Hear an audio interview with UCSF cardiologist Dr. Anne Thorson discussing the risk of heart disease in women.
Heart disease is the number one killer of women in the United States, claiming 500,000 lives a year, but there are steps that a woman can take to help minimize her risk. Coming up, we'll hear from an expert in assessing and treating cardiovascular disease in women. It's all next on Patient Power.
Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr.
Well, I bet if you ask 10 women what was the greatest threat to their life they would say cancer, but guess what. If you took all the cancer deaths among women in America and put it together the total would be much less than the total of women who die every year from heart disease. So, ladies, you need to be thinking about your heart health.
We're going to talk about that with a leading expert in assessing the risk of heart disease in women and helping with prevention. Joining us is Dr. Anne Thorson. Dr. Thorson is a cardiologist, of course, and she's co-director of the UCSF Center for Prevention of Heart and Vascular Disease. It's located at Mission Bay in San Francisco. Dr. Thorson, thank you so much for being with us.
Thank you for having me.
Let's go over some of these really incredible statistics I was thinking about. First of all, I think people are aware that maybe if you're overweight you're at higher risk for heart disease. So is this right? More than 60 percent now of American women are either overweight or obese?
That's correct. And the statistics are staggering when you take into account the childhood obesity epidemic. It's estimated that if we keep on this same trajectory, that somewhere on the order of 70 to 75 percent of women will be overweight in 25 years.
It does. So some of these fats that are being deposited in our — bodies underneath the skin are also being processed in the liver and being deposited inside the blood vessel walls where they can cause plaque to build up, and plaque is just a combination of fatty substances, cholesterol, some other smooth muscle cells that then begins to build up in the artery like rust in a pipe, and if enough of that substance builds up it can block the flow of blood through the artery.
Alright. And then physical activity, that keeps that blood flowing, and it also keeps our weight down, but here's another statistic: 25 percent of women don't do any type of physical activity in the U.S.?
That's right, and this means no physical activity other than just the normal activities that it takes to get out of the bed in the morning and brush your teeth and make your food. So one of the things that we've really got to get across to women is that they have control over reducing their risk of heart disease, and it may be just as simple as getting off the couch and getting into a regular exercise routine.
Now, another one: More than 50 percent of women over age 45 have high blood pressure, and that, of course, can lead to stroke. But it's all together, right? It's all bad for you, and many of these women don't even know it, right?
That's correct. So one of the problems with having high blood pressure is that most of the time people who have high blood pressure have absolutely no idea that their blood pressure is high so that it's imperative that we have people get their blood pressure screened on a fairly routine basis so that we can discover those people who have high blood pressure.
We've kind of identified five major risk factors for developing artery disease, and with each one of those that you pile on top of the other your risk goes up. One of the major ones is having other people in your family with heart disease, but that's one we cannot modify. But the other four major ones, including blood pressure and having high cholesterol and smoking and having blood sugar that is too high, those four are all modifiable, and we have control over those with medications and lifestyle changes that we make.
Now, here's another statistic: 40 percent of American women over 55 have high cholesterol. And I wanted to ask you, one of the statistics I saw that was heart disease and heart attack things like that, often show up in women 10 years after men. And I wondered when I think about age 55, etc., is there a connection with estrogen and going through menopause? In other words, are postmenopausal women particularly at risk for a heart event?
We think that they are. We know that having a high HDL or good cholesterol protects us a bit against developing that plaque buildup inside of arteries, and in general premenopausal women have fairly high levels of HDL cholesterol. As women get to menopause the level of HDL or good cholesterol begins to fall generally, and the bad cholesterol begins to go up. So that's why in women we tend to see heart disease emerge about 10 years after it does in men.
So we've heard that the symptoms of heart disease and let's say an oncoming heart attack in women can be different, and so we have this, unfortunately, high mortality among women who ignore the signs. And I know there's a nurse I interviewed just the other day, actually. Fortunately, they saved her life, but she'd been having pain on the right side of her body for a week, and it had been getting worse, but she thought, well, if it's an oncoming heart attack it's on the left side, and I'll have pain down my left arm. Let's talk about that for a minute and how the symptoms for women can be different.
Well, if we look the symptoms and signs of a heart attack for both men and women, the most common sign of a heart attack is the same. It's pain or discomfort, usually not a sharp discomfort. It's usually described as a dull ache or a pressure like sensation that's in the center of the chest and can radiate to the left arm.
