A Heart Attack Of Her Own The women of the baby boom are nearing their prime heart attack years. Neither they nor their doctors are paying enough attention.
(FORTUNE Magazine) – Before Dwight Eisenhower, men's heart attacks were marked by whispered rumors and hidden recoveries. Before Norman Schwarzkopf and Andy Grove, prostate cancer was borne in silence and shame. Until Betty Ford came along, an announcement of breast cancer invited ostracism and humiliation. But for female baby-boomers, a major killer remains in the shadows. Women's heart attacks have never had a poster girl. Almost certainly, that is about to change.
Millions of female baby-boomers are hitting menopause; tens of millions will follow in the coming decade. All these women are on the verge of losing their biggest resident protector against heart attacks: estrogen. It shields younger women's hearts in a myriad of ways, such as boosting levels of so-called good cholesterol and keeping "bad" cholesterol relatively low. When menopause hits, that protection evaporates. The good news: Women get heart attacks on average ten to 15 years later than men. The bad: Over the course of a lifetime, heart attacks become an equal-opportunity killer.
You wouldn't know it from heart attacks' public profile. Polls show that they fail to register on most women's health-worry lists. Women are uninformed about the symptoms, which can differ dramatically from symptoms in men. Doctors misdiagnose women's heart attacks with alarming frequency, especially in women who are relatively young. Yet heart attacks are the biggest killer of American women, striking some 440,000 each year and burying nearly 250,000--more than stroke, lung cancer, and breast cancer combined. "The bottom line is that women are not as worried about heart attacks as they should be," says Vicki Seltzer, former president of the American College of Obstetricians and Gynecologists, which, with Bayer, has launched an educational campaign targeting women.
Conspicuously absent from that campaign and others like it is a big-time survivor--a Betty Ford of heart disease. Though today's women are far more activist in matters of health and far more influential in business and public life, the instincts of powerful women run the opposite way where heart attacks are concerned. When women are hit, they make a beeline for the closet.
Says Marianne Legato, a cardiologist who directs the Partnership for Women's Health at Columbia University: "They won't talk. I have some very famous, very high-powered women patients who refuse to discuss the fact that they have heart disease. They think it brands them as old and having a grim outlook."
"With men, it's almost a bragging right," adds Nancy Loving, a Bethesda, Md., publicist who had a heart attack at 48. "With women, it's stigmatized, it's hidden, it's not talked about, it's a source of shame."
Women in Ignorance
Late in her bruising 1996 congressional campaign, Julia Carson began to worry. The bone-deep exhaustion she had been fighting was worsening. She felt a constant, electric tingling in her fingers and toes. And when the pain came--sporadic, basketball-sized pain in her gut, like indigestion, but worse--the 58-year-old Democratic politician would tell her staff to wait, while she hugged both arms to her body and closed her eyes, unable to speak.
A high-energy, six-foot-tall, 200-pound woman, Carson had taken her problem to her longtime internist that September. She commonly rose at 4:30 A.M. to start work, she told the doctor; now she could hardly get out of bed. She said she was worried about her heart. "I said, 'I want you to check my heart, because something funny is going on,'" Carson recalls. "He immediately dismissed it and said, 'Nothing is going on with your heart.'" And although her cholesterol turned out to be high, the doctor didn't run further tests that pick up heart-attacks-in-waiting. Instead he advised her to lay off the fried-egg sandwiches and potato chips, handing her a book on healthy eating.
Carson pushed aside her worries and went on to win the 1996 election in a squeaker, becoming the first black to represent majority-white Indianapolis. But days before her scheduled congressional inauguration in January 1997, she was too weak to walk to the buffet table during a lunch meeting. She went straight to an Indianapolis emergency room, where doctors found that one of the most important arteries to her heart was totally blocked. Another was 90% occluded. To stave off an imminent heart attack, surgeons performed emergency double bypass surgery.
To be sure, Carson's risk was especially high because of her race--black women's heart-disease death rates are 34% higher than white women's. But Carson's experience and her doctor's behavior are alarmingly typical. She suspected that her heart was in trouble, but didn't push the case. Instead she minimized her symptoms until it was almost too late. More distressing still, Carson's doctor ignored her symptoms, despite practically being handed a diagnosis of heart disease.
