Healthy Aging

Coronary Artery Disease Affect on Older Women
by Tricia Booi

The leading cause of death in women and men today is cardiovascular disease (CVD). The most common form of CVD is Coronary Artery Disease (CAD). This condition is characterized by the accumulation of plaque (fat, calcium and scar tissue) deposited into the arteries that supply blood to the heart. This build up restricts blood from entering the heart as it narrows or blocks the arteries causing angina (chest pain) or heart attack (Heart and Stroke Foundation of Canada, 2008). CAD affects 15 to 20 percent of all women. In the past CAD initially regarded as a disease primarily affecting men, is in fact the leading cause of heart attack among women. Women are actually more likely to die from a heart attack than men (Goodman & Kirwan, 2001). Men’s mortality rates for CAD have been on a steady decline since 1975, whereas the decline for women’s mortality rates remains relatively high (Goodman & Kirwan, 2001). Most research and studies on the disease contain a higher distribution of the male population, ignoring the ways in which the disease affects women. The lack of female representation in past research leads to a current lack of understanding and under-diagnosis of the condition in women. Many women do not consider CAD to be a major health risk even though it affects one in three women over the age of 65 (Wenger, 1997). Increasing awareness and understanding the affects associated with CAD is crucial, to better treat and educate women on the importance of early detection and prevention. To combat the increasing number of cases of CAD in women, they must acknowledge the various risk factors, work towards preventative methods of decreasing their likelihood to the disease, and educate themselves on maintaining a healthy, active lifestyle.

Symptoms

Symptoms for Coronary Artery Disease are relatively similar for men and women. These symptoms differ between gender in their severity and onset. The main symptom related to this disease in men and women is pain or pressure of the chest. Men generally show signs of CAD with acute myocardial infraction (heart attack) whereas women are more likely to exhibit a condition known as angina pectoris. This condition causes sharp pain in the chest due to a lack of oxygen and blood entering the heart (Tecce et al., 2003). Older women (75 years and older) with CAD usually display atypical symptoms prior to an MI. These symptoms include pain in the abdomen rather than in the chest, shortness of breath, fatigue, indigestion, nausea, pain in the jaw, shoulder, and lower back. Other symptoms that occurred one month prior to myocardial infarction are unusual fatigue along with sleep disturbances, shortness of breath, indigestion and anxiety (Tecce et al., 2003).

Studies show that women’s description of CAD symptoms differs from that of men’s. These results concluded that it is generally easier for clinicians to diagnose CAD in men (Vodopiutz, Poller, Schneider, Lalouschek, Menz & Stollberger, 2002). In the study done by Vodopiutz et al., found that chest pain was more likely to occur gradually over time in women, and is often relieved by rest (2002). This study also showed strong differences between the genders in the description of chest pain. Males presented themselves as “well informed about their illness, as actively managing pain in order to treat it, cooperative, and interested in detection of pain causes” (Vodopiutz et al., 2002, p.272). Males had a tendency to observe and describe their pain concretely and seriously. Women’s description of the pain was rather different in comparison to men “women had the tendency to utilize an emotional self-description and down play symptoms of pain. They were less interested in determining the cause of the pain then men” (Vodopiutz et al., 2002). The under-diagnosis of CAD in women may be related to the fact that this was formerly considered a man’s disease and was primarily treated by male physicians. Another aspect that may be associated with the under-diagnosis of women with CAD, are the different descriptions and presentations of the disease portrayed by women (Vodopiutz et al., 2002). For many years, women’s symptoms of CAD went overlooked. In reality, men and women have a different presentation of the symptoms and may need different treatments. Physicians and health care professionals need to inform older women about the symptoms that they may experience so they can seek the necessary treatment. With physician’s and health care professionals, becoming more aware of the differences in presentation of symptoms between genders there should be a decrease in the under-diagnosis. If women have these symptoms present, they should not hesitate to seek medical attention.

Risk Factors

Risk factors are personal lifestyle choices or characteristics that are associated with a greater chance of developing this disease (Nieman, 2007). CAD has multiple risk factors that increase your risk for developing the condition. The more risk factors an individual possesses results in a higher risk of developing CAD (Ali, 2002). Men and women have many of the same risk factors for Coronary Artery Disease, with the exception of menopause, which is exclusive to women. The risk factors however differ in severity between genders, because certain factors are more prevalent in women. Risk factors, as stated by the National Cholesterol Education Program (NCEP) and American Heart Association (AHA) for Coronary Artery Disease that cannot be modified are as follows: age (55 and over in women), family history, gender and menopause. Risk factors that have potential to be changed include diabetes, hypertension (high blood pressure), smoking, obesity, high fat diets, sedentary lifestyles, and dyslipidemia (high LDL cholesterol and/or low HDL cholesterol) (Nieman, 2007). Factors such as smoking, diabetes, hypertension, dyslipidemia and the effects of menopause put women at a greater risk for CAD than men. The disease is mainly preventable as many of the risks are modifiable through diet, exercise, maintaining a healthy weight and controlling other risks (such as diabetes, hypertension) through medications if required.

