1. Cheek, Dennis RN, PhD, FAHA
  2. Jensen, Lindsey
  3. Smith, Hollie McGehee BS


More women than men die of heart disease, yet a woman's heart disease symptoms are more likely to be overlooked. Learn how to recognize heart disease in women and help them get the treatment they need.


Article Content

Cardiovascular disease (CVD) is the leading cause of death in both women and men in the United States. Although many women believe that they're more likely to be diagnosed with breast cancer, their risk of CVD is actually significantly greater. In fact, heart-disease- related deaths outnumber the next seven causes of death combined, including cancer.


One in three U.S. women eventually succumbs to heart disease, according to the American Heart Association. And while the rates for men are declining, the rates for women are rising steadily. Many of these deaths result from high blood pressure, stroke, and coronary heart disease, which includes myocardial infarction (MI), acute ischemic (coronary) heart disease, atherosclerosis, angina pectoris, and other forms of ischemic heart disease.


In women, signs and symptoms of heart disease can differ significantly from those in men. Because health care providers don't always recognize signs that differ from "classic" ones typical in men, many women with heart disease aren't diagnosed correctly.


Many health care providers fail to discuss heart disease or its risk factors with their female patients because they think of heart disease as primarily a man's disease or as less serious in women. This thinking leads to less aggressive treatment-or even no treatment at all. In fact, women are more likely than men to die after their first cardiac event, and women who survive an MI have a higher risk than men of having another infarction or dying.


Obviously, preventing heart disease is just as important for women as men; any woman can benefit from increased awareness of the risks, and younger women who adopt healthy lifestyle behaviors now may avoid developing CVD later in life.

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The National Heart, Lung, and Blood Institute is campaigning for women's self-empowerment to prevent heart disease by making information available about how to reduce risk and how to discuss testing or treatment with health care providers. (See The Heart Truth.)


As a nurse, you can assist in this initiative by staying current with emerging information about CVD, simplifying and interpreting it for your patient, and telling her about her risks or treatment options. Encourage her to discuss any concerns with her health care provider and advocate for more testing or referrals if CVD is suspected.


Same risk factors, worse prognosis

So what are the risk factors? Men and women have similar risk factors for CVD, but in women, they may indicate a worse prognosis. This is especially true for diabetes and hypertension; in women, each is a stronger predictor of heart disease and a poor outcome.


The best cues we currently have concerning a woman's risk of CVD are postmenopausal status, family history, diabetes, hypertension, peripheral vascular disease, hyperlipidemia, obesity, physical inactivity, and cigarette smoking.


Some risk factors can't be modified, such as postmenopausal status or family history. But you can help a woman take control of modifiable risk factors, including smoking, obesity, and lack of exercise. Let's look more closely at key factors affecting a woman's risk of CVD.


Diabetes. The Nurses' Health Study showed a sevenfold increase in cardiovascular events for women with diabetes, and about half of all women with diabetes die of heart disease. Young women with diabetes have the same risk of developing coronary artery disease as men of the same age who don't have diabetes.


Hypertension. Women with hypertension have a much greater risk of CVD than normotensive women or men, and this rate increases even more significantly if they're premenopausal. Because hypertension becomes more prevalent with age, screen elderly women for hypertension and CVD as well.


Ethnic group. A woman's ethnic heritage influences her risk of CVD. For example, African-American women are more likely to have hypertension than other women, and Hispanic and African-American women share high death rates from diabetes.


Smoking. About a quarter of all women smoke, and the rate is higher in postmenopausal women. A woman who's smoked her entire adult life has a risk of CVD that's even higher than that for men. The Nurses' Health Study also showed that even a few daily cigarettes caused a greater risk of CVD or a fatal MI.


Obesity and hyperlipidemia. A sedentary lifestyle and poor diet contribute to obesity, hyperlipidemia, and atherosclerosis in women. Central obesity is especially dangerous: The waist-hip circumference confers a greater risk than body mass index, so encourage women to maintain a waist circumference of less than 35 inches (87.5 cm).


The Framingham Study showed that women with high total cholesterol levels were twice as likely to develop coronary artery disease than other women. Recent studies have also shown that high-density lipoprotein (HDL-C)-or "good" cholesterol-levels are a much stronger predictor of coronary heart disease mortality in women than men. The optimal level for HDL-C is greater than 50 mg/dl.


Lack of exercise. The many benefits of exercise include increasing HDL-C levels and decreasing blood pressure, blood glucose levels, and low-density lipoprotein cholesterol (LDL-C). Exercise may decrease a woman's risk of heart disease by half, and postmenopausal women who've experienced an MI can significantly decrease their risk of a second MI by beginning an exercise program. Women can benefit from simply walking or doing light to moderate activity for a minimum of 30 minutes most days of the week.


Stress. Women experiencing "high stress, low control" situations anywhere in their lives, whether in their family, social life, or work, have a much greater risk of developing disease and having poorer outcomes. Ask women with CVD about their level of stress and advise them to handle it in healthy ways, such as by exercising or meditating, rather than by smoking, drinking alcohol, using illegal drugs, or overeating. Refer them for treatment if needed.


Depression. Women who are also depressed may have more cardiac events or may be less likely to seek diagnosis, treatment, or rehabilitation. Evaluate women with CVD for depression and refer them for treatment, if indicated.