By flagging her heart for her doctor, Carson was doing better than most. Polls show that many women are woefully uninformed about heart disease. Eighty percent don't know that heart attacks are women's biggest killer. They say they are more than twice as frightened of breast cancer, which in 1998 killed one in 28 of them, as they are of heart attacks, which killed one in five. Only about a third feel confident that they would recognize their heart attack symptoms. Those symptoms can be far subtler than the chest-crushing pain common to men. Women may be only nauseated, exhausted, or breathless. They may feel only mild chest discomfort, or inexplicable back pain or jaw pain. They may have abdominal pain that, like Carson's, is easily mistaken for severe indigestion. They may even feel nothing at all. Studies show that up to 45% of female heart attacks go unnoticed or unreported. It's thought that, in many of these cases, the symptoms are unremarkable or atypical enough that women ignore them or attribute them to something else.
For women going to school on heart attacks, one lesson trumps all others: Preventing attacks is the most important thing you can do. It's a project that should start in early adulthood. And if you're tempted to pooh-pooh the thought of 20-year-olds watching their cholesterol, consider this: Two-thirds of women who die from heart attacks have no warning symptoms of any kind. For them, prevention--a decades-long undertaking--is truly the only cure.
Women don't seem to be paying attention. In the past ten years they haven't enjoyed the same fall in heart attack death rates that men have--a drop partly attributable to men's new vigilance in avoiding heart disease. This year the American Heart Association called trends in the prevalence of heart attack risk factors among women "alarming."
Other recent news should light a fire under any younger woman who's feeling complacent about prevention. It concerns women who get heart attacks early. A landmark report in The New England Journal of Medicine in July found that younger women hospitalized for heart attacks died at higher rates than their male counterparts. The younger the woman, the higher the relative death rate; women under 50 died at more than twice the rate of men their age. The study is particularly credible because of the huge number of heart attack patients--nearly 400,000.
The take-home message, from Viola Vaccarino, the Yale epidemiologist who led the study: "If women do get heart attacks prematurely, these heart attacks are particularly severe. Until we find some specific genetic marker that can identify women at high risk for heart attacks, all women should pay attention to preventing them."
Where the Doctors Go Wrong
The woman, whom we'll call Suzanne Smith, is a public-relations executive who runs her own Manhattan firm. She stands five feet, six inches tall and weighs 104 pounds. Her gray trousers look as if they would fall down if it weren't for her belt. She is totally Type A.
One afternoon in 1993, Smith suddenly felt unwell during a business meeting. She begged off a black-tie dinner with her husband that night. As he dressed, her left arm grew numb and began tingling from her fingertips to her shoulder. Sporadic, sharp pains began on the left side of her chest. Her husband suggested they go to the emergency room. She said, "Don't be silly."
Smith told herself that she was skinny and only in her late 40s. She had never smoked, and heart attacks hadn't been a problem in her family. Sure, she was a big fan of steak and spareribs, and her cholesterol had been high--235 mg per deciliter--for years. But doctors had told her not to worry about it; she didn't have any of the risk factors for a heart attack.
Yet the next morning, when the pain and tingling remained, Smith went to her doctor's office and said she was having heart pain. The doctor, a pulmonologist who had long treated her asthma, didn't see her for 90 minutes.
Then he ran an electrocardiogram, or EKG, which measures the electrical performance of the heart. An EKG often shows telltale changes during a heart attack, and it is the first test doctors perform when they suspect one.
The EKG was normal. The doctor did a brief physical exam and told her not to worry: Her pain was not cardiac pain but a viral condition.
Driving to her Connecticut country home with her husband that afternoon, Smith, whose symptoms persisted, struggled with herself. "I'm getting cold chills thinking, This guy was wrong. Half of me kept saying, But what if he's right? You're going to look foolish if you go to emergency."
That night, near 5 A.M., she awoke with "sledgehammer" chest pain, nausea, and profuse sweating. The nearest hospital was 25 minutes away. Her husband drove, stopping midway so she could vomit. The first doctor to see her diagnosed shingles, a painful skin infection. By the time a young female doctor diagnosed a heart attack--38 hours after her symptoms started--10% of her heart tissue was dead.
A heart attack--the death of part of the heart from lack of oxygen--usually culminates a decades-long process. Cholesterol-laden deposits of cells and fiber known as plaque build up inside arteries that supply oxygen-bearing blood to the heart. A narrowed artery can restrict blood flow enough to deprive the heart of oxygen, causing pain, especially during stress or exercise. A heart attack occurs when a vessel becomes completely blocked, usually by a clot or a chunk of plaque that suddenly bursts.
Smith's steaks and spareribs had doubtless been laying down plaque in her arteries for decades. But she was lucky. The damage to her heart was contained enough that she leads an active life--riding horses, doing yoga--and still logs 12-hour workdays. All the same, she says, she's angry with the doctor who missed her heart attack. "He could have done further tests. He could have measured my blood enzymes. He could have put me in the hospital for observation. He did none of those. None." The result was a near miss that put Smith's life in jeopardy.