Menopause

In the absence of other risk factors such as hypertension and diabetes, Coronary Artery Disease is relatively uncommon in pre-menopausal women (Crosignani, 2006). Prior to menopause estrogen is produced naturally in the female body which has a protective effect on the cardiovascular system, by reducing the development of plaque in the coronary arteries (Crosignani, 2006). The risk for CAD increases in women who reach menopause at an earlier age (less than 44 years of age) naturally or surgically, as the protective effects of estrogen are lost. Plaque is therefore able to build in the arteries at an earlier age causing them narrow (Douglas & Poppas, 2007). Hormone Replacement Therapy (HRT) is an option for those who are at risk for CAD. Evidence suggests that HRT may be protective against plaque accumulation and other cardiovascular risk factors if taken soon after onset of menopause (Crosignani, 2006). Hormone replacement therapy is very controversial among academic studies. The Heart and Estrogen Replacement Study (HERS) found no significant reduction of risk for CAD in women who utilize HRT. Other studies suggest negative side effects occur with utilization of HRT mainly related to increased risk of breast cancer (Tecce et al., 2003). These studies suggest that the effectiveness of the drug decreasing the risk of CAD is debatable and its harmful side effects outweigh its benefits. As age and menopause uncontrollably increase women’s risk of developing heart disease substantially, women need to take charge of their health and control modifiable risk factors to enable them to reduce their risk of CAD.

Diabetes

Diabetes is another risk factor that has a stronger effect on women. Not only is diabetes twice as likely to occur in women over the age of 45 than men, but it also has more adverse effects in relation to CAD and heart attacks (Wenger, 1997). Women with diabetes have a “three to seven fold increased risk of death from CAD compared to non-diabetic women” (Tecce et al., 2003). Regular glucose screening and maintenance of blood glucose levels is critical in all diabetic patients to reduce their likelihood of developing CAD (Williams et al., 2002). With such a great impact on women, it is extremely important for them to maintain their blood sugar levels. This is attainable by following a healthy diet and getting regular exercise to maintain a healthy body weight, thus reducing their risk of CAD.

Smoking

Smoking is yet another factor that increases the risk of CAD . Approximately 30 percent of all deaths from CAD are attributable to smoking (Nieman, 2007), effecting women more substantially. This may be due to women’s smaller body size and their metabolism. Smoking is also a multifactor risk, as it not only increases the chance of developing CAD but it also increases the potential of developing other CAD risk factors such as hypertension (Nieman, 2007). Smoking is linked to one-half of all coronary events that occur in women (Douglas & Poppas, 2007). It also triples the risk for myocardial infraction (heart attack) in men and women, the greater impact being on women (Wenger, 1997). Studies have shown that risks for Coronary Artery Disease in men and women begin to decline within months of quitting smoking (Tecce et al., 2003). In a study conducted by Douglas and Poppas, the relative risk in women who had not smoked in three or more years was indistinguishable from that in women who had never smoked (2007). A 50-70 percent reduction in risk of CAD can occur within five years of quitting (Nieman, 2007). Thus, it is crucial for physicians and healthcare providers to encourage women, especially older women, to quit smoking and reduce their risks of developing CAD substantially.

Hypertension

Hypertension also known as high blood pressure is a common condition in older adults, as it becomes more prevalent with the onset of age. This condition can be defined as having at least two systolic blood pressure readings of 140 mmHg or greater and/or a diastolic blood pressure of 90 mmHg or greater (Williams et al., 2002). Men are more likely to have hypertension at a younger age. However women’s blood pressure “increases rather dramatically with age as 70 percent of women age 65 and over and 80 percent of those aged 75 and over have been diagnosed with hypertensive heart disease” (Tecce et al., 2003). High blood pressure is the result of multiple factors such as diet, lack of exercise, stress, and family history. Many people are unaware that they have hypertension because there are no symptoms. Therefore, it is essential to measure blood pressure levels to avoid causing damage to the heart and arteries (BC Health Guide, 2007). Monitoring these levels can reduce the risk of heart disease by 50 percent (Heart and Stroke Foundation, 2008). Blood pressure levels are easy to monitor with the various products available today such as the old fashion method done with a blood pressure cuff and stethoscope. Women have all the means necessary to monitor their blood pressure levels, as there is an electronic reading device in many stores today as well as portable devices to take at home. Knowing their blood pressure levels is the first step in controlling them. Levels can lower through changes to the diet, decreasing salt intake as well as including regular exercise.

