One in four American women dies of heart disease every year. In 2004, nearly 60 percent more women died of cardiovascular disease (both heart disease and stroke) than from all cancers combined. Here's what you need to know now to prevent problems later.

What it is

Heart disease includes a number of problems affecting the heart and the blood vessels in the heart. Types of heart disease include:

• Coronary artery disease (CAD) is the most common type and is the leading cause of heart attacks. When you have CAD, your arteries become hard and narrow. Blood has a hard time getting to the heart, so the heart does not get all the blood it needs. CAD can lead to:
• Angina—chest pain or discomfort that happens when the heart does not get enough blood. It may feel like a pressing or squeezing pain, often in the chest, but sometimes the pain is in the shoulders, arms, neck, jaw, or back. It can also feel like indigestion (upset stomach). Angina is not a heart attack, but having angina means you are more likely to have a heart attack.
• Heart attack--occurs when an artery is severely or completely blocked, and the heart does not get the blood it needs for more than 20 minutes.
• Heart failure occurs when the heart is not able to pump blood through the body as well as it should. This means that other organs, which normally get blood from the heart, do not get enough blood. It does not mean that the heart stops. Signs of heart failure include:
• Shortness of breath (feeling like you can't get enough air)
• Swelling in feet, ankles, and legs
• Extreme tiredness
• Heart arrhythmias are changes in the beat of the heart. Most people have felt dizzy, faint, out of breath or had chest pains at one time. In general, these changes in heartbeat are harmless. As you get older, you are more likely to have arrhythmias. Don't panic if you have a few flutters or if your heart races once in a while. But if you have flutters and other symptoms such as dizziness or shortness of breath, call 911 right away.

Symptoms

Heart disease often has no symptoms. But, there are some signs to watch for:

• Chest or arm pain or discomfort can be a symptom of heart disease and a warning sign of a heart attack.
• Shortness of breath (feeling like you can't get enough air)
• Dizziness
• Nausea (feeling sick to your stomach)
• Abnormal heartbeats
• Feeling very tired

Talk with your doctor if you're having any of these symptoms. Tell your doctor that you are concerned about your heart. Your doctor will take a medical history, do a physical exam, and may order tests.

Signs of a heart attack
For both women and men, the most common sign of a heart attack is pain or discomfort in the center of the chest. The pain or discomfort can be mild or strong. It can last more than a few minutes, or it can go away and come back.
Other common signs of a heart attack include:

• Pain or discomfort in one or both arms, back, neck, jaw, or stomach
• Shortness of breath (feeling like you can't get enough air). The shortness of breath often occurs before or along with the chest pain or discomfort.
• Nausea (feeling sick to your stomach) or vomiting
• Feeling faint or woozy
• Breaking out in a cold sweat

Women are more likely than men to have these other common signs of a heart attack, particularly shortness of breath, nausea or vomiting, and pain in the back, neck, or jaw. Women are also more likely to have less common signs of a heart attack, including:

• Heartburn
• Loss of appetite
• Feeling tired or weak
• Coughing
• Heart flutters

Sometimes the signs of a heart attack happen suddenly, but they can also develop slowly, over hours, days, and even weeks before a heart attack occurs.

The more heart attack signs that you have, the more likely it is that you are having a heart attack. Also, if you've already had a heart attack, know that your symptoms may not be the same for another one. Even if you're not sure you're having a heart attack, you should still have it checked out.

Who is at risk?

The older a woman gets, the more likely she is to get heart disease. But women of all ages should be concerned about heart disease and take steps to prevent it.
Both men and women have heart attacks, but more women who have heart attacks die from them. Treatments can limit heart damage but they must be given as soon as possible after a heart attack starts. Ideally, treatment should start within one hour of the first symptoms. Factors that increase risk include:

• Family history (If your dad or brother had a heart attack before age 55, or if your mom or sister had one before age 65, you're more likely to develop heart disease.)
• Obesity
• Lack of physical activity
• High blood pressure
• Diabetes
• Being African American and Hispanic American/Latina

The role of high blood pressure
Blood pressure is the force your blood makes against the walls of your arteries. The pressure is highest when your heart pumps blood into your arteries—when it beats. It is lowest between heartbeats, when your heart relaxes. A doctor or nurse will record your blood pressure as the higher number over the lower number. A blood pressure reading below 120/80 is usually considered normal. Very low blood pressure (lower than 90/60) can sometimes be a cause of concern and should be checked out by a doctor.

