Heart Disease

Overview

As women, we are used to listening to our guts. But we should also be listening carefully to our hearts. Many of us think of heart disease as more of a “guy" problem. We worry about female diseases, like breast cancer and other female cancers. But as the health-conscious women that we are, we shouldn't dismiss heart disease. After all, heart disease is the number one cause of death in women; one in five female deaths result from heart disease. Six times as many women die from heart attack, stroke, and other coronary heart diseases as they do from breast cancer. And in each year since 1984, more women have died from cardiovascular diseases than men. So clearly, heart disease is a women's disease, too.

With these statistics in mind, most of us know at least one woman who has had a heart attack or other problem associated with heart disease. The scary thing about heart disease is that it often produces no symptoms, so women don't know there's a problem until they are in the middle of a heart attack or other cardiac event So, we need to be more mindful of heart disease and its risk factors, for the sake of ourselves and all the women we love.

What is heart disease?

To understand heart disease, it helps to know the anatomy of the heart. The heart pumps blood through a network of arteries and veins called the cardiovascular system. There are four chambers in the heart and valves between each chamber.

• Blood comes from different areas of the body through the veins and is received by the right atrium.
• From the right atrium, blood is pumped to the right ventricle where it is then pumped to the lungs.
• The lungs load the blood with oxygen and the blood then travels to the left atrium.
• From the left atrium, oxygen-rich blood is pumped to the left ventricle and out to the rest of the body.

There are two major coronary arteries that branch from the aorta, which is the main artery coming from the heart; these two arteries and the smaller branches that come off them supply the heart muscle with blood. Coronary arteries wrap around the outside of the heart, and small branches dive into the heart muscle to deliver blood and oxygen.

Understanding the anatomy of the heart is useful for understanding the diseases that can affect the heart.

There are several terms for heart disease and its related conditions, which can be confusing. Cardiovascular disease refers to the heart and all the blood vessels in the body. Heart disease includes only the heart.

The most common form of heart disease is ischemic heart disease, which occurs when the arteries cannot deliver enough blood to the heart because of narrowed heart arteries. It's the leading cause of death in the United States. Most of these deaths from ischemic heart disease result from coronary artery disease (CAD), also referred to as coronary heart disease (CHD). One in 16 women age 20 or older have coronary artery disease.

CAD is the buildup of a waxy substance called plaque inside the coronary arteries. As plaque builds on artery walls, they narrow, which makes it harder for blood to flow. If a blood clot forms in a narrow artery, a blockage can form and prevent blood from reaching the heart. The result: a heart attack or cardiac arrest.

Some of the most common conditions associated with heart disease include the following:

Heart attack: A heart attack occurs when a blood clot partially or completely blocks flood flow to the heart. If blood flow from an artery is totally blocked, the part of the heart supplied by that artery can start to die. Good news is, many women who suffer a heart attack survive it with little or no lasting symptoms. Women who have had a heart attack often need to make changes, however, either by taking medication or altering their lifestyles. Symptoms of a heart attack include chest pain or chest discomfort; neck pain; upper back pain; heartburn; indigestion; extreme fatigue; nausea or vomiting; dizziness; and shortness of breath. Symptoms of a heart attack may be different in women, compared to men, leading to under-diagnosis of women.

Arrhythmia: Arrhythmia is an irregular heart rhythm. A rhythm that is too fast (more than 100 beats per minute) is called tachycardia. A rhythm that's too slow (fewer than 60 beats per minute) is called bradycardia. When the heart beats too fast or too slow, your heart may not be able to pump the right amount of blood to meet your body's needs. Symptoms of arrythmia include heart palpitations and a fluttering sensation in the chest.

Heart failure: A woman is said to be in heart failure (or congestive heart failure) when her heart fails to pump blood as forcefully as it should. The heart pumps, but it doesn't get the proper amount of blood (and therefore, oxygen) to the body. Symptoms of heart failure include fatigue and shortness of breath and swelling in the legs, ankles feet, neck veins, or abdomen as fluid builds.

Heart valve problems: In some women, heart valves don't open wide enough to allow enough blood to flow through (stenosis). In other cases, valves don't close tightly enough and blood leaks out (regurgitation). And sometimes, valves can bulge back into the upper chamber of the heart (prolapse).

Congenital heart disease: A congenital heart defect is a problem with the structure of the heart that is present at birth. Congenital heart defects can involve the arteries, valves, walls of the heart, and veins near the heart and disrupt normal blood flow. Blood may flow in the wrong direction or be completely blocked.

Risk Factors of Heart Disease

Nine out of 10 women have at least one risk factor for heart disease. The more risk factors you have, the more likely you will be to develop heart problems. There are some risk factors, such as your age, family history of heart disease, or other health conditions, you cannot change. Others, such as your diet and exercise habits, you can.

