Listen To Your Heart

Shari Sudano knew something wasn’t right. The then-44-year-old single mother from Eldersburg had unusual feelings of indigestion on and off for a week, and felt out of breath from simple activities. “It got worse,” says Sudano. “I felt tired, and just walking up a flight of steps would make me get out of breath—which wasn’t normal.”

About a week after her symptoms began, she went to the emergency room for chest pain. She was diagnosed with coronary artery disease in May 2014, and a cardiac catheterization at The Johns Hopkins Hospital subsequently revealed a 95 percent blockage in her main artery, which was opened surgically with a stent.

Although she had some family history of heart attacks, Sudano says she wasn’t aware of the risk for women of her age. “I was healthy, I exercise, I don’t smoke—what did I have to worry about? I definitely don’t fit the stereotype.”

Then, just a few months after her first procedure, Sudano felt the familiar symptoms return. “When I told the doctor, he sort of chuckled,” she says. But she listened to her gut and was persistent. After another trip to the emergency room, Sudano underwent double-bypass surgery. Now, she hopes sharing her story as an American Heart Association Go Red Ambassador may save other women’s lives.

“I can’t express this enough—if you feel something, talk to your doctor, be your own advocate, and don’t give up.”

While it’s often thought of as a man’s disease, heart disease is the No. 1 killer of women, causing one in three deaths each year—that’s about one woman every minute, according to the American Heart Association. And despite the public focus on breast and uterine cancers, heart disease, in fact, kills more women than all cancers combined.

But most women haven’t gotten the memo: Only one in five believes heart disease is her greatest health threat. That’s partly due to low awareness of risk factors and symptoms, which are often different in women than men.

“Men are more likely to be diagnosed with heart disease, even though women make up more than half of all the fatalities,” says Dr. Christina Stasiuk, Cigna’s national medical director for health disparities. “And after a heart attack, women are more likely to die of heart disease than men.” That inequality in outcomes is what’s called a health disparity.

“A health disparity is an avoidable and unfair difference . . . between segments of the population,” says Stasiuk, who worked as an internist for many years before joining Cigna.

Through her position at Cigna, Stasiuk works to improve these sobering statistics by promoting health equity, or the pursuit of eliminating health disparities and inequalities, work for which Cigna was awarded the Surgeon General’s Medallion in 2012.

“If you take this big bucket of women and you divide them more, Hispanic women are likely to develop heart disease 10 years earlier than Caucasian women. If you look at the statistics, only three in 10 Hispanic women have ever been told that they’re at higher risk,” she says. “And if you look at the bucket of African-American women, they have higher rates of blood pressure, which puts them at higher risk for developing cardiovascular disease than white women, but only one in five African-American women actually thinks she’s at risk of heart disease.”

Heart disease in women is unique in many ways, from risk factors to symptoms. The Johns Hopkins Women’s Cardiovascular Health Center brings together specialists and other health care providers with experience treating women’s bodies, making them more in tune to the risks and signs of heart disease that are unique to their patients.

“There are some differences in risk factors in women and men, and not all providers are aware of that,” says Dr. Erin Michos, a cardiologist and associate professor of medicine at The Johns Hopkins University School of Medicine. “So it’s helpful to have providers who have experience in treating women.”

While the traditional risk factors—like blood pressure, cholesterol, and smoking—are just as important in women as men, many people don’t realize that some of those factors cause greater risks to women. “Diabetes causes a three- to seven-fold increased risk of heart disease in women, compared to a two-fold increase in men,” says Michos. Similarly, women who smoke are three times more likely to develop heart disease, while, for men, the risk doubles.

Pregnancy and menopause outcomes are important risk factors that providers often overlook, says Michos. “Women who’ve had a history with preeclampsia [a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys] have nearly double the risk of heart attack and stroke, even 10 to 12 years after the pregnancy,” explains Michos. “And they have a greater risk of dying in the long-term. So this is a really important group that we need to identify.”