High blood pressure, or hypertension, is a blood pressure reading of 140/90 or higher. Years of high blood pressure can damage artery walls, causing them to become stiff and narrow. This includes the arteries carrying blood to the heart. As a result, your heart cannot get the blood it needs to work well. This can cause a heart attack.

A blood pressure reading of 120/80 to 139/89 is considered pre-hypertension. This means that you don't have high blood pressure now but are likely to develop it in the future.

The role of high cholesterol
Cholesterol is a waxy substance found in cells in all parts of the body. When there is too much cholesterol in your blood, cholesterol can build up on the walls of your arteries and cause blood clots. Cholesterol can clog your arteries and keep your heart from getting the blood it needs. This can cause a heart attack.

There are two types of cholesterol:

• Low-density lipoprotein (LDL) is often called the "bad" type of cholesterol because it can clog the arteries that carry blood to your heart. For LDL, lower numbers are better.
• High-density lipoprotein (HDL) is known as "good" cholesterol because it takes the bad cholesterol out of your blood and keeps it from building up in your arteries. For HDL, higher numbers are better.

All women age 20 and older should have their blood cholesterol and triglyceride levels checked at least once every 5 years.

Understanding the numbers

Total cholesterol level—Lower is better.
 Less than 200 mg/dL - Desirable
 200 - 239 mg/dL – Borderline High
 240 mg/dL and above - High
                 

LDL (bad) cholesterol - Lower is better.
Less than 100 mg/dL - Optimal
100-129 mg/dL -  Near optimal/above optimal
130-159 mg/dL -  Borderline high
160-189 mg/dL - High
190 mg/dL and above - Very high

HDL (good) cholesterol - Higher is better. More than 60 mg/dL is best.

Triglyceride levels - Lower is better. Less than 150mg/dL is best.

Birth control pills
Taking birth control pills (or the patch) is generally safe for young, healthy women if they do not smoke. But birth control pills can pose heart disease risks for some women, especially women older than 35; women with high blood pressure, diabetes, or high cholesterol; and women who smoke. Talk with your doctor if you have questions about the pill.

If you're taking birth control pills, watch for signs of trouble, including:

• Eye problems such as blurred or double vision
• Pain in the upper body or arm
• Bad headaches
• Problems breathing
• Spitting up blood
• Swelling or pain in the leg
• Yellowing of the skin or eyes
• Breast lumps
• Unusual (not normal) heavy bleeding from your vagina

Research is underway to see if the risk for blood clots is higher in patch users. Blood clots can lead to heart attack or stroke. Talk with your doctor if you have questions about the patch.

Menopausal Hormone Therapy (MHT)
Menopausal hormone therapy (MHT) can help with some symptoms of menopause, including hot flashes, vaginal dryness, mood swings, and bone loss, but there are risks, too. For some women, taking hormones can increase their chances of having a heart attack or stroke. If you decide to use hormones, use them at the lowest dose that helps for the shortest time needed. Talk with your doctor if you have questions about MHT.

Diagnosis

Your doctor will diagnose coronary artery disease (CAD) based on:

• Your medical and family histories
• Your risk factors
• The results of a physical exam and diagnostic tests and procedures

No single test can diagnose CAD. If your doctor thinks you have CAD, he or she will probably do one or more of the following tests:

EKG (Electrocardiogram)
An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart.

Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack.

Stress Testing
During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate.

When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

• Abnormal changes in your heart rate or blood pressure
• Symptoms such as shortness of breath or chest pain
• Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness).

Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest.

These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats.

Echocardiography
This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working.

The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

Chest X-Ray
A chest x-ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. It can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Blood Tests
Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD.

Electron-Beam Computed Tomography
Your doctor may recommend electron-beam computed tomography (EBCT). This test finds and measures calcium deposits (called calcifications) in and around the coronary arteries. The more calcium detected, the more likely you are to have CAD.

