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The Myths
the Truth&
H E A R T D I S E A S E I N W O M E N
The Myths
the Truth& H E A R T D I S E A S E I N W O M E N
The Women’s Heart Program at Yale-New Haven Hospital is committed to the health
and welfare of women. That’s why we are pleased to present you with Heart Disease
in Women: The Myths & the Truth, a compilation of questions and answers covering
symptoms, risk factors and treatment options for women with heart disease.
The Women’s Heart Program at Yale-New Haven Hospital was launched in March 2001.
Since its inception, the mission of the program has been to promote the cardiovascular
health of women and continue to improve the overall outcomes for women with heart
disease by:
• Improving knowledge of women concerning their risks of cardiovascular disease
• Increasing early recognition of symptoms
• Changing behavior of women toward heart disease through action-oriented primary and secondary prevention
• Decreasing time from the onset of symptoms to receipt of rapid and appropriate care
We hope you enjoy this publication.
Sincerely,
Gail D’Onofrio, MD Lisa Freed, MD Janet Parkosewich, RN, MSN Medical Director Co-Director Co-Director
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TA B L E O F C O N T E N T S
Overview and Symptoms About the Disease 2
Symptoms 2
Identify Your Risk Factors “Know Your Numbers” 4
High Blood Cholesterol 4
High Blood Pressure 5
Obesity 7
Physical Inactivity 7
Diabetes 7
Smoking 8
Additional Risk FactorsFamily History 9
Menopause 9
Tests, Treatments and PreventionDiagnostic Tests, Procedures and Treatments 9
Medications 10
Primary Prevention 12
Secondary Prevention 15
The information contained within this booklet is intended for your general knowledge and is
not a substitute for medical advice or treatment for specific medical conditions. You should
seek prompt medical care for any specific health issues by consulting your physician. For a
Yale-New Haven Hospital physician referral, call toll-free 888.700.6543.
2
O V E R V I E W A N D S Y M P T O M S
About the Disease
What is coronary artery disease?
Coronary artery disease (CAD) is the most common
form of heart disease. This condition occurs when
the coronary arteries, which are the blood vessels
that supply oxygen-rich blood to your heart muscle,
gradually become narrowed or blocked by plaque
deposits. Poor blood flow can “starve” the heart
muscle and lead to chest pain, also known as angina.
A heart attack occurs when an area of heart muscle is
completely deprived of blood and the heart muscle
cells die. This usually happens when a blood clot
forms over a ruptured plaque within a coronary artery.
What causes coronary artery disease?
CAD is caused by the buildup of plaque within an
area in one or more of the arteries supplying the heart
with nutrients and oxygen. These arteries are called
coronary arteries. Conditions such as high cholesterol,
high blood pressure, diabetes, and smoking damage
the artery walls and initiate plaque formation. Plaque
is made up of excess cholesterol and other substances
that float in your blood and, over time, become
lodged within the walls of the coronary arteries. This
disease process is called atherosclerosis, or hardening
of the arteries, and it can affect other arteries
supplying the brain and legs.
I thought coronary artery disease is a disease
that affects men. Does CAD affect men and
women equally?
Coronary artery disease is the leading cause of
death in the United States for men and women.
Approximately 500,000 women die each year due
to CAD. Unfortunately, the number of women dying
annually from coronary artery disease remains
constant compared to men, where the death rate is
declining. Younger women under 55 are twice as likely
to die after a heart attack and their risk of dying after
hospitalization is still about 50 percent higher than
men. Within six years of a heart attack 35 percent
of women, compared to 18 percent of men, will
experience another heart attack.
Symptoms
What are the symptoms of a heart attack?
According to the American Heart Association, heart
attack symptoms include:
Chest discomfort. Most heart attacks involve
discomfort in the center of the chest that lasts
more than a few minutes, or that goes away and
comes back. It can feel like uncomfortable pressure,
squeezing, fullness or pain.