Risk factors include the following:

• Smoking. Smoking increases risk for heart disease by increasing blood pressure, damaging blood vessels and making blood stickier and more likely to clot. It also makes you less likely to exercise and decreases good HDL cholesterol. Women who smoke are two to six times more likely to suffer a heart attack than nonsmoking women, and the risk increases with the number of cigarettes smoked per day. Constant exposure to other people's smoke—called environmental tobacco smoke, secondhand smoke or passive smoking—increases the risk of heart disease, even for nonsmokers. And, of course, smoking also increases your risk for lung and other cancers.
• High blood pressure. Over time, high blood pressure damages the arteries, which causes them to narrow and collect plaque. High blood pressure is defined as 130 or higher for the first number (systolic pressure) and 80 or higher for the second number (diastolic pressure). Systolic blood pressure measures how much the blood pushes against the artery walls when the heart beats. Diastolic blood pressure measures how much blood is pushing against the artery walls when the heart rests between beats. Optimally, your blood pressure should be below 120/80 mm Hg.
• High triglycerides. Triglycerides are a type of fat found in your blood. Normal triglyceride levels vary by age and sex. Obesity, cigarette smoking, sedentary lifestyle, excess alcohol consumption, and a diet high in carbohydrates (more than 60 percent of calories) can all raise triglycerides. You should aim for a triglyceride level below 150.
• High cholesterol. Cholesterol is a fatty substance in your blood. Your body makes some cholesterol, and you get some from food. When the amount of cholesterol in the blood is too high, that cholesterol can collect on and narrow artery walls, increasing risk for coronary artery disease. There are two main types of cholesterol---low density lipoprotein (LDL) and high density lipoprotein (HDL). It helps to know your numbers and what they mean. Ideally, you should shoot for an LDL cholesterol number less than 100 and an HDL cholesterol number higher than 50. Also important is your total cholesterol number, which is HDL + LDL + 20 percent of your triglycerides level (provided that your triglyceride level is below 400).
• Sedentary lifestyle. Movement helps protect your heart. In one study, sedentary people who reported more than 23 hours a week of sedentary behavior had a 37 percent higher risk of cardiovascular disease than those who reported fewer than 11 sedentary hours a week.
• Overweight or obesity. A body mass index (BMI) of between 25 and 29.9 puts a person in the overweight category. Obesity is a BMI of 30 or above. Women who are overweight or obese are more likely to have high cholesterol, high blood pressure, diabetes and other health problems that lead to heart disease. In addition, high body weight makes the heart work harder to pump blood to all the areas of the body.
• Diabetes or prediabetes. According to the American Heart Association, nearly 70 percent of people over age 65 who have diabetes die from some form of heart disease. Women with diabetes progress more rapidly to heart disease than men with diabetes.
• High C-Reactive protein (CRP). A high blood level of CRP, a sign of inflammation, may mean that the walls of the arteries in the heart are inflamed, which raises heart disease risk.
• Systemic autoimmune diseases. Systemic autoimmune diseases, such as lupus and rheumatoid arthritis, can increase risk of heart disease.
• Metabolic syndrome. Having a cluster of symptoms, including abdominal obesity, high blood pressure, glucose intolerance (or prediabetes), high triglycerides and low HDL cholesterol, is associated with developing cardiovascular disease.
• Family history of heart disease. Women whose mothers, fathers, sisters, or brothers have heart disease are more likely to develop it themselves.
• Personal history of preeclampsia. If you develop, or have a history of, preeclampsia, a dangerous condition characterized by high blood pressure during pregnancy, you're more likely to have heart disease later in life.
• Older age (55 years or older for women). Women are at higher risk for heart disease after menopause when their estrogen levels drop. Pre-menopausal women are protected from heart disease, likely because of estrogen, although the exact mechanism by which estrogen does this is not entirely clear. Women who go through early menopause naturally or after a hysterectomy have double the risk of heart disease as compared to women the same age who are not yet in menopause.

Symptoms of heart disease

Some women experience no symptoms of heart disease and don't know they have it until they have a heart attack or stroke.

When symptoms do occur, they may strike anytime, anywhere. They include:

• A dull, heavy, or sharp pain in the chest, called angina
• Chest discomfort
• Pain in the jaw, throat, or neck
• Pain in the back or upper abdomen
• Nausea and vomiting
• Feeling of impending doom (women's intuition)
• Fatigue

If you experience any of the above symptoms, call 911 or head to your nearest emergency room.

