WOMEN'S HEART ATTACKS Unseen health risks

By VALERIE REITMAN
LOS ANGELES TIMES
AT AGE 30 AND SEEMING-ly in great health, Cindy DeMarco was jolted awake early one Saturday three years ago with nausea, upper back pain, shortness of breath and a strange pressure in her chest. She thought the pain had to be related to her distance running or the racquetball game she had played the previous evening.
She took some ibuprofen. When the pain hadn't relented 12 hours later, she went to the hospital, where she was given muscle relaxers and advised to go home. Instead, DeMarco demanded an electrocardiogram. Even after the nurses reluctantly hooked it up, they thought the machine had to be malfunctioning when it indicated she was having a heart attack.
"Because I was young and female, they weren't even thinking of that," DeMarco said.
Like most women, the Alexandria, Va., attorney feared that she'd get breast or some other type of cancer one day. But in reality, 10 times as many women die of heart disease and stroke as they do of breast cancer -- about half a million each year in the United States. A woman's risk of heart disease rises substantially after menopause, but not all victims of heart disease have reached that milestone. About 10,000 women under age 50 died of heart disease in 1998, far greater than the 6,286 who died of breast cancer that year, the last year for which such figures were readily available.
Moreover, women under 50 are more than twice as likely to die of heart attacks as are men in the same age group. One reason: Women are more likely to be misdiagnosed in the emergency room.
Common misdiagnoses
Misdiagnoses occur in male and female heart attack patients. In a study of about 10,700 patients, at least 2 percent of heart attacks and cases of unstable angina were misdiagnosed in men and women, said Dr. Harry Selker, the study's lead investigator. Selker, who is chief of clinical care research at Tufts-New England Medical Center and a professor at the Tufts University School of Medicine in Boston, says the error rate indicates that about 26,000 people having heart attacks are mistakenly sent home without adequate treatment each year in the United States, making it the most frequent cause of malpractice complaints. Those not hospitalized were about twice as likely to die as those who were admitted, Selker said.
Women under age 55 were the prime candidates for misdiagnosis: They were 6.7 times more likely to be misdiagnosed and sent home.
"They [emergency room staffers] have a stereotype that a person having a heart attack looks like [Vice President] Dick Cheney -- in his 50s or 60s and white," says Nancy Loving, executive director of the National Coalition for Women With Heart Disease, who had a heart attack at age 48 and who co-founded the nonprofit advocacy and support organization with two other women who also had suffered heart attacks.
Become involved
Cases of misdiagnosis in younger women abound. Paula Upshaw of Laurel, Md., was in the bleachers, cheering her son's football team when she had a heart attack at age 34. The emergency room doctors went through the proper protocol, asking numerous questions about risk factors and symptoms, checking her blood for enzymes that indicate a heart attack, and performing an electrocardiogram. But they told her the tests were normal and sent her home with instructions to take Mylanta for indigestion.
A week later, in pain she describes as being "off the charts," she returned to the hospital and refused to leave until she was admitted. The doctor on duty still didn't think she was having heart problems, until the staff cardiologist -- who had come in the next day to review EKGs -- asked to see "the 34-year-old who had the massive heart attack." Upshaw immediately had double-bypass surgery.
She is unable to return to the busy job she had as a respiratory therapist at another hospital -- where she worked with heart patients. Upshaw remains permanently disabled 12 years later, with just 60 percent of normal heart function because of the extensive damage to her heart muscle.
"I always tell women to ask to see the [test] results ... ," Upshaw says. "Even if you don't know what it means, act like you know what it means because it forces the doctor to explain it and look at them himself."
Low awareness
Emergency room doctors and nurses have become better at recognizing the symptoms of heart attacks in a woman, thanks to awareness campaigns about the prevalence of heart disease in women -- 10 percent of women ages 45 to 74, and 25 percent age 65 and over suffer from it. Medical schools and hospitals also have improved training in evaluating symptoms.
Still, a lack of awareness among women remains a problem, contributing to the mortality rates. In women, the symptoms of a heart attack can be nausea and upper back and jaw pain -- with or without the crushing chest pain typically found in male heart attack victims. So, instead of telling emergency room personnel that they are having chest pain, women often say they have indigestion or muscle aches. That puts them lower on the priority list in crowded emergency rooms.
"The biggest issue is getting across [to women] that when they have an unbearable sensation, they shouldn't be embarrassed to call 911 and go with the ambulance drivers and be saved," said Dr. Debra R. Judelson, a cardiologist with the Cardiovascular Medical Group of Southern California in Beverly Hills, Calif.
The medical establishment is partly to blame for the relatively low awareness about the prevalence of heart disease in women, says cardiologist C. Noel Bairey Merz, medical director of the Women's Health Program and the Preventive Cardiac Center at Cedars-Sinai Medical Center in Los Angeles.
"We wrote a lot in the 1960s, '70s and '80s that women were protected from heart disease, and that with the exception of diabetics, they never get it," Bairey Merz said.
Little research on women
Doctors may know less about women and cardiovascular disease because so few women have been studied by researchers. Even now, only 25 percent of subjects in heart-related research are women -- up from just 20 percent in 1990, says the National Coalition's Loving.
Women get just one-third of the bypasses, angiograms, stents, angioplasties and implantable defibrillators in heart patients; men get the rest.
"We have to be half-dead before we get treated," Loving says.
Many middle-aged women, such as Toni Miller of West Los Angeles, never know they are at risk until they have a heart attack. Miller's occurred in October 2001 at age 50.
She didn't smoke or drink, she wasn't obese and she was energetic -- skating over to her mother's house, running a busy oral surgeon's office and being what she calls the "go-to gal" when friends and family needed things done.
"I wasn't sitting on the couch eating butter for the past 10 years; I was active," Miller says with a raucous laugh.
Miller had kept up with her Pap smears and mammograms. But like many other women, she had relied on her gynecologist for primary medical care, she hadn't had any cholesterol tests and she hadn't paid much attention to her family history (both of her parents had heart disease.)
It took several months to recuperate from the initial heart attack, a second attack suffered while she was doing a stress test on a treadmill and triple-bypass surgery for three blocked arteries. Miller still tires easily. In addition, she was diagnosed with breast cancer about a year ago and has been undergoing chemotherapy.
Taking control
These days, Miller is taking drugs called statins, which have reduced her cholesterol levels. She's become a hawk when it comes to reading food labels: She's cut saturated fats such as ice cream, butter, red meat and sour cream from her diet.
Now, she says, she wants to do whatever it takes so she can meet her future grandchildren .
"It's so cliche, but I so appreciate just the green trees or just being able to walk the dogs," says Miller.
Recent studies have indicated that the hormone replacement therapy that many women were taking during and after menopause increases the risk of heart disease, opposite of the effect it was thought to have. As a result, many gynecologists now refer women who may be at risk of heart disease to a cardiologist before prescribing hormones.
That way, a woman can get a full work-up and the doctor can give her a stress test, a physical workout that can be an indicator of heart disease. However, the tests aren't completely reliable, and they seem to be about 7 percent to 10 percent less reliable in women than in men, Bairey Merz said. They produce false negatives in about one-third of the cases, she added.
Tests that are generally more reliable (and more expensive) include a nuclear scan, in which radioactive material is injected into a vein to show the working of the heart muscle; echocardiography, which changes sound waves into pictures that show the heart's size, shape and movement and how much blood is pumped out by the heart when it contracts; and coronary angiography, which shows blood-flow problems and blockages in the coronary arteries.