Women's heart attacks are easy to miss for doctors who aren't on the ball. And Smith's former pulmonologist (she refused to see him again) is hardly the only one. In a Gallup survey, 88% of primary-care doctors didn't know that women's heart attack symptoms may differ substantially from men's. Nor did 33% recognize heart attacks as women's biggest killer. Even at hospitals, the front line for heart attack treatment, doctors take longer to diagnose heart attacks in women than in men.
Perhaps it's not surprising. "I came out of my training with the idea that heart disease was largely a man's disease," says Elizabeth Ross, a Washington, D.C., cardiologist who trained at the National Institutes of Health in the 1980s. "After about the 200th woman heart attack patient, I thought, Something isn't right here."
It's not clear that medical education has improved in the intervening decade. In a 1997 study at the State University of New York at Stonybrook, senior medical students and residents were presented with descriptions of an anxious 48-year-old man and an anxious 58-year-old woman, both of whom also had identical heart-disease symptoms. By large margins, they referred the man to a cardiologist and the woman to a psychologist.
Doctors can have rational grounds for pushing heart attacks down their list of likely diagnoses in women. Despite the fact that virtually the same number of men and women die of heart attacks, it's also true that the odds are still greater that a man with chest pain is having a heart attack than is a woman with the same symptoms. And there are plenty of bona fide nonheart causes of female chest pain, from indigestion to gallstones.
Debra Judelson, a cardiologist who is director of the Women's Heart Institute in Beverly Hills, recalls witnessing a scene several years ago in an emergency room when a man in his mid-40s and a woman in her 60s arrived simultaneously. The man screamed that he was having a heart attack. Doctors, nurses, and technicians buzzed around him, running an EKG, getting an intravenous line set up, drawing blood. The woman sat quietly in a chair, saying that she didn't feel well. A nurse checked her blood pressure and pulse, but it was 45 minutes before an EKG was run. When the results came back, a doctor snapped at the technician for mixing up the two EKGs. But there was no mistake. The man had indigestion. The woman was having a heart attack.
"The man came in and said, 'Heart!' so everyone jumped to it," says Judelson. "The woman came in and said, 'I feel sick,' and didn't impress on people the fact that there was something serious going on." But as Smith's experience shows, even crying "heart" may not work for a woman. Faced with her normal EKG--which isn't unusual early in the course of a heart attack--her doctor needed to have "an index of suspicion that the EKG was wrong and the patient was right," notes Ross, the D.C. cardiologist. "If you don't go looking for the possibility of a heart attack, you're not going to find it."
When a Heart Attack Strikes
During a heart attack, time is muscle. The sooner a woman recognizes what's happening and gets medical care, the more likely it is that doctors will be able to save heart muscle with therapies like clot-busting drugs that depend for their effectiveness on being given early. But too many women ignore their symptoms and delay getting help.
Things were going well for Judy Mingram. Her 40th birthday was just behind her, her 14-year-old daughter was happily ensconced in high school, and Mingram's new, high-pressure job as a corporate sales rep for Sun Microsystems in Los Angeles was looking like a keeper. It was then that Mingram, a single mother and two-pack-a-day smoker with high cholesterol, began getting chest pain that radiated into her jaw.
The chest pain felt like heartburn, and the jaw pain was electric. Together they were bad enough to keep her up at night. For three weeks while it was happening, she would sit in her kitchen in the wee hours, thinking about making her quota, and smoking.
The last night there was no time for smoking. Almost knocked over by "total, crushing" chest pain, Mingram barely managed to stagger to her roommate's door and, gasping, ask her to call 911. At a nearby hospital, her heart stopped twice. Only electric shocks to her heart revived her.
Mingram feels lucky that she's around to tell the tale of her near miss--and of the denial that almost cost her her life. "I didn't take myself seriously," she says. "I sat there with pain for three weeks and did nothing. Because I was busy. I had a big job and I was a single parent and I was very busy."
The world's great caretakers, women often push aside the pain and soldier on--whether it's to close the deal, win the election, or tuck in the kids. "I have had patients having heart attacks who clean their house, pay their bills, and make sure everything is in order before going to the hospital," says Legato, the Columbia cardiologist. Possibly as a result of their well-documented tendency to show up at hospitals hours later than men, women having heart attacks are less likely to get clot-busting drugs.
That may be one reason that women are also more likely than men to die after being diagnosed with a heart attack. Mingram is thriving eight years after hers, but she was at high risk in the year that followed, when 44% of women will die, vs. 27% of men.