Diagnosis

If you exhibit any symptoms of heart disease, see a health care provider. Depending on your symptoms, risk factors, and medical history, he or she will order tests. Those tests will include one or more of the following:

Cardiac catheterization (“cardiac cath"): Your doctor may order a cardiac cath to check for a range of problems, from a blocked artery to problems with your chambers or valves. During the test, he or she will put a long, thin, flexible tube called a catheter into a blood vessel in your body and thread it to your heart. The catheter may go into a vessel in your neck, arm, or groin, depending on where your doctor thinks the blockage may be. He or she will then take x-rays of your heart. Depending on the findings, your doctor may order coronary angiography (explained below), take samples of your heart muscle, or perform other procedures, such as angioplasty or heart surgery.

Cardiac Computed Tomography (CT) Scan: This is a painless test that helps your doctor look for signs of heart disease, including problems with your heart values or aorta; calcium buildup in your arteries; or pericardial disease. (Pericardial disease is inflammation of the sac that surrounds the heart). It involves taking x-ray images of your heart and blood vessels. A computer then combines those pictures to create a 3-D image of your entire heart. Before your CT scan, you'll get an injection of contrast dye that will light up your heart and blood vessels. You'll then lie in a tube-shaped machine for about 15 minutes while the scanner takes the pictures.

Cardiac Magnetic Resonance Imaging (Cardiac MRI): The MRI can help diagnose heart problems including CAD; tumors; damage from a prior heart attack; pericarditis; and heart valve problems. Also painless, this test uses magnets and radio waves to create computerized, detailed pictures of your heart. It can help your doctor detect whether you have heart disease, and if you have it, how severely. During the MRI, you will lie in a tube-shaped machine that makes loud noises as it takes pictures of your heart. You may or may not get an injection of contrast dye before the test. The entire test takes between 30 and 90 minutes.

Chest x-ray: Your doctor may order a chest x-ray to check for heart failure or to rule out lung problems and other conditions that may be causing symptoms of heart disease. It involves taking pictures of your heart and other organs inside your chest.

Angiography: You may undergo angiography if you have chest pain, cardiac arrest, or abnormal results from another heart test. A coronary angiogram takes pictures of the inside of your arteries after you receive a contrast injection or catheter containing contrast dye. It can show whether you have a blockage in your arteries, and if so, how severe it is.

Echocardiography (“echo"): An echo can show how well blood pumps through your heart, as well as your heart's size and shape. It can also check to see if your chambers and valves are working properly. The test uses ultrasound to create real-time images of your heart. After applying gel to your chest, a technician moves a wand-like device to take pictures of your heart. Those images go to a computer screen, where your doctor can look at them and assess any problems.

Electrocardiogram (EKG, ECG): This test checks your heart's electrical activity. It measures how fast your heart beats and whether the rhythm is steady or irregular. Your doctor may use an EKG to screen for heart disease or to look for problems like a previous heart attack, arrhythmia, or heart failure. It's a simple, painless test that involves lying on a table while a technician attaches electrodes to your arms, legs, and chest.

Stress test: A stress test checks to see how hard your heart works when it's under physical stress. Your doctor may order a stress test to check to see if you have CAD, and if so, how severe it is. It can also help diagnose or rule out heart failure and valve problems. The test involves walking on a treadmill to raise your heart rate and make it work harder than normal. (If you cannot exercise, you can take a medication to do the same thing). As you exercise, a technician will perform an EKG and monitor your blood pressure. You may also get an echo or other imaging test during a stress test.

High-sensitivity C-reactive protein (CRP) blood test. This blood test detects a protein that elevates in response to inflammation, called high-sensitivity (hs) C-reactive protein (hs-CRP). Inflammation is associated with an increased risk of atherosclerosis, although it is not clear if it actually causes the disease.

Treatment

Treatment for heart disease will depend on a few factors, including the severity of the heart disease and any other health conditions you have. Your health care provider may prescribe lifestyle changes, medication, or procedures to help get heart disease under control.

Medications:

Medications can help manage symptoms of heart disease, reduce risk factors, and treat underlying causes. Some treat health conditions that can contribute to heart disease, such as diabetes and high blood pressure. Here are some of the most common medicines for heart disease:

Statins help reduce blood cholesterol. They work by interrupting formation of cholesterol in your liver. Your doctor may prescribe statins if your cholesterol levels are high and/or you are at increased risk for ischemic heart disease or stroke or you have diabetes. Common statins include atorvastatin (Lipitor), rosuvastatin (Crestor), and simvastatin (Zocor)

Non-statin drugs may be an option if statins fail to lower the LDL cholesterol in your blood to a desirable level or if you experience serious side effects. These medicines include ezetimibe, bile acid sequestrants, and PCSK9 inhibitors (evolocumab, or alirocumab).