Some other signs, though, can be some patients will develop pain or discomfort in their arm, and it can be either the right arm or the left arm, some up in their neck where they feel as if somebody is tightening a neck tie around their neck, or even an aching feeling in the jaw. Another symptom that's common is shortness of breath, the feeling very suddenly like you're unable to take a deep breath. And then other symptoms include nausea, feeling faint or kind of woozy, or breaking out into a cold sweat.
As it turns out, women are more likely than men to have the symptoms of shortness of breath, nausea or vomiting, or pain that goes to the neck or the jaw or radiates through to the back. That is more common in women than it is in men. They're also more likely to have just feeling a general weakness or a sensation of heartburn that seems to be related to exertion rather than to any kind of association with eating. So the symptoms are somewhat different in men and women.
And because of that, women often just sort of keep on keeping on, right, and they don't get help?
That's correct. Particularly if they get some of these atypical symptoms where the pain may be occurring in the mid back between the shoulder blades or down the right arm, or I've had women that have had this sort of intermittent sort of tightening in their jaw which they've kind of written off to, oh, maybe I've got a dental problem or maybe I've got TMJ syndrome. So I think any of those symptoms that we discussed should prompt a person to at least mention these symptoms to their doctor so that they can be investigated.
So — just women understand, a heart attack — is caused by a blockage in the blood flow to the heart muscle.
And if that continues the heart muscle begins to die, and in a massive heart attack you die. So early intervention is critical, isn't it?
That's right. We tell our patients that the sooner after an episode that's concerning, whether it's pain in the back or pain in the chest or pain in the arms occurs the sooner a patient can get themselves to a hospital where we can do an electrocardiogram and get some blood tests and diagnose a heart attack, the sooner we can intervene and even prevent a heart attack. So we try to get our patients to get to the hospital within — 30 minutes to an hour at the very outside.
Let's go back to prevention. So you kind of ticked it off. So I have this image of if a woman could do regular exercise starting at an early age just as part of her life, maintain a healthy weight, monitor blood pressure, and if you have a family history, maybe your body produces more cholesterol naturally, whatever, that's all in discussion with your doctor. Maybe there's a medication that comes into play. But that's all part of good management that you can do, right?
Correct. And there have been some studies looking at if we were able to intervene on what we know are risk factors for heart disease, that is, if we were able to optimize a patient's blood pressure, keep their blood sugar in a normal range, get them exercising and keep any excess weight down, keep the cholesterol in the range of normal, which is less than 200 for the total cholesterol, and if a patient is a smoker if we can get them off the cigarettes, we could probably reduce the incidence of coronary heart disease by up to 80 percent.
Now, a lot of people, unfortunately, still smoke. Many have quit, and I know a lot of people who still smoke, have tried many times to quit. Help us understand, why is smoking a bad guy when it comes to heart disease? What is it doing?
Well, we know a couple of things that smoking does that are bad for arteries in general. It turns out that what starts this whole plaque buildup inside of the blood vessels is something occurs to damage that inner layer of the blood vessel, and some — damage occurs that begins that whole process of depositing cholesterol and depositing calcium in the blood vessel. And one of the things that we know can do that is carbon monoxide, which is one of the by products of smoking cigarettes. So there's a probably direct toxic effect of the carbon monoxide to the blood vessel.
Add on to that the fact that we know that as little as one or two cigarettes can cause increased blood clotting to occur, and obviously we don't like blood clots to form inside of blood vessels. As you pointed out earlier, that's what causes a heart attack to happen. A blood clot forms in the artery, blocks the flow of blood to the muscle, and the muscle dies. And that really is what a heart attack is. So we know of at least two ways, and there are potentially more ways that smoking is harmful to the heart.
Dr. Thorson, we have maybe 25 million people in America who are diabetic.
My understanding is if you're diabetic then all of these numbers related to what your cholesterol should be and your blood pressure, they have to be even tighter, if you will. Maybe talk for a minute about heart disease in women who are diabetic.
Well, we know that having diabetes confers about twice the risk to a woman than not having diabetes does. So a diabetic woman is twice as likely to develop heart disease as a woman who does not have diabetes. And that's probably — it's a more potent risk factor in women even than it is in men. So what I tell my diabetic patients is that because all of these risk factors are additive, they add on to one another, that I hold my diabetic women to a higher standard. That's what I tell them, that their blood pressure has to be even better than a non-diabetic woman or their cholesterol even needs to be driven a slight bit lower than in someone who didn't have diabetes because of the excess risk that the diabetes carries with it.