Mingram probably benefited from how hard and fast her doctors moved to repair her heart. Her doctors found that two key arteries to Mingram's heart were 75% and 90% blocked. They tried angioplasty, a procedure in which a catheter is threaded up into the heart vessels and a balloon at its tip is inflated to clear blockages. The procedure didn't go well: The catheter dislodged a piece of plaque that slammed down across one of the arteries, totally blocking it. Surgeons hustled her into emergency double bypass surgery.
Such aggressive treatment isn't a given. A 1998 paper in Archives of Internal Medicine--one of many reaching similar conclusions--looked at 350,000 heart attack patients and found that women were less likely than men to be treated with aspirin, clot-busters, and other key drugs. They also had lower rates of a gold-standard test: cardiac catheterization, when dye injected through a catheter snaked into the heart vessels enables doctors to see where blockages are, as a road map for bypass surgery or angioplasty. The Archives study, like many others, found that women undergo fewer of either procedure. It also found that, as in dozens of other studies, women died in the hospital at a higher rate.
"What is alarming is this high case fatality for women and a clear picture of less aggressive treatment of women who have symptoms that are suggestive of heart disease," says Patrice Nickens, who directs heart research at the National Heart, Lung, and Blood Institute. To be fair, it's not clear whether women are treated less aggressively because they aren't offered procedures in the first place or because they turn them down. What's more, some of the difference in treatment comes from doctors' reluctance to subject women who are, on average, older and frailer than men, to traumatic procedures like open-heart surgery. Nonetheless, says Legato, "if we really tried to offer men and women equally aggressive treatment, we might change the mortality data."
Silence Is Lethal
Carole Hyatt will never forget the last words of her longtime partner, June Esserman--the other half of Hyatt-Esserman Research Associates, a New York City market-research firm. Esserman, 52 and ghastly pale, was lying on the couch in their Madison Avenue office in the throes of a heart attack that would take her life within hours. As paramedics labored over her, Esserman fixed her gaze on Hyatt. "She said, 'Carole, don't tell anyone about this. This will be bad for business.'"
Esserman was hardly the first to try to put the hush on a heart attack. The rule of silence applies everywhere from the drawing rooms of Atlanta matrons to the sets of Hollywood, where aging female movie stars see their roles getting even scarcer if word reaches skittish producers. "People really do not want their name used," says Judelson, the Beverly Hills cardiologist. "There's no poster child that I've found. And I beg people."
There's another reason women hide their heart attacks, according to Nancy Loving, the Bethesda PR consultant and heart attack survivor. Loving thinks that, in classic fashion, women blame themselves for what happened. They shouldn't have let their weight go. They should have exercised. They should have quit smoking years ago. For men, having a heart attack can be a testament to a high-powered, hard-charging, macho track record. For women, it's cause for embarrassment and silence. Having a high-profile job only compounds the problem. Says Mingram, the Sun sales rep: "You don't want your employer to know. Of course they have to, but you feel like you're proving yourself after that."
Suzanne Smith, the New York publicist who declined to provide her real name for this article, says that she's not willing to risk losing clients by going public. "I don't want anyone to think I can't handle it. Because I can. And I have."
Julia Carson, the Congresswoman, believes that Smith's only taking a pragmatic stand. She says she was barely out of the hospital before she heard that hungry fellow Democrats were rubbing their hands over her seat. They assumed she wouldn't be running again--an assumption rarely made of the dozens of Congressmen who are veterans of heart attacks and bypass surgery.
The big numbers of male heart attack survivors give rise to something else too: a network of guys ready to lend a hand to the newest survivor on the block. Mingram remembers attending a meeting of a group called Mended Hearts shortly after her heart attack. She was the only woman there. "They all wanted to know whose wife I was."
Loving, a PR veteran who has worked with major drug companies, was shocked to discover that female support groups simply don't exist. "Naively, I had assumed there was going to be this big network of support for women heart attack survivors," she says. "Instead it was the most socially isolating experience I have ever had." Loving has teamed with Mingram and Smith to battle the culture of secrecy. This fall they launched the National Coalition for Women with Heart Disease. Its centerpiece: a Website devoted to helping women with heart disease find each other for mutual support and advocacy (www.womenheart.org).
In the meantime, some experts say that a jump-start is what's needed to get women's heart attacks out of the closet. "We almost need a prominent woman to have a heart attack, recover, and go back to work like President Eisenhower did," says Nanette Wenger, a professor of cardiology at the Emory University School of Medicine.
It's only a matter of time. The Census Bureau projects that, in 2010, there will be ten million more 45- to 65-year-old women in the U.S. than there are today--40 million such women in all. That's a lot of heart attacks waiting to happen. Unless, of course, women get smart now.