(Some cholesterol lowering drugs (both statins and nonstatins) can interact with grapefruit juice and pomegranate juice. Talk to your health care provider about these risks).

Low-dose aspirin—up to 325 mg per day—may help prevent heart attack in people who have previously had a heart attack or cardiac procedure. The American Heart Association recommends these people take low-dose aspirin daily, or as recommended by their health care providers, to prevent another event.

Anticoagulants, also called blood thinners, decrease the blood's ability to clot. They prevent clots from forming in the blood vessels and causing more serious problems. Common anticoagulants include warfarin (Coumadin) and Rivaroxaban (Xarelto).

Antiplatelet medications prevent blood platelets from sticking together, so blood clots are less likely to form. Your doctor may prescribe antiplatelet medications for angina or to prevent future problems if you've had a heart attack or stroke. You may also take these medications if you have plaque buildup in your arteries but no blockages. Drugs in this class include clopidogrel (Plavix), Dipyridamole, and aspirin.

Dual antiplatelet therapy (DAPT) is treatment with two different antiplatelets at the same time—one being aspirin--to prevent blood clots. Your doctor may prescribe DAPT if you've had a heart attack, you have a stent in your arteries, or you've had coronary artery bypass graft surgery (CABG).

Calcium channel blockers stop calcium from entering the cells of the blood vessels and heart. This may relax blood vessels and reduce the heart's pumping strength. Doctors prescribe these drugs for people with high blood pressure, chest pain (angina), and arrhythmias. Examples include Amlodipine (Lotrel) and Nimodipine (Nimotop).

Angiotensin-Converting Enzyme (ACE) inhibitors work to expand blood vessels and decrease levels of angiotensin II. These actions allow blood to flow more freely, lowering blood pressure. ACE inhibitors help treat high blood pressure and heart failure. Common ACE inhibitors include ramipril (Altace), Captopril (Capoten), and Benazepril (Lotensin).

Angiotensin II receptor blockers (ARBs) prevent angiotensin II from affecting the heart and blood vessels, which keeps blood pressure from climbing too high. These drugs help treat high blood pressure and heart failure. Examples include candesartan (Atacand), losartan (Cozaar), and valsartan (Diovan).

Angiotensin-receptor neprilysin inhibitors (ARNIs) are a new drug combination of an ARB and a neprilysin inhibitor. Neprilysin is an enzyme that breaks down substances in the body that keep arteries open. By limiting this enzyme, these medications help keep arteries open and improve blood flow. ARNIs are used for heart failure. An example is sacubitril/valsartan (Entresto).

Nitrates, also called vasodilators, relax blood vessels, increase blood supply to the heart, and reduce the heart's workload. They are typically prescribed for chest pain and include nitroglycerin tablets and nesiritide (Natrecor). Vasodilators come in chewable tablets, capsules, and topical application.

Digitalis preparations are drugs that make the heart pump with greater force. They are used to treat heart failure and irregular heartbeats. Doctors often prescribe these drugs when a patient doesn't respond to an ACE inhibitor or diuretic. Lanoxin is a commonly prescribed digitalis preparation.

Diuretics, or water pills, help the body get rid of excess fluids and sodium. They increase urination. This action lowers the heart's workload and reduces blood pressure and swelling. Common diuretics include hydrochlorthiazide, amiloride (Midamor) and furosemide (Lasix).

Beta blockers are medicines that decrease the heart rate, which lowers blood pressure and causes the heart to beat less forcefully. Doctors prescribe beta blockers to help lower blood pressure and to treat arrhythmias and chest pain. Beta blockers can also help prevent future heart attacks in people who have already suffered one. Common beta blockers include propranolol (Inderal) and Bisoprolol (Zebeta).

Procedures to treat heart disease

Depending on your individual case, your doctor may recommend a cardiac procedure. Possible procedures include the following:

Angioplasty. Angioplasty opens a blocked artery. The procedure involves threading special tubing with a deflated balloon at the end to the coronary arteries. Once the balloon is in place, the surgeon inflates it to widen narrowed areas. The surgeon may also implant a stent to keep the artery open and help prevent future blockage. Angioplasty is minimally invasive and lasts between 30 minutes to a few hours.

Laser angioplasty. Similar to angioplasty, this procedure uses a catheter with a laser tip instead of a balloon to open the blocked artery. Then, pulsing beams of light break up the plaque in the narrowed artery.

Atherectomy. Also similar to angioplasty, instead of a balloon, the tip of the catheter has a rotating shaver on the end that shaves plaque out of the blocked artery.

Radiofrequency ablation. Otherwise known as catheter ablation, this procedure treats many types of arrhythmias. It involves guiding a catheter with an electrode on the tip through your veins and to your heart. The surgeon places the catheter in the spot where the abnormal rhythm originates and sends radiofrequency energy to destroy the muscle cells in that area.