EBCT isn't used routinely to diagnose CAD, because its accuracy isn't yet known.

Coronary Angiography and Cardiac Catheterization
Your doctor may ask you to have coronary angiography if other tests or factors show that you're likely to have CAD. This test uses dye and special x-rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is inserted into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.

Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

Treatment

Treatment for coronary artery disease (CAD) may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

• Relieve symptoms
• Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque
• Lower the risk of blood clots forming, which can cause a heart attack
• Widen or bypass clogged arteries
• Prevent complications of CAD

Lifestyle Changes
Making lifestyle changes that include a heart-healthy eating plan, not smoking, limiting alcohol, exercise and stress reduction can often help prevent or treat CAD. For some people, these changes may be the only treatment needed.

Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting event—particularly one involving anger. But some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy.

Physical activity can help relieve stress and reduce other CAD risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress.

Medicines
You may need medicines to treat CAD if lifestyle changes aren't enough. Medicines can:

• Decrease the workload on your heart and relieve CAD symptoms
• Decrease your chance of having a heart attack or dying suddenly
• Lower your cholesterol and blood pressure
• Prevent blood clots
• Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting (CABG))

Medicines used to treat CAD include anticoagulants, aspirin and other antiplatelet medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids.

Medical Procedures
You may need a medical procedure to treat CAD. Both angioplasty and CABG are used as treatments.

• Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood.
  
  Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure.

• In CABG, arteries or veins from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.

You and your doctor will determine which treatment is right for you.

Prevention

You can reduce your chances of getting heart disease by taking these steps:

• Know your blood pressure. Years of high blood pressure can lead to heart disease. People with high blood pressure often have no symptoms, so have your blood pressure checked every 1 to 2 years and get treatment if you need it.
• Don't smoke. If you smoke, try to quit. If you're having trouble quitting, ask your doctor or nurse about nicotine patches and gums or other products and programs that can help you quit.

• Get tested for diabetes. People with diabetes have high blood glucose (often called blood sugar). Often, they don't have any symptoms, so have your blood glucose checked regularly. Having diabetes raises your chances of getting heart disease. If you have diabetes, your doctor will decide if you need diabetes pills or insulin shots. Your doctor can also help you create a healthy eating and exercise plan.
• Get your cholesterol and triglyceride levels tested. High blood cholesterol can clog your arteries and keep your heart from getting the blood it needs. This can cause a heart attack. High levels of triglycerides, a form of fat in your blood stream, are linked to heart disease in some people. People with high blood cholesterol or high blood triglycerides often have no symptoms, so have both levels checked regularly. If your levels are high, talk to your doctor about what you can do to lower them. You may be able to lower both by eating better and exercising more. (Exercise can help lower LDL and raise HDL.) Your doctor may prescribe medication to help lower your cholesterol.
• Maintain a healthy weight. Being overweight raises your risk for heart disease. Calculate your Body Mass Index (BMI) to see if you are at a healthy weight. Healthy food choices and physical activity are important to staying at a healthy weight:
• Start by adding more fruits, vegetables, and whole grains to your diet.
• Each week, aim to get at least 2 hours and 30 minutes of moderate physical activity, 1 hour and 15 minutes of vigorous physical activity, or a combination of moderate and vigorous activity.
• Limit alcohol consumption. If you drink alcohol, limit it to no more than one drink (one 12 ounce beer, one 5 ounce glass of wine, or one 1.5 ounce shot of hard liquor) a day.
• An aspirin a day. Aspirin may be helpful for women at high risk, such as those who have already had a heart attack. But sspirin can have serious side effects and may be harmful when mixed with certain medicines. If you're thinking about taking aspirin, talk to your doctor first. If your doctor thinks aspirin is a good choice for you, be sure to take it exactly as prescribed
• Find healthy ways to cope with stress. Lower your stress level by talking to your friends, exercising, or writing in a journal.

Sources: National Heart Lung and Blood Institute (www.nhlbi.nih.gov); The National Women's Health Information Center (www.womenshealth.gov)