Evaluating signs and symptoms

Besides teaching the patient about her risk factors and how to prevent CVD, you should also assess her for indications of CVD. As a patient advocate, you can encourage a patient who's experiencing atypical symptoms to seek further care.


Women with CVD sometimes report more symptoms than men, but these symptoms are often atypical and may cause only moderate discomfort. Typically, a man is having an MI when he first seeks help for heart-related symptoms. In contrast, a woman is more likely to seek help initially for angina.


The "classic" chest pain pattern of infarction is intense crushing or squeezing substernal pain, often precipitated by exertion or emotion and unrelieved by rest or nitroglycerin. This pattern is typical for men but not for women.


In women, atypical chest pain may include pain in the left chest, abdomen, midback, shoulder, or arm rather than in the midchest area, possibly accompanied by palpitations. The woman may report a heavy or squeezing feeling, or she may describe the pain as "sharp" or "fleeting." The pain, which may be repeated or prolonged, may have no relation to exercise and may not be relieved with rest or nitroglycerin, though antacids may help.


During an acute MI, a woman's symptoms may include chest, neck, back, arm, or shoulder pain or she may not have any of these symptoms. Instead, she may have nausea or vomiting, dyspnea, palpitations, indigestion, upper abdominal pain, fatigue, diaphoresis, dizziness or fainting, jaw pain, or throat pain. A woman having an MI is also far less likely to have ST-segment elevation on electrocardiogram.


Treatment for women

To help a woman at risk for CVD, the first step is to address risk factors that can be modified. (See Go Red for Women for details about the American Heart Association initiative to teach women how to protect themselves against heart disease.)


Diet and exercise. Making dietary changes and starting an exercise program under the guidance of a health care provider are the most effective interventions for reducing complications associated with diabetes, hypertension, hyperlipidemia, and obesity. Advantages of exercise and healthy weight maintenance include decreased insulin resistance, decreased risk of type 2 diabetes mellitus, improved blood lipid profile, healthier blood pressure, and a greater ability to handle stress.


Dietary guidelines recommended by the American Heart Association include decreasing consumption of saturated fats, trans-fatty acids, and cholesterol and limiting alcohol to one drink per day. The dietary guidelines also advise consuming more fruits, vegetables, whole grains, fiber, low-fat or nonfat dairy products, legumes, and protein sources that are low in saturated fat.


Because fish has high levels of omega-3 fatty acids, eating more fish (or taking fish oil supplements to limit mercury exposure) may also be protective. In high-risk women, consider folic acid supplements if they have higher than normal levels of homocysteine.


Smoking cessation. Encourage a patient who smokes to start a smoking cessation program immediately. Inform her about the dangers of passive smoking and encourage her to avoid secondhand smoke as much as possible.


Once a diagnosis of coronary heart disease is confirmed, treatment is essential.


Medications that may be prescribed include:


* aspirin to prevent thromboembolic complications


* angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers, which have been shown to reduce the incidence of infarctions and decrease the risk of sudden death


* sublingual or aerosol nitrates for acute episodes of anginal symptoms and prophylactic treatment


* long-acting nitrates to relieve symptoms and improve exercise tolerance


* statins to decrease LDL-C. Recently, research has shown that statins greatly decrease the rates of nonfatal MI and stroke and reduce the need for coronary artery bypass surgery or percutaneous coronary interventions, such as stenting or angioplasty.



Research has recently focused on estrogen's role in providing a cardioprotective effect. Unexpectedly, trials with exogenous replacement of estrogen (or a combination of estrogen and progesterone) for postmenopausal women have resulted in more thrombolytic events. Consequently, hormone replacement therapy is no longer indicated to prevent CVD in postmenopausal women.


Surgical treatment, such as coronary artery bypass grafting, introduces its own risks that seem to affect women more significantly than men. Women can have greater or more severe complications during hospitalization, especially with moderate or severe bleeding from catheterization or surgery.


If your patient has had an MI or a procedure such as revascularization, she should be referred to a program of cardiac rehabilitation.


Learning about cardiac rehabilitation

Two main goals of cardiac rehabilitation are to reduce risk and to restore functional capacity. A formal rehabilitation program focuses on early ambulation, behavioral changes to reduce risk, and psychosocial support, including stress management training, vocational counseling, and sexual counseling. She should be encouraged to exercise 30 minutes a day on most days, or as directed. Women and especially elderly women aren't likely to be referred to a program of cardiac rehabilitation, but the benefits to women of all ages are clear. Encourage your patient to ask for a referral for rehabilitation and then encourage her to follow through with the program.


The heart of the matter

All women should be counseled about the dangers of heart disease, the importance of prevention, and the variability of symptoms. At-risk women need to be identified, diagnosed, and treated and referred to a cardiac rehabilitation program if appropriate. As a nurse, you're in the ideal position to educate patients, their families, and your colleagues about how they can protect themselves and help curb heart disease.



American Heart Association


Dennis Cheek is a professor and Lindsey Jensen and Hollie McGehee Smith are research assistants at Texas Christian University in Fort Worth, Tex.




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Mosca, L., et al.: "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women," Circulation. 109(5):672-693, March 2004.