CORONARY HEART DISEASE
Easy Guide To: CHD In Women

Coronary Heart Disease

• What Is Coronary Heart Disease?
• Who Develops CHD?
• What Are The Symptoms?
• Can I Be Screened For CHD?
• How Is It Diagnosed?
• How Is It Treated?
• Can CHD Be Prevented?

What is Coronary Heart Disease?

Coronary heart disease (CHD) is a narrowing of the arteries which supply blood and oxygen to the heart (these arteries are called the coronary arteries). When blood flow is restricted, the heart gradually becomes damaged and cannot function efficiently. Angina (chest pain due to lack of oxygen reaching the heart) is a typical symptom and if the arteries become too blocked it can lead to a heart attack. CHD is the number one killer of both men and women in the Western world, although it tends to affect women 10 to 15 years later in life. This difference is thought to be due to the protective factor of estrogen in women which seems to slow the process of atherosclerosis, the main cause of CHD. Atherosclerosis (image) is where cholesterol and fat is dumped along the lining of the arteries and this gradual build up of materials eventually causes blockages and prevents the flow of blood. Initially the build up may not produce symptoms but as atherosclerosis progresses it can cause angina attacks, usually after exercise or stress when the heart needs higher levels of oxygen. If one or more of the arteries becomes seriously restricted a heart attack occurs (technically called myocardial infarction). During a heart attack the cells of the heart become severely starved of blood and oxygen causing them to cease working. Unless the blocked artery is opened quickly this results in permanent damage to the heart muscle and depending on the extent of muscle damage, death can occur. If the heart attack was caused by a blood clot which became stuck in a narrowed artery, which is often the case, this is known as a coronary thrombosis.

Who Develops CHD?

Gender is one of the most important risk factors for CHD - see Causes of coronary heart disease. Simply being a man puts your chances of developing CHD at 3.5 times greater than being a woman. The biggest risk factor for women is age. After menopause a woman's chance of heart disease increases and by the time she is 70 she has nearly the same risk ratio as men. Women who have had their ovaries removed and enter premature menopause are also at increased risk because they are no longer protected by the estrogen produced by the ovaries. A hysterectomy operation (the removal of the womb) does not necessarily increase risk as long as at least one ovary is left in place. Menopause itself does not increase a woman's risk of CHD, but it does take away the protective factor of estrogen. Estrogen delays the aging of the cardiovascular system and slows the process of atherosclerosis. Most of the other risk factors for heart disease are similar for both men and women and these include hypertension, high cholesterol, diabetes mellitus, obesity, smoking and a sedentary lifestyle. See also, latest health statistics.

What Are The Symptoms?

For some, symptoms of coronary heart disease may be very noticeable, while others can have CHD without noticing any problems. Symptoms range from none at all to chest pain (angina) or a heart attack. Some women report palpitations (irregular heartbeats) and unusual breathlessness. Just which symptoms occur depends on the extent of damage and blockage in the arteries.

What Does An Angina Attack Feel Like?

Angina is a symptom of CHD, it occurs because of blockages in the arteries which supply blood to the heart. An 'angina attack' is a chest pain which usually occurs after physical exertion. It usually lasts a few minutes and disappears when the person stops and rests. This is known as stable angina. It may feel like:
• Pressure/squeezing chest pain which can radiate to the shoulders, arms, neck and jaw. See also chest pain in women.
• Sensation of indigestion or heartburn.
A person can usually predict when an angina attack is likely to occur - if however it starts to appear at unpredictable times (such as at rest) it indicates a worsening of CHD. This is known as unstable angina. Unstable pain suggests that the arteries have become severely blocked which raises the risk of a heart attack.

Can I Be Screened for CHD?

Yes, and people who are in a high risk factor category for developing the disease are usually recommended heart disease tests. This includes people with a history of heart disease in the family at a young age, those with long-term high cholesterol levels or high blood pressure (chronic hypertension) and diabetes. Initial screening for CHD usually involves stressing the heart under controlled conditions to see how it reacts. An electrocardiogram (ECG/EKG -image) is a simple and popular test which measures the electrical activity of the heart by attaching sensors to certain parts of the body. If a problem is suspected, the condition will need to be evaluated further. An ECG usually costs about $150-$200 but some insurance plans reimburse part if not all of the cost.

How Is It Diagnosed?

The 3 most common methods currently being used for evaluating CHD are stress tests, perfusion imaging and heart angiography (image).

Exercise Stress Tests
Also called exercise electrocardiography or exercise tolerance test (ETT), an exercise stress test (image) involves some form of exercise such as walking on a treadmill or cycling on a stationary bike. The results are monitored with an ECG and a blood pressure reading is taken. The test continues until a target heart rate is reached or the patient develops chest pain or experiences a dramatic rise or fall in blood pressure. The heart is monitored for another 15 minutes after the test or until the heart rate returns to normal. Sometimes an exercise stress test is combined with perfusion imaging known as a nuclear heart scan (image). This involves injecting a small amount of radioactive agents (radionuclide) into the blood stream which are then tracked for radiation emissions. The amount of radiation emitted reflects the amount of blood which has reached the various parts of the heart.

