Heart attacks in women: A silent killer

Women are more likely to die from a heart attack than breast cancer. Yet patients and doctors too often fail to recognise the symptoms

Cath Haywood didn't know she was having a heart attack. When her arm began to ache, she put it down over-enthusiastic ball throwing – her springer spaniel demanded at least 50 lobs during their hour-long walks. One Saturday in August 2006 Cath felt the first signs of flu. "My arm ached and I felt a bit under the weather, not 100 per cent," recalls the retired police officer from Porthcawl, south Wales. "I was snapping at everybody and I was generally miserable. I just wasn't feeling right."

Early the following evening, she went out with her 13-year old son, Dafydd, to walk the dog. "I had this dreadful ache in my right arm and thought, 'I've really got to lay off throwing this ball'." Such was the discomfort that she cut the walk short and returned home. As the pain got worse, Cath brushed aside pleas from her husband and two sons to call an ambulance and went to bed. Finally, however, the 49-year-old relented.

"It didn't even cross my mind that I might be having a heart attack," she adds. "You see actors on television where they have this terrible, crushing pain and collapse in a heap on the floor. Well, that just didn't happen. It didn't happen at all."

Like eight out of 10 women over 35, Cath did not consider herself to be at risk of heart disease. Nor did the symptoms she was experiencing fit any textbook description. She felt tired, under the weather, a bit uncomfortable. There was no shooting pain down her left arm – it was her right arm that was sore – and no vice-like grip around her chest to bring her to her knees. And yet the facts are sobering. Each year, 103,000 women in Britain have heart attacks, while at least 47,000 die from coronary heart disease. The illness kills nearly 10 times more women a year than breast cancer and, in Europe, it kills more women than men. Standard cardiac treatments, such as aspirin and by-pass surgery, are designed for men and there is no solid evidence that traditional drugs used to treat coronary heart disease are as effective in women as in men.

A study released this month by researchers at the University of British Columbia in Vancouver, and published in BMC Medicine, suggests that aspirin – which is used in small doses to help prevent heart attacks – may really be a man's drug. The Canadian team looked again at 23 clinical trials involving more than 113,000 patients to study the effects of aspirin in heart attack prevention. They then analysed what impact the ratio of men to women in the trials had on the outcomes, and found that those involving mainly women failed to show that aspirin significantly reduced the risk of non-fatal heart attacks. "We would caution clinicians on the prescribing of aspirin to women, especially for primary prevention of heart attacks," said one of the study authors, Dr Don Sin. "Women should consult their doctors to make sure that the benefits will outweigh the risks related to aspirin."

This report is the latest in a growing body of evidence highlighting the fact that female heart patients may need different treatment to male ones. Their symptoms, for one, are often different. And yet this important message has failed to filter down to some GPs and casualty departments, and to women patients themselves. It is a subject about which Dr Ghada Mikhail, a consultant cardiologist St Mary's Hospital in west London, is passionate. Last year, she and her colleagues launched the Her At Heart campaign to raise awareness among health professionals and the public of the under-diagnosis of cardiovascular disease in women. She says: "Men are so aware of heart disease that, if they get a tightness across the chest they run to casualty, or their wives tell them to go. If it's the other way round, a woman will sit there with a little bit of indigestion, discomfort and jaw pain and would never think it was heart disease.

"Women go to hospital much later than men because they are unaware they could have heart disease. The biggest thing on a woman's mind is breast cancer. And yet the biggest killer for a woman is not breast cancer, it's heart disease."

Cath Haywood did experience a pain in her jaw but put it down to an old neck injury. She brushed aside her symptoms – none of which she associated with heart disease. She was fit, relatively young, had just lost 28lb, did not smoke and drank only occasionally. Why bother the ambulance crew? "It never occurred to me that I was having a heart attack until they put a pill under my tongue and gave me an intravenous drip," she says. "Women tend to brush things aside a bit because we are doing other things."

Indeed, studies in America and Europe confirm that women delay seeking medical help. When they do, they will often have more problems, such as diabetes, high blood pressure and high cholesterol. Martin Cowie, a cardiology professor at the National Heart and Lung Institute, is curious as to why this should be so. He and his colleagues have asked the Government for £2m to fund a study of gender bias in cardiac treatment, and to find out why women often ignore symptoms and delay going to hospital. The reasons are not that hard to fathom. Cardiac symptoms in women are much more subtle and vague than those in men and include tightness across the chest, pain in the jaw, neck and upper back, fatigue, breathlessness and anxiety. All these can be too easily dismissed, says Dr Mikhail. While experienced GPs will spot cardiac disease in women, others may not. Prof Cowie adds: "Textbooks have oversimplified the symptoms. Real life is more complex. Doctors do treat women with heart disease differently – they do fewer investigations and treat them less aggressively."

Basic heart investigations – such as electrocardiograms and an exercise tests – are less sensitive in women than in men, while deaths during angioplasty (where a tiny balloon is passed through arteries to expand them) and heart bypass are more common in women than in men. A woman's hormones, body weight and different sized heart and arteries mean she may react differently to treatments which have been tested successfully on men. Only 30 to 35 per cent of participants in heart trials have been women and, in some tests, the figure was as low as 20 per cent. Dr Mikhail has researched drug-coated stents – the tiny, lattice-shaped metal tubes inserted permanently into arteries to keep them open – and has found that women do just as well as men with the devices. Indeed, they are much more effective than the bare metal stents which suit men better.

Cath Haywood, now fitted with a stent and taking a low-dose statin, blood pressure tablets, aspirin and blood thinning tablets, regrets that she did not know more about the disease which struck her down. "I was told that women don't have the same symptoms as men but I never knew that. If I had known a little earlier, maybe I could have prevented the heart attack happening. But you don't think, do you?"



Her At Heart: www.heratheart.org.uk, British Heart Foundation: www.bhf.org.uk

Cutting risk and spotting signs

* Major symptoms before a heart attack in women include: fatigue; sleep disturbance; shortness of breath; anxiety; and indigestion.

* Major symptoms during the heart attack include: chest pain (though this might not always be present); shortness of breath; weakness; fatigue; cold sweats; dizziness; and neck and jaw pain.

* Cut back on caffeine and drink plenty of water.

* To help prevent a heart attack, don't smoke, eat healthily and exercise regularly, and start doing these things in your 20s.

* Get your blood pressure, cholesterol levels and sugar levels checked regularly.

* Aspirin should not be prescribed to women to prevent or protect against a heart attack, says the British Heart Foundation,but it is effective at preventing further attacks.

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