Heart valve replacement. In the case of a heart valve that isn't working properly, this procedure replaces the unhealthy heart valve with a healthy one.

Bypass surgery. Also known as coronary artery bypass graft (CABG), this surgery treats blocked arteries, improves blood flow to the heart, reduces risk of heart attack, and improves overall health and wellbeing. It involves taking veins or arteries from other parts of your body and placing them in the area of the blockage to bypass the clogged artery and get blood to your heart muscle. Depending on how many arteries are blocked, there may be one, two, three or more bypass grafts. This is major surgery that requires several days in the hospital. You may need to take medication following the surgery, including antiplatelet drugs.

Minimally invasive heart surgery. During this procedure, which is a less invasive option to CABG, the surgeon makes small cuts (called ports) in your chest. He or she then attaches arteries or veins from your legs to your heart to bypass the blockage. The surgeon performs this procedure on a video monitor instead of directly on the patient. Different from CABG, which is done while the heart is stopped, this surgery is done when the heart is still beating. It also requires several days in the hospital.

Cardiac rehabilitation. Women who have recently had a heart attack or a procedure such as angioplasty or bypass surgery should participate in some form of cardiac rehabilitation (rehab). Cardiac rehab helps heart patients recover and improve their overall physical and mental health. It also provides tools to help prevent another cardiac event. Programs include counseling, emotional support, exercise, help with modifying risk factors and tips for returning to work.

Lifestyle changes for a healthy heart

Many of the things that lead to heart disease are habits you can control. And you're never too old to make changes that can improve your health and wellbeing. Here are some things you can do:

Quit smoking. Women who smoke are significantly more likely to suffer a heart attack than women who don't, and that risk increases with the number of cigarettes smoked per day.

The good news is, quitting dramatically cuts the risk to your heart, even during the first year. This is the case no matter what your age. Even if you've had a heart attack, you'll benefit from quitting—risk of having a second heart attack is cut by 50 percent or more after you stop smoking.

Eat a heart-healthy diet. Eat foods high in fiber, rich in vitamins, and minerals, and lower in calories, and lower in saturated fat. The DASH (Dietary Approaches to Stop Hypertension) diet, endorsed by the major heart organizations, is one strategy for boosting heart health. It is low in sodium and includes lower-calorie foods such as fruits and vegetables, fish, poultry, beans, seeds, nuts, low-fat or fat-free dairy products and whole grains.

Some large studies also point to the Mediterranean diet as a beneficial pattern of eating to reduce your risk of heart disease. Like the DASH diet, the Mediterranean eating pattern focuses on fruits, vegetables, whole grains, nuts and seeds. It also includes olive oil as a significant source of monounsaturated fat and wine in low to moderate amounts. The major protein sources are dairy, fish and poultry, with minimal red meat.

Here are some tips on eating for heart health:

• Eat fatty fish such as salmon, tuna, or mackerel, at least two times a week, if possible.

• Choose lean cuts of meat, removing fats from meats and skin from chicken before cooking. Eat up to six ounces per day.

• Limit sugary beverages and sweets.

• Broil, bake, roast or poach foods rather than fry them.

• Cut down on sausage, bacon and processed high-fat cold cuts.

• Limit organ meats such as liver, kidney or brain.

• Drink skim or one percent milk instead of whole. Try nonfat or low-fat yogurt in place of sour cream. Choose nonfat or low-fat cheeses.

• Instead of butter, use olive oil or liquid vegetable oils high in poly- or monounsaturated fats. Use all fats and oils sparingly.

• Eat as little trans fat as you can. Trans fats, which you may find in commercial baked goods and fried foods, increase LDL cholesterol and lower HDL cholesterol Trans fats are associated with higher risk for heart attack, stroke, and type 2 diabetes.

• Aim for 25 to 35 percent or fewer of your daily calories from fat. Most of that fat should come from unsaturated sources. Limit your saturated fat to less than 10 percent of your total calories per day.
• Try to keep your sodium intake to no more than 2,300 mg per day.
• Consume foods rich in soluble fiber. For a 2,000 calorie-per-day diet, the United States Food and Drug Administration recommends at least 25 grams of soluble fiber a dayEat plenty of fresh fruits and vegetables, as well as cereals, breads, rice and pasta made from whole grains (for example, rye bread, whole wheat spaghetti and bran cereal). These foods are a good source of energy, nutrients, and fiber, and most contain no cholesterol and little or no saturated fat.
• Use liquid vegetable oils for sautéing vegetables, browning potatoes, popping corn and making baked goods, pancakes and waffles. Use small amounts or try a vegetable oil cooking spray.