Chemical Stress Tests
As women tend on average to suffer from CHD 10-15 years later than men, they often have more age-related physical problems carrying out an exercise stress test (such as arthritis). For this reason they may be offered a chemical stress test instead. A pharmacologic stressor (such as Persantine) is injected into the blood stream, artificially causing the blood vessels to dilate, mimicking the effects of exercise. Other medications, such as dobuamine, are used to make the heart pump faster. The results are normally monitored with either a PET (positron emission tomography) or SPECT scan (single photon emission computed tomography). Or by ECG or echocardiogram.

Coronary Angiography
Sometimes referred to as heart catheterization, this is the considered the gold standard for testing for CHD. During this procedure a hollow thin tube (cath or catheter) is guided into the coronary artery and a dye is injected. An X-ray follows the flow of the dye as it works its way through the coronary arteries. It is usually very accurate in depicting any blockages. This procedure is always performed before any surgery for coronary heart disease.

How Is It Treated?

Coronary heart disease treatment can involve either medication or surgery. The patient is responsible for eliminating or controlling some of the behavioral risk factors, such as obesity, smoking and drinking. Which medical therapy is used will depend on the patients age, her general health and the severity of her symptoms. Unfortunately for women, most treatment trials and studies for heart disease have revolved around men, and are less well understood in women. Until recently clinical trials routinely excluded women because the maximum age of volunteers was 75, and women are much more likely to suffer CHD at a later age. For more, read about coronary heart disease in women.

Medical Interventions

Cholesterol Lowering Therapy
Even before CHD produces symptoms, a doctor may prescribe cholesterol lowering medications, particularly to postmenopause women who have consistently raised cholesterol.

Nitrates
Nitrate medications, including Ismo, Isordil and nitroglycerin are thought to increase blood flow to the heart by dilating the coronary arteries. They are often prescribed to women with angina.

Beta Blockers
Beta blockers work by reducing the heart's demands for blood. They are also prescribed to patients after a heart attack.

Calcium Channel Blockers
Calcium channel blockers help prevent arteries from going into temporary spasms and restricting blood flow. This is a common cause of chest pain in women.

Thrombolytic Therapy
If a heart attack has occurred, thrombolytic therapy medications can cause any remaining blood clots to dissolve, reducing the risk of a recurrence. For these drugs to work, they have to be administered within a few hours of the heart attack.

Surgery

Coronary Angioplasty

Coronary angioplasty (image) has become the most commonly performed treatment for CHD. A cath (long thin tube) with a small balloon at the end is inserted into the affected artery. It is pushed into the blockage until the obstruction has been forced aside and blood flow resumes as normal. A metal stent may be inserted to keep the artery permanently open. Angioplasty is the preferred method for treating heart attack patients (over thrombolytic therapy) for medical centers with suitable facilities.

Coronary Bypass Surgery

Heart bypass surgery (image) is a serious procedure which is not undertaken lightly. A short piece of vein is taken from the thigh or other internal organ and grafted onto the narrowed coronary artery. This allows the blood to re-route around the blockage. There is evidence to suggest that this surgery is effective in relieving angina pain which has not responded to medication. In fact nearly 50 percent of those who undergo the surgery remain pain free for 5 years after the surgery. On the negative side, the surgery cannot prevent atherosclerosis forming in the bypass artery. In fact 4 out of every 5 patients develop life-threatening blockages in the graft within 10 years. There is still some debate on whether or not the surgery prolongs life expectancy. Women are in fact twice as likely to die than men during the procedure or soon after. For these reasons they are less likely to be offered the operation.

Can CHD Be Prevented?

CHD has many causes, yet it is possible to lower the risk of developing the disease by changing certain habits. This is discussed in more under Coronary heart disease prevention. Some tips:

Quit smoking: More than half of all heart attacks in women under the age of 50 can be attributed to smoking. Additionally, women who quit smoking after a heart attack have a longer life expectancy than women who do not.

Control Blood Pressure: Women with high blood pressure reduce their CHD risk considerably by lowering their blood pressure to below 130/80 mm/HG. Ensure you have regular health screenings.

Obesity: A waist circumference less than 35 inches (89 cm) in women is ideal. Even a weight loss of 10 to 20 pounds in a middle aged woman reduces her risks of CHD.

Blood Fat & Lipid Levels: HDL cholesterol less than 50 mg/dL and fasting triglycerides less than 150 mg/dL are ideal in women.

Exercise: Increasing exercise to 60 minutes physical activity every day has great benefits.

Type 1 Diabetes: Women with type 1 diabetes may be able to reduce their risk factor by controlling their blood sugar level and using intensive insulin therapy. It is not clear whether this is as affective in those with type 2 diabetes.

Stress: Avoiding stress as much as possible is better for heart health. See, dangers of stress.

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