other conditions. If you do drink alcohol, do so in moderation, which in females, no more than one drink per day. More than that can increase risk for high blood pressure, unhealthy levels of triglycerides, and heart failure. Moderate drinking is also linked to breast cancer, violence, and injuries. No amount of alcohol is safe during pregnancy.
7. Stay active and exercise.
Regular exercise has a wide range of benefits and improves mental and physical health. There is even some evidence that a sedentary lifestyle may be more strongly associated with premature death than smoking, high blood pressure, or diabetes. Exercise is as important to consider as body mass index and waist circumference in reducing heart attack risk. Most guidelines recommend the equivalent of 150 minutes of moderate to vigorous aerobic activity each week. However, some physical activity is better than none! It is much more important to just do some exercise, rather than worry about achieving the exact amount. A common mistake with a new exercise plan is that people do not increase intensity as their fitness improves. Failure of increasing intensity as fitness improves prevents one from achieving maximal reduction in cardiovascular disease risk. Some strength training is also recommended at least 2 days per week. Finally, consider a smart watch or pedometer as a motivation tool to achieve your physical activity targets.
8. Quit smoking!
Smoking increases the risk of heart attack sixfold in women, and threefold in men, who smoke at least 20 cigarettes per day (compared to non-smokers). Smokeless tobacco has also been shown to increase the risk of cardiovascular disease. Even if you only smoke a small amount, you’re still at increased risk. Studies have shown that those that smoke 1-2 cigarettes per day are twice as likely to die of any cause compared to non-smokers. The risks increase the more you smoke. Once you quit smoking, after about 10-15 years, your risk of heart attack is about the same someone who has never smoked!
9. Take care of yourself.
Stress, anxiety, low mood, and lack of sleep can increase your risk for heart disease. Take care of yourself with simple measures such as adequate sleep (seven to eight hours each night), adequate hydration and stress management techniques such as mediation or yoga to allow your mind to relax and unwind. In addition, if your mood is low, you have trouble coping and you have lost interest in activities you previously enjoyed, you may have depression – in this case, discuss this with your doctor who may recommend counselling or medications to treat this.
10. Have a well-woman check to learn your heart attack risk.
Of all the compelling reasons to keep your annual appointment for a check-up with your doctor, even if you’re not due for a Pap smear or mammogram, checking up on your heart attack risk may be the most important. At that appointment, your doctor will check your cholesterol, blood pressure, blood sugar, waist circumference and body mass index. Depending on the results, as well as your family history, your doctor may recommend other tests such as a calcium score find our more about calcium scores to obtain an accurate picture of your risk for a heart attack, and as a result may recommend lifestyle changes or medications to minimise your heart attack risk.
Reference:Ten Things To Know About Ten Cardiovascular Disease Risk Factors Am J Prev Cardiol. 2021, Mar; 5: 100149. H Bays, P Taub, E Epstein et al.