Move your body every day. Women who get at least 150 minutes of moderate-intensity physical activity per week (about 30 minutes a day) reap lots of benefits when it comes to heart health. Regular exercise helps lower blood pressure, reduce cholesterol, maintain a healthy weight, and extend the length of your life.

If you exercise vigorously, you can lower the amount of time you spend exercising to 25 minutes per day at least three days per week. And if you do a combination of moderate and vigorous exercise, you can meet somewhere in the middle. Examples of moderate activity are brisk walking, bicycling, raking leaves and gardening. Vigorous exercise includes running, jogging, swimming laps and cross-country skiing. Being physically fit and active provides cardiovascular benefits independent of weight loss. In addition to aerobic exercise, for additional health benefits, the American Heart Association (AHA) recommends moderate- to high-intensity muscle-strengthening activity at least two days a week. A 2018 study published in the European Heart Journal found that people who are physically fit may have half the risk of a heart attack compared to people who are less fit.

You also can benefit from exercise if you have existing heart disease. As little as 30 minutes of moderate activity on at least five, and preferably all, days of the week helps protect the heart and is recommended by the AHA.

Maintain a healthy weight. Overweight women are much more likely to develop heart-related problems than are normal weight women, even if they have no other risk factors. Being overweight contributes to high blood pressure, high blood cholesterol and diabetes. The more overweight you are, the higher your risk for heart disease.

Body shape may also affect heart health. "Apple-shaped" women with extra fat at the waistline may have a higher risk than "pear-shaped" women with heavy hips and thighs. If your waist is nearly as large as, or larger than, the size of your hips, you may have a higher risk for coronary heart disease.

Ideally, the AHA preventive guidelines for women recommend women maintain/achieve a body mass index (BMI) between 18.5 and 24.9 and a waist circumference of less than 35 inches.

The secret is to lose and maintain weight in healthy ways—exercising with a combination of cardio and strength training, watching calorie intake, and eating the right kinds of foods. Fad diets and supplements are not the way to go for healthy weight loss.

Don't wine too much. Research is conflicting about whether a moderate amount of alcohol—up to one drink a day for women and up to two drinks a day for men—may improve heart health. The National Institute on Alcohol Abuse and Alcoholism defines one drink as 1 ½ fluid ounces of 80-proof spirits (Scotch, vodka, gin, bourbon), 5 fluid ounces of wine, or 12 fluid ounces of regular beer. Drink more than this, and the bad effects will quickly outweigh the good. Over-imbibing can raise your blood pressure and blood lipids, increase cardiomyopathy (disease of the heart muscle), spark arrhythmia, cause you to gain weight, and harm your liver. Alcohol use also increases the risk of breast cancer: the more alcohol, the higher the risk. The risk of breast cancer is slightly increased even with small amounts of daily alcohol consumption.

Lower stress. Some research has shown that emotional stress equals a higher risk for heart disease. When you're under stress, you're more likely to eat too much and the wrong kinds of foods, smoke, and drink too much alcohol—all of which can up your risk for heart-related conditions. To reduce the amount of stress in your life, make sure you get enough sleep, don't be afraid to say 'no' when you feel overwhelmed, and take time for activities you enjoy. When stress strikes in the short-term, get outside and take a walk, practice yoga or deep breathing, or take a long, relaxing bath.

Know the symptoms of a heart attack. If you feel pressure, discomfort or pain in the center of your chest, pain that spreads to your arm, neck or jaw, or a crushing or squeezing sensation with shortness of breath, tiredness or upset stomach, you could be having a heart attack. Call 9-1-1. After you call 9-1-1, the operator may recommend that you chew one adult-strength (325 mg) aspirin after he or she makes sure you don't have an allergy to aspirin or a condition that may make taking it too risky. If the operator doesn't talk to you about chewing an aspirin, the emergency medical technicians or physicians at the hospital will give you one if it's right for you.

Facts to Know

1. According to the United States Centers for Disease Control and Prevention, in 2017, cardiovascular disease killed 299,578 women, and accounts for one in every five female deaths.
2. More women die from heart attacks than men.
3. African-American women are more likely to die of CHD than Caucasian women.
4. Coronary heart disease is a disease of the heart's blood vessels that, if untreated, can cause heart attacks. When the coronary arteries become narrowed or clogged and cannot supply enough blood to the heart, CHD results.
5. Smoking is a major risk factor for coronary artery disease. Women who smoke are two to four times more likely to suffer a heart attack or stroke than nonsmoking women, and the risk increases with the number of cigarettes smoked per day.
6. Even slightly elevated blood pressure increases your risk for coronary heart disease. According to the CDC, at least one in three Americans has high blood pressure.
7. Overweight women are much more likely to develop heart-related problems than women who are at a normal weight. Obesity is linked with coronary heart disease, stroke, congestive heart failure death from heart-related causes, and diabetes The higher your BMI, the higher your risk for heart disease.

