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Many people think of heart disease as something that mostly afflicts men. But heart disease actually kills more women in the United States than anything else, according to the National Heart, Lung and Blood Institute. And diabetes plays a stronger role in risk for heart disease in women than it does in men.
Experts point to myriad known and potential reasons for the disparity, from socioeconomic issues to the timing of diagnosis and preventive care. But they also say that women have the power to make a significant difference in the health of their hearts.
"Every woman with diabetes, whether it's well-controlled or not, has increased risk of heart disease," said Dr. Elizabeth Ross, who wrote Healing the Female Heart and has specialized in treating women with heart disease for two decades in Washington, D.C. "But there are a lot of things women can do. Exercise is the big thing, after quitting smoking. What women don't realize is that it really decreases their risk even just a week after they quit."
What's different about women
While deaths from heart disease have decreased significantly among men with diabetes in recent years, women have not fared nearly as well. From 1971 to 2000, the rate of death from heart disease among men with diabetes decreased from 16.8 deaths per 1000 men to 8.1 deaths per 1000, according to American Diabetes Association statistics. Among women with diabetes, however, deaths from heart disease did not decline from 1971 to 2000, and the difference in death rate from all causes between diabetic and nondiabetic women more than doubled, from a difference of 8.3 to 18.2 annual deaths per 1000 women.
Cardiologist Sharonne Hayes, director of the Women's Heart Clinic at Mayo Clinic in Rochester, Minnesota, said a combination of biological and social differences are to blame.
"The reasons are complex," she said. "We have gaps in our knowledge about the prevention and treatment of heart disease in women."
Disparities in care and socioeconomic issues are partly to blame, Hayes said. Screening can also be a problem. For example, a National Institutes of Health study indicated that as many as 3 million women previously diagnosed with healthy arteries could actually have an increased risk of heart attack after all. The study, called the Women's Ischemia Syndrome Evaluation (WISE), found that the gold standard test for assessing coronary artery disease - the coronary angiogram - may not spot the more diffuse buildup of plaques that often forms in the smaller coronary arteries of women's hearts.
Diabetes adds a significant burden on top of other gender-specific risk factors. Metabolic syndrome - a combination of abdominal obesity, increased blood pressure, elevated blood glucose, and triglycerides - as well as mental stress and depression, smoking, and low estrogen levels before menopause all add up to heart disease posing a greater threat to women.
"Overall, women in the United States are protected from heart disease until menopause," Ross said. "But diabetes completely negates that benefit of being a premenopausal woman."
Ross said women are also more likely to suffer complications after a heart attack, most likely because they are older than men when they have them and are more likely to have diabetes than men. But not all women have equal risk, she said. A C-reactive protein blood test can differentiate higher risk patients, Ross said.
Douglas Weaver said atypical symptoms of heart disease in women - and the resulting delay in treatment - may also be a factor.
"Women may present with shortness of breath, as opposed to the more characteristic chest pain associated with a heart attack," Weaver said. "It may not be obvious."
Additional symptoms unrelated to chest pain may include neck, shoulder, upper back, or abdominal discomfort, nausea or vomiting, sweating, lightheadedness or dizziness, and unusual fatigue.
Prevention is possible
Perhaps more than anything else, the statistics suggest that women aren't using the power they have to prevent heart disease. Despite limitations of and disparities in care, research, and screening, women can do plenty to ensure that their hearts are as healthy as possible and beat the odds, experts say.
Next to smoking, cardiologists said the fact that most women - diabetic or otherwise - are either overweight or obese means that their heart health suffers. Of course, diet and exercise can change that; experts agree that means 30 minutes of activity, five days a week.
"The hurdle for most women is not putting themselves last in the priority of things to get done," Ross said. "I try to get them to commit to a half hour that's just about them and their health. You don't have to go to the gym. Put on a pair of tennis shoes and walk ... enough that you can still talk but not sing."
Ross said that even women of normal weight should be exercising daily to reduce their risk by keeping blood glucose, blood lipid profile, and blood pressure in good range.
"But very few women are of normal, healthy weight," she said. "More than 60 percent are overweight or obese, and when you consider minorities, that number jumps to 80 percent. My challenge in my practice is the motivation of women to take care of themselves. That's really where the disconnect is. I think what women don't understand is what a healthy weight is. They perceive themselves at a healthy weight when they're not. If your waist is more than 35 inches, you're at risk."
Turning the tide
Despite awareness efforts by physicians and groups such as the American Diabetes Association, Hayes said, more education and research are key to turning the tide for women and heart disease.
A 2003 American Heart Association study of over 1,000 women, conducted by Harris Interactive, Inc., indeed revealed a lack of understanding among women regarding the dangers of heart disease and stroke. According to the results, 13 percent of women in America believe that heart disease and stroke are the greatest health threat to women. And, despite facing the highest risk of death from heart disease and stroke, minority women demonstrated lower awareness.
Hayes said heart disease death rates - after years of decline - have been flattening out in some small population samples.
"There's a real concern that those numbers may go up," she said. "What we could be doing better for diabetic women is making sure that gap in preventive care between men and women is closed. The potential benefit is huge because women live longer. We need to start intervention much earlier."
Hayes said women would do well to become their own advocates.
"This is not a message they necessarily want to hear. They're already doing so much, and they don't want to have to do more," Hayes said. "Women with breast cancer are demanding the care they need, and women with diabetes aren't demanding it, and they need to."
Facts about women's risk, diagnosis, and treatment
Cardiovascular Disease is #1
Source: American Heart Association