Luckily, she made it to the hospital in time, and is now recovering with the help of regular appointments with a University of Michigan cardiologist and rehabilitation program. But her heart attack, which came without any warning symptoms, changed her life forever. It also changed her attitudes about who gets heart disease.

"I thought this was more of a men's condition," she says today. "Now, I'm becoming more aware of how young people can have heart attacks, with no known history of cardiac disease, and how it can happen to anybody, including a lot of females - more than I had thought."

Sue's story should help all women realize the danger they face from heart disease -- and the steps they can take to prevent it -- at any age, says U-M Health System cardiologist and assistant professor of internal medicine Claire Duvernoy, M.D.

"Most women in this country perceive themselves as not threatened by cardiovascular disease, but the fact is that it's the most common killer of women in the country," Duvernoy says. "If you ask most women, they'll tell you that the major threat to their life and health is cancer, especially breast cancer. I don't want to downplay the significance of cancer, but more women die of heart disease in the U.S. than die of all forms of cancer combined."

Another thing that surprises many women, she continues, is that more women than men die of heart disease, and that women who get heart disease often fare worse overall than men. These facts contradict the stereotype that heart problems are mostly a man's concern.

Worse still, such wrong impressions can escalate women's risk even more, Duvernoy warns. They may fail to take preventive steps, recognize symptoms, manage their other heart-damaging health conditions effectively, or pursue the best treatment for a heart problem.

Early diagnosis, and appropriate measures to stave off problems, are key to evening the odds. That's why the U-M Health System offers its Preventive Cardiology Service, where women and men can be evaluated for their cardiovascular risk, prescribed a range of preventive strategies, and treated. Those women who prefer a female cardiologist can ask to be seen by one.

Part of the reason for the difference between heart disease death rates for women and men is the difference in life span. Women tend to develop serious heart problems about 10 years later than men do, but they live longer overall, and advanced age is a risk factor for heart disease.

So is menopause -- possibly due in part to the fact that a woman's level of estrogen, which seems to protect the cardiovascular system, decreases as she approaches and enters menopause. Duvernoy's own research focuses on the effect of estrogen on blood flow in small blood vessels. Women who wish to enroll in her clinical trials of hormone replacement therapy and hormone alternatives can call 734-769-7100, ext. 5425.

Women are also more likely than men to have the kind of chronic health problems, like obesity, diabetes and high blood pressure, that can harm the cardiovascular system over time. More girls and women are smoking at younger ages, posing a long-term risk to their heart. All of these factors can remove the heart-risk advantage that younger women have over men their age.

These "co-morbidities", or existing conditions, not only help cause heart disease -- they can also make a woman who has heart disease harder to treat and less likely to do well after treatment.

"Once a woman's been diagnosed with heart disease, she does not have as good a prognosis on average as a man of her age group who has been diagnosed," she says.

Part of the problem in American health care as a whole, Duvernoy says, is that doctors and other health care providers have the same skewed perceptions as women themselves. They may not be as quick to consider heart problems as a possible cause of a woman's symptoms, or they may not treat a woman's condition as aggressively as they would a man's.

Another problem involves actual differences in the way women experience, react to and report symptoms. For example, unlike Sue, women who have a heart attack sometimes don't even realize what's happening to them. They may report their warning signs as general malaise, nausea, abdominal pain or excessive fatigue, which don't match the chest pain, gray color and sweatiness that are widely thought of as a heart attack's "typical" symptoms.

As a result, some women don't seek medical attention quickly enough, and when they do, they may not get checked quickly for a heart attack. That can hurt their chances; early identification and treatment of any heart problem is key to making the outcome as good as possible.

So, Duvernoy says, women must learn what to look for, and take symptoms seriously. "The message for women should be: Be aware of your body. Pay attention to what's going on. Don't downplay your symptoms because you 'don't have time for this,'" she says. "If you feel like something's wrong, you need to seek medical attention immediately."

After a heart attack or other problem, it's important for patients to get follow-up rehabilitation, including carefully planned exercise. But Duvernoy finds that women are less likely to follow through.

"Women have a lot more barriers to enrollment in rehab. They tend to be the caregiver in the family and they don't think they have the time to go and do something for themselves because they're taking care of their children, husbands or parents," she says. "But rehab is very helpful in improving a woman's prognosis, and making her feel a lot better."

Preventive and follow-up care for heart disease have a lot in common, says Duvernoy. In general, she recommends that women follow these steps:

· Exercise regularly, whether it's walking your dog, doing aerobics or another activity.

· Eat a heart-healthy diet, watching your fat and cholesterol intake.

· Don't smoke, or if you already do, quit.

· Get regular medical checkups, including blood pressure checks and blood tests.

· Control your weight, especially if you have diabetes.

· If you have diabetes, control your blood sugar to help cut your high risk of heart disease.

· Monitor your blood pressure, and if you already know it's high, take your medication.

· Keep track of the levels of 'good' and 'bad' cholesterol in your blood - women whose levels of these substances are out of balance are more likely to develop a heart problem than men. If you have a high 'bad' cholesterol level, ask your doctor about medication.

· If you're an African-American or Hispanic woman, realize that your risk is even greater than that of white women, and work hard on prevention.

· Don't count on hormone replacement therapy to reduce your heart risk after menopause. Duvernoy counsels that there's not yet enough evidence that hormone replacement protects the heart, or that it doesn't increase stroke risk, though she doesn't recommend that women stop hormones taken to ease menopause's effects or cut osteoporosis risk.

· If you've had a heart attack, make sure you follow rehabilitation recommendations.

Facts about women and heart disease from the American Heart Association:

· Cardiovascular disease is the leading killer of American women, and kills more women than men in the United States. In 1998, 503,927 women died from cardiovascular diseases, accounting for 53.1 percent of all cardiovascular deaths.

· Heart disease kills more women than all cancers combined. In 1998, 259,467 women died of cancer - just over half the number that died of heart disease.

· Women up to age 65 are less likely than men of the same age to have a form of cardiovascular disease, but women aged 65 to 74 are just as likely to have it as men of the same age, and after age 75 women are more likely than men to have it.

· Post-menopausal women are two to three times more likely to have coronary heart disease as pre-menopausal women of the same age.

· 38 percent of women who have a recognized heart attack will die within one year. Those who survive up to six years are more than twice as likely as men to develop heart failure. - By Kara Gavin

Related websites:

U-M Health System, Health Topics A to Z: Women and Heart Disease

U-M Health System, Health Topics A to Z: Heart Information

National Heart, Lung and Blood Institute: Information for the Public

American Heart Association: Women and Heart Disease

[Contact: Kara Gavin, Valerie Gliem]

05-Feb-2001