Questions to Ask

Review the following Questions to Ask about heart disease so you're prepared to discuss this important health issue with your health care professional.

1. What tests should I have, and how often, to monitor my risk factors for developing heart disease or other cardiovascular diseases?
2. What do my test results mean? Do I have heart disease?
3. What treatments do you recommend?
4. Am I at high risk for heart-related complications if I take birth control pills or have taken them in the past?
5. What are the possible side effects of medications I've been prescribed?
6. What should I do if I experience chest pain or if I think I'm having a heart attack?
7. How can I tell the difference between angina and a heart attack?
8. Is it safe to use hormone therapy?
9. What lifestyle changes can I make to improve my cardiovascular health?
10. Should I take aspirin to help prevent a heart attack? If so, how much and how often?

Key Q&A

1. What's the difference between angina and a heart attack?
   When blood flow to the heart is restricted, chest pain, or angina, can result. If blood flow is nearly or completely blocked, a heart attack can occur, killing muscle cells in the heart. Angina usually disappears with rest or medicine, such as nitroglycerin. A heart attack requires much more intensive therapy in a hospital. If the pain is severe or doesn't go away, or if the symptoms are those of a heart attack, call 911 and get evaluated at a nearby hospital emergency room.
2. I've been smoking for a long time—isn't it too late to quit?
   It's never too late to quit. Quitting smoking dramatically cuts the risk to your heart, even during the first year, no matter what your age or how long you've been smoking. After only one year of quitting, your excess risk for heart disease is half that of a person who smokes. Recent AHA guidelines recommend counseling, nicotine replacement and other forms of therapy to help women stop smoking.
3. Isn't heart disease dictated by genes?
   A family history of heart disease is indeed a risk factor for heart disease, but it plays a smaller role than the risk factors you can control—smoking, diabetes, weight, activity levels, blood pressure and cholesterol levels.
4. What's the connection between estrogen and heart disease?
   Prior to menopause, naturally circulating estrogen in a woman's body may help keep her arteries free from plaque, although the exact mechanism is not understood. . Estrogen helps keep the lining of blood vessels strong and pliable. When estrogen levels drop at menopause, a woman starts to lose these protective effects, and her risk for heart disease rises.
5. Do birth control pills increase risk for heart disease?
   Oral contraceptives used to have much higher doses of estrogen than they do today. These high-dose pills increased the risk of vascular and heart disease, especially among women who smoked. Today, most birth control pills contain 35 micrograms of estrogen or less. However, even the lower-dose pills carry a risk of increasing blood pressure. Talk to your health care provider of the benefits versus risks of birth control pills if you have concerns about your heart health. Also make sure your provider knows if you smoke. Even with the low-dose pill, smoking boosts the risks of serious cardiovascular problems, particularly in women over 35.
6. What are the current recommendations for hormone replacement therapy and heart disease?
   In the 1980s and 90s, doctors prescribed menopausal hormone therapy—also known as hormone replacement therapy—for preventing heart disease in addition to treating menopausal symptoms such as hot flashes. But, findings from the Women's Health Initiative suggest that some forms of menopausal hormone therapy increase a woman's risk of cardiovascular disease rather than prevent it. Talk to your health care provider about your individual benefits versus risks if you are considering menopausal hormone therapy.
7. I'm under 40. Should I be concerned about heart disease?
   Yes. The lifestyle you lead now—the foods you eat, how much you exercise, the amount of alcohol you drink—may be contributing to atherosclerotic buildup in your arteries. All women over age 20 should have their blood cholesterol tested every four to six years and their blood pressure checked every one to two years. You should get your blood pressure checked every time you visit a health care professional.
8. Should I exercise if I've been diagnosed with coronary heart disease?
   The short answer is, yes. Getting regular exercise is important because it helps strengthen your heart muscle, lower your blood pressure, and decrease cholesterol. It also keeps your blood sugar in check. A steady workout routine can also help you lose weight, reducing your risk of complications related to heart disease. With that being said, however, it's important to check with your health care professional before you start any exercise program with existing heart disease. He or she will go over safe exercises for you, as well as guidelines you should follow as you engage in physical activity.