High Cholesterol

High cholesterol is another risk factor that affects CAD as the cholesterol deposits into the arteries it causes them to narrow or eventually blocks them completely. Cholesterol produces in the body naturally but can develop through the diet as well (Nieman, 2007). About 50 percent of Canadian women have cholesterol that exceeds the normal range, therefore increasing their risk for developing CAD (Heart and Stroke Foundation, 2008). There are different types of cholesterol that have dissimilar roles in the body, which either increase or decrease the formation of plaque in the arteries (Nieman, 2007). HDL (high-density lipoprotein) considered the good cholesterol because it helps pick up excess cholesterol in the blood preventing a clog in the arteries. Having higher levels of this cholesterol is actually protective against heart disease. According to a study conducted by Pamela Douglas and Athena Poppas, “in women low levels of HDL cholesterol are more predictive of coronary risk” (2007). Maintaining a high level of HDL cholesterol is beneficial for women as it reduces the risk of CAD. LDL (low-density lipoprotein) also known as the bad cholesterol has the opposite function of HDL. LDL carries cholesterol into the arteries increasing the risk of developing CAD (Nieman, 2007). High cholesterol has no symptoms, thus it is important to have blood lipids tested regularly in order to maintain them within the recommended range. To prevent CAD women should know what their normal blood lipid values are and have them tested annually to avoid damage to the arteries. If other risk factors were present such as diabetes, obesity or family history having the values tested more frequently and at an earlier age would be beneficial.

Conclusion

For years, women’s prevalence in heart disease went unnoticed, but the reality is, CAD is a major health concern for older women. The first step in prevention and early diagnosis of CAD is education about risk and symptoms specific to women. Presentation of symptoms for CAD differs between genders. This difference may be responsible for some of the under-diagnosis by physicians in the past. Physicians, health care professionals and women need to become aware of the symptoms that females experience in a heart attack. Common female symptoms of a heart attack include pain in the chest, shoulder and jaw, unusual fatigue, shortness of breath, indigestion and nausea. Having the knowledge of these symptoms will allow women to realize if they need to seek medical assistance. The risk factors for women and men are relatively the same except for the severity. Smoking, diabetes, hypertension, and high cholesterol have shown to increase a woman’s chance of developing CAD or causing a heart attack. As many of the risks for CAD are avoidable, women can simply make changes in their everyday behaviour to decrease their risk of developing the disease. Monitoring blood pressure and cholesterol levels greatly reduces the chance of CAD occurrence. Maintaining these levels in the recommended range helps prevent the building of plaque that blocks the arteries to the heart. Diabetes in women greatly increases the risk of CAD and death, and maintaining a healthy body weight, exercising regularly and monitoring blood sugar levels will decrease the damage done to the arteries. Smoking not only increases risk of heart disease but increases chances of multiple risk factors. Quitting has shown to have a large reduction in risk for developing heart disease by up to 50-70 percent within five years of quitting (Nieman, 2007). With knowledge on the symptoms and risk factors on heart disease, women are better equipped to combat this disease. With this disease taking so many lives, it is essential to minimize these risks to avoid a fatality.

References

Ali, N. S., (2002). Prediction of coronary heart disease preventive behaviours in women: A test of the health belief model. Women and Health, 35(1), 83-95

British Columbia Health Guide (2007). High blood pressure (hypertension). Retrieved March 25, 2008, from http://www.bchealthguide.org/kbase/topic/special/hw62787/sec1.htm

Crosignani, P.G., (2006). Hormones and cardiovascular health in women. Human Reproduction Update , (12), 5, 483–497

Douglas, P. S. & Poppas, A., (2007). Determinants and management of cardiovascular risk in women. Up to date.

Heart and Stroke Foundation of Canada (2008). The heart truth. Retrieved March 24, 2008, from http://www.thehearttruth.ca/

Nieman , D.C. (2007) Exercise testing and prescription: A health related approach (6 thed.) McGraw Hill (pp. 369- 387)

Tecce, M. A., Dasgupa, I. & Doherty, J. U., (2003). Heart disease in older women gender differences affect diagnosis and treatment. Geriatrics, 58 (12), 33-39

Vodopiutz, J., Poller, S., Schneider, B., Lalouschek, J., Menz, F. & Stollberger, C., (2002). Chest pain in hospitalized patients: Cause-specific and gender-specific differences. Journal of Women’s Health, 11 (8), 719-726

Wenger, N. K., (1997). Coronary heart disease: An older woman’s major health risk. BMJ ,315