Another risk factor associated with pregnancy is gestational diabetes. Even if a mother’s blood sugar returned to normal after giving birth, she is more likely to develop Type 2 diabetes within 10 years.

Not all risk factors are physical. “We know emotional and mental stress is a risk factor,” says Michos. “Divorce, especially multiple divorces, is a strong risk factor for heart disease.” In fact, divorced women are 24 percent more likely to have a heart attack than women who remain married, according to a study by Duke University. And for those with two or more divorces, the risk jumps to 77 percent. “Going through that stress, it raises your heart rate. There’s a big mind-body connection, and emotional and mental stressors seem to confer more risks to women’s hearts than men’s hearts,” says Michos.Li

One of the potential reasons more women die from heart disease than men is that the symptoms of a heart attack in women can be mistaken for other common ailments. Women often experience nausea, jaw or neck pain, lower back pain, shortness of breath, and fatigue in the days leading up to a heart attack. Women who are unaware of their symptoms’ association with heart disease may let the problem go unchecked, or even worse, doctors may not suspect heart disease due to the patient’s age or fitness level.

“Women can certainly get the classic angina, heaviness in the chest that goes to the neck and the arms, when you’re walking and exerting yourself getting short of breath,” says Michos. “But women are far more likely to get atypical symptoms. Sometimes they don’t have chest discomfort at all.”

More women than men also suffer from angina without any significant blockages. A condition called microvascular angina, which affects the tiny coronary arteries that supply oxygen to the heart muscle, is more common in women than men. Because it occurs without the type of large blockage to main arteries that can be cleared with stents and bypasses, it often goes undetected because it doesn’t show up the same way on an angiogram.

“With microvascular disease, you can have more atypical symptoms—you have chest pain that can come on with rest rather than exercise, or it can come on with emotional stress, such as a fight with your spouse, rather than a physical stress,” says Michos. Combined, these factors make the condition trickier to diagnose. “Microvascular angina can be both very limiting in terms of symptoms, and it’s associated with higher risk [of heart attack compared to women without angina], so it’s important that women with the condition are recognized.”

Because of the unique symptoms, Michos recommends women see a doctor who’s familiar with women’s heart disease. “They’re just a little more sensitive to some of these issues.”

But there is some good news: The overall mortality rate is going down among women. “What’s concerning is there’s actually been a stagnation or plateau in this decline for younger women, ages 25 to 54,” says Michos. So while fewer women overall are dying from heart disease, the rates for younger women are staying the same. That’s why it’s important for young women to take charge of their health. And a good start is to get screened every four to six years, starting at age 20.

Also important is knowing your numbers, like blood pressure and cholesterol. “I see these really educated women who take care of their whole family’s finances and all their kids’ soccer schedules and often are working full-time, and I ask them, ‘What’s your cholesterol?’ and they’re like, ‘I don’t know, I think it’s good,’” says Michos. “I encourage women to know their numbers and track them, and be an active partner in engaging their doctor in their health.”

Cardiovascular disease statistics can be intimidating, but it’s important to remember that the disease is preventable. While prevention includes a big-picture look at your lifestyle, there are a few steps you can take to get started.

In addition to knowing your numbers, Cigna’s Stasiuk recommends lifestyle changes like getting active, eating better, stopping smoking, and limiting alcohol. “It sounds simple, but you can’t do seven things at once,” Stasiuk advises. “The important thing is to pick which ones are important to you, and do what you think you can do. Start small, get support, get information, and track your progress.”

When it comes to prevention, it’s important to rally the support of your community. “We know that 80 percent of health care decisions are made by women, and we also know that the health of a woman’s village is dependent on a woman, because the woman still does the vast majority of grocery shopping, cooking, et cetera,” says Stasiuk. “One of the biggest challenges is for women to carve out time for themselves.” She recommends women reach out to their family and friends for help “so that the time that a woman typically spends doing for others, others can do for her, and she can take that time to think about her health.”