Now, a woman may be listening, she looks at her body, she says, I'm overweight. I don't get off the couch much or go outside the house. I don't go to the track at the local school, and it's too late. All is lost. Is it ever too late?
It is never too late to begin a moderate exercise or moderate physical activity program. I would say that if you're — if you're older than about 55 I think it's a wise idea to check with your doctor about an exercise program before you initiate it, but there's good evidence that as little as 60 minutes of moderate — and this is not break a sweat, panting exercises — moderate physical activity, 60 minutes a week is going to reduce your risk of having heart disease.
So that could be when you go to the mall, walk around the mall. It can be park your car further in the shopping center parking lot. Go up the steps.
Instead of the elevator.
If you're going to work and you can park 10 minutes away from your job, you can do the 10 minute brisk walk to the office, you have to do the 10 minute walk at the end of the day to get back to your car, and if you do 10 minutes lap around the building during lunchtime, you've got in 30 minutes at least one day a week. The goal that I try to get my patients to is 30 minutes of moderate exercise five days a week. But some is better than none. If it's only two days a week, that's better than nothing.
I have a couple of dogs, and I take them for a walk in the park. And it is just a great thing where I see groups of women walking together. And they're chatting, and they're walking the dogs, and they're out there every day. And I have to say they're pretty trim, too, so there are many steps. You know, I think about this. One of my dear friends is our family pediatrician, and her mother retired, and yes, she had been a smoker early in life, and then in the first week of retirement she dropped dead of a heart attack. What a tragedy.
It is a tragedy. And it doesn't have to happen. These are things that are really under our control. A lot of this is just making — making simple — now, I'm not saying that they're all easy, but simple changes in our lifestyle that can have really big — a big impact when it comes to our risk of developing heart disease.
And a specialist such as yourself, patients have conversations with you and you're there to help them.
Certainly. We are never bothered by a person that comes in and wants to know if their symptoms could be related to their heart. I always encourage my patients, if you're in doubt, go to a medical professional who has the capability to get an EKG, to get some blood tests, to do a physical examination. If it turns out to be something else, we're all thrilled. But if it turns out to be related to the heart maybe we can intervene early and prevent a heart attack from happening.
Amen. And all these lifestyle changes that one can make, be in conversation with your doctor about that. Say, I'm not really clear, help me get started. And, Dr. Thorson, you would certainly help in that regard too.
Absolutely. I encourage my patients to be proactive. I tell them that it's very important for them to know their numbers, and by that I mean know what your blood pressure is, know what the normal for blood pressure is. And normal is less than 140 over 90. Know that that's a normal blood pressure and keep track of your own blood pressure. There are lots of good over the counter blood pressure monitoring machines that are quite accurate that allow you to keep track of that at home.
If you're a smoker there's lots of help out there to help get you off the cigarettes. If you don't know what your blood sugar is, be proactive, tell your doctor, have you checked my blood sugar? Am I diabetic? If you don't know your cholesterol numbers find out. And it's not enough just to know the total, the total should be less than 200, it's important to know the bad cholesterol number, which is the LDL. Ideally, we would like that to be less than a hundred.
And, you know, know what your BMI is. BMI is body mass index, and that tells us whether your weight is in a healthy range. Your doctor can calculate that for you, or you can go on the internet and just Google "BMI calculator," and it will tell you how to calculate your BMI to see if your weight is in a normal range.
So there are — if you get to your health professional they're very happy to help you try to get these pieces of information that you can then keep track of, and you can be a participant in your own healthcare that way.
Great, great information. Listeners, ladies in particular, we haven't done so well in the past with women and heart disease, not well at all, and now here's the road map to how to do better. Dr. Anne Thorson, co-director of the UCSF Center For Prevention of Heart Disease and Vascular Disease located there at Mission Bay in San Francisco, thank you so much for being with us. Hopefully, we've saved some lives and some trauma among women with this discussion. Thank you.
Thank you very much. My pleasure.
Well, this is what I do on Patient Power. I learned so much and hopefully you have too so that the women in our lives can lead long, healthy lives.
I'm Andrew Schorr, remember, knowledge can be the best medicine of all.
Interviewed on June 2012
Photo by Tom Seawell.
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
Cardiovascular Care and Prevention Center at Mission Bay
535 Mission Bay Blvd. South
San Francisco, CA 94158
Phone: (415) 353-2873
Fax: (415) 353-2528