Most women, when they think of scary sickness, focus on breast cancer. But heart attack is a greater threat.
Heart attack is far and away the No. 1 killer of American women, as it is of American men. Of the 520,000 people who die of heart attacks each year, 247,000 -- only a little less than half the total -- are women. That's about six times as many as die of breast cancer.
Mattie Matthews found that out five years ago. She was just about to begin her Christmas baking -- cookies and cakes, all done from scratch -- when the pain struck.
"It felt like something heavy was sitting on my chest, and I broke out in perspiration," she said. "I knew this wasn't indigestion. I said to myself, 'This could be my heart.' "
She was right. Despite statistics that show heart attack is rare in women under age 50, and despite the prevailing mythology of female invulnerability to heart disease, Mattie Matthews, at age 45, was having a heart attack.
Women are not, in fact, lion-hearted Amazons. Coronary risk factors are equal-opportunity attackers, and Ms. Matthews had a bunch of them: She was a smoker, with diabetes and blood vessel disease that had already required a bypass to restore circulation to a leg. There was, besides, heart disease in her family.
"Earlier in life, women have considerably lower incidence of heart disease than men. Post-menopausally, the disease rate seems to be identical," according to Dr. Michael Kelemen, a cardiologist and president of the Maryland division of the American Heart Association.
But even pre-menopausally, women are not immune. "In the past year, I've seen two or three women under age 50," said Dr. Rick Veltri, director of cardiology at Sinai Hospital.
Recent studies also show that when women have heart attacks, the outcomes are often worse: Women are more likely to die within afew weeks of the attack, more likely to die within a year of the attack, less likely to survive or improve after coronary artery bypass surgery.
"Some people believe this is [a result of] smaller blood vessels, which make it technically more difficult to do procedures," said Dr. David Meyerson, director of the Center for Preventive Cardiology at the University of Maryland Medical Center. "Smaller vessels also have less blood flow and may clot off more easily. And there may be other factors that have not been worked out yet."
One other factor that has been suggested is that doctors are less likely to suspect heart disease in women with chest pain, and therefore less likely to treat it as such until it's too advanced to ignore.
Indeed, Dr. Veltri said, women -- more often than men -- do have chest pain from other disorders, such as hiatus hernia or breast problems.
But that doesn't mean the possibility of heart disease is ignored. "No internist or cardiologist would look at the complaints of a 40-year-old woman and not think of heart disease any more," Dr. Meyerson said.
And focusing on the particular problems of women, doctors have also recognized risk factors in addition to those that apply to men. "The combination of cigarettes and oral contraceptives is particularly lethal," Dr. Meyerson said.
And, he added, "In women, the higher the level of triglycerides, the higher the chance of heart disease. High triglycerides plus diabetes -- in both men and women -- is also high risk for heart disease."
(A normal level of triglycerides, a kind of blood-carried fat, is 200 or below; it is one of the measurements produced in a cholesterol test. According to Dr. Meyerson, the relationship between triglyceride level and heart disease in non-diabetic men is unclear.)
While prevention and treatment of heart disease is, in general, the same for both sexes, there is one major addition for women. The body's natural estrogen, pre-menopausally, appears to raise HDL cholesterol --the good kind -- while reducing total cholesterol.
Most experts believe that estrogen supplementation, after menopause, will exert the same protective influence. According to Dr. Meyerson, low-dose estrogen -- 0.625 milligrams a day -- is more effective than higher doses.
Unfortunately, estrogen supplements have been associated with cancer of the uterine lining. When progestin, another female hormone, is taken along with estrogen, that risk is reduced. But it also appears progestin wipes out the cholesterol-improving effect of estrogen alone.
Otherwise, heart-saving advice for women is to stop smoking; reduce dietary fats; exercise; and keep weight, blood pressure and cholesterol under control. An aspirin a day might also be recommended for people with some early evidence of heart disease as well as those who have had attacks, Dr. Meyerson said, though he also warned that no one should put herself on this kind of regimen without medical advice.