Organizations and Support

For information and support on coping with Heart Disease, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Cardiology (ACC)
Website: https://www.acc.org
Address: Heart House
2400 N Street, NW
Washington, DC 20037
Hotline: 1-800-253-4636
Phone: 202-375-6000
Email: resource@acc.org

American Heart Association (AHA)
Website: http://www.americanheart.org
Address: 7272 Greenville Avenue
Dallas, TX 75231
Hotline: 1-800-AHA-USA-1 (1-800-242-8721)
Email: Review.personal.info@heart.org

American Society of Hypertension
Website: http://www.ash-us.org
Address: 148 Madison Avenue, Fifth Floor
New York, NY 10016
Phone: 212-696-9099
Email: ash@ash-us.org

American Stroke Association
Website: http://www.strokeassociation.org
Address: 7272 Greenville Avenue
Dallas, TX 75231
Hotline: 1-888-4-STROKE (1-888-478-7653)

Heart Failure Society of America
Website: http://www.hfsa.org
Address: Court International, Suite 240 S
2550 University Avenue West
Saint Paul, MN 55114
Phone: 651-642-1633
Email: info@hfsa.org

Medivizor
Website: https://medivizor.com

National Heart, Lung, and Blood Institute (NHLBI) - NHLBI Health Information Center
Website: http://www.nhlbi.nih.gov
Address: Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

National Stroke Association
Website: http://www.stroke.org
Address: 9707 E. Easter Lane
Centennial, CO 80112
Hotline: 1-800-STROKES (1-800-787-6537)
Email: info@stroke.org

Pulmonary Hypertension Association
Website: http://www.phassociation.org
Address: 801 Roeder Road, Suite 400
Silver Spring, MD 20910
Hotline: 1-800-748-7274
Phone: 301-565-3004
Email: adrienne@phassociation.org

Sister to Sister: The Women's Heart Health Foundation
Website: http://www.sistertosister.org
Address: 4701 Willard Avenue, Suite 223
Chevy Chase, MD 20815
Hotline: 1-888-718-8033
Phone: 301-718-8033
Email: webmaster@sistertosister.org

Vascular Cures
Website: http://vascularcures.org
Address: 274 Redwood Shores Parkway, #717
Redwood City, CA 94065
Phone: 650-368-6022
Email: info@vascularcures.org

WomenHeart: National Coalition for Women with Heart Disease
Website: http://www.womenheart.org
Address: 818 18th Street, NW, Suite 930
Washington, DC 20006
Hotline: 877-771-0030
Phone: 202-728-7199
Email: mail@womenheart.org

Women's Health Initiative (WHI)
Website: https://www.whi.org
Address: Women's Health Initiative
Clinical Coordinating Center
Fred Hutchinson Cancer Research Center
1100 Fairview Ave N, M3-A410
PO Box 19024
Seattle, WA 98109-1024
Phone: 800-218-8415
Email: helpdesk@whi.org

Women's Heart Foundation
Website: http://www.womensheart.org
Address: P.O. Box 7827
West Trenton, NJ 08628
Phone: 609-771-9600

Books

American Heart Association Quick & Easy Cookbook: More Than 200 Healthful Recipes You Can Make in Minutes
by American Heart Association

The China Study: The Most Comprehensive Study of Nutrition Ever Conducted And the Startling Implications for Diet, Weight Loss, And Long-term Health
by T. Colin Campbell , Thomas M. Campbell II , Howard Lyman, John Robbins

Heal Your Heart - How You Can Prevent or Reverse Heart Disease
by K. Lance Gould

Heart of the Matter: The African American's Guide to Heart Disease, Heart Treatment, and Heart Wellness
by Hilton M. Hudson, Herbert Stern PhD

High Blood Pressure: The Black Man and Woman's Guide to Living with Hypertension
by Hilton M. Hudson II MD FACS, James R. Reed

Johns Hopkins Complete Guide to Preventing & Reversing Heart Disease
by Peter M Kwiterovich Jr.

RealAge Makeover: Take Years Off Your Looks and Add Them to Your Life
by Michael F. Roizen

What to Eat If You Have Heart Disease: Nutritional Therapy for the Prevention & Treatment of Cardiovascular Disease
by Maureen Keane, Daniella Chace

Women's Concise Guide to a Healthier Heart
by Karen J. Carlson , Stephanie A. Eisenstat M.D., Terra Ziporyn Ph.D.

Spanish-language resources

Spanish Society of Cardiology
Website: http://www.secardiologia.es
Address: Madrid, Espana
Phone: 917242370

American Heart Association
Website: https://international.heart.org/es
Address: 7272 Greenville Ave
Dallas, TX 75231
Hotline: 1-800-AHA-USA1

Medline Plus
Website: http://www.nlm.nih.gov/medlineplus/spanish/heartdiseases.html
Address: 8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

womenshealth.gov
Website: https://espanol.womenshealth.gov/heart-disease-and-stroke
Address: National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA 22031
Hotline: 1-800-994-9662
Email: http://www.womenshealth.gov/contact/