Discomfort in other areas of the upper body.
Symptoms can include pain or discomfort in one or
both arms, the back, neck, jaw or stomach.
Shortness of breath. May occur with or without
chest discomfort.
Other signs. These signs may include breaking out
in a cold sweat, nausea or lightheadedness.
I have heard
doctors talk
about atypical
symptoms of
a heart attack.
What are atypical
symptoms?
A heart attack
can be preceded
by typical (usual) or atypical (unusual) symptoms.
Typical symptoms include chest pain felt under the
sternum (breast bone) or to the right or left of the
chest. People describe this pain as an uncomfortable
pressure, fullness, heaviness or squeezing feeling.
Often this chest pain or discomfort spreads to one
or both arms or shoulders, neck, jaw or upper back.
Atypical symptoms are ones that do not include
chest pain, such as: pain or discomfort in the upper
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abdomen or back between the shoulder blades; one
or both arms or shoulders; unexplained weakness
or extreme fatigue; or shortness of breath. People
describe atypical symptoms as indigestion or gas-like
fullness or burning. Both typical and atypical heart
attack symptoms can be accompanied by shortness
of breath, sweating, lightheadedness, nausea or
vomiting, or feelings of impending doom. Nearly
50 percent of women may experience atypical
symptoms, and chest pain may be absent.
I am 45-years-old with a strong family history
of heart disease. Lately I have been experiencing
vague symptoms including tiredness and
discomfort between my shoulder blades.
Should I be concerned?
You are right to be concerned. The symptoms you
describe are similar to the early warning signs of
a heart attack referred to as prodromal symptoms.
These vague symptoms come and go and are easily
attributed to stress or lack of sleep. They include
mild chest, shoulder or upper-back discomfort,
indigestion, shortness of breath, unusual fatigue
and sleep disturbances. In fact, 90 percent of women
experience prodromal symptoms in the days or weeks
preceding a heart attack. Make an appointment to see
your primary care physician, even if you think your
symptoms are vague and not serious ones.
What should I do if I experience symptoms that
could signal a heart attack?
Call 911 and get to the emergency room quickly
to minimize possible damage to the heart muscle.
Consider taking aspirin at the first sign of heart attack
symptoms.
I have had heartburn and indigestion for three
days now without any relief with antacids. The
pain goes all the way into my back. Although
I am only 29, I am concerned I may be having
heart attack warning symptoms, especially
because I smoke.
Sometimes it is very hard to tell the difference
between indigestion and heart attack symptoms
because they are so similar. This similarity occurs
because the stomach and esophagus lie so close to
the heart. Heartburn or indigestion is a feeling of
burning, warmth, heat or pain that often starts in the
upper abdomen just beneath the lower breastbone
and ribs. This discomfort may spread in waves upward
into the throat. A sour taste in the mouth may occur
with this burning sensation. You may also have
burping, nausea, bloating or difficulty swallowing. The
discomfort and pain of heartburn can last up to two
hours and sometimes
longer. Often these
symptoms are worse
after eating. Usually
the symptoms are
worse when lying
down or bending over
and are relieved by
sitting or standing up.
See your doctor to find
out if your symptoms
are from indigestion or
from another serious
medical condition such as coronary artery disease.
Quitting smoking is highly recommended, as it is not
only harmful to the heart but causes chronic lung
disease and many types of cancers.
I am 40-years-old and for the past few months
I have been waking up nearly every night with
a racing heart. I’m very anxious during the
episode, which lasts about 10-15 minutes. I also
experience slight stomach discomfort, which
soon passes. Could something be wrong with
my heart or is it anxiety?
Sometimes heart arrhythmias occur resulting in the
type of symptoms you describe. An arrhythmia is
a change in the regular beat of the heart. When an
arrhythmia occurs a number of sensations can be
experienced. The heart can feel like it is skipping a
beat or it can feel as if it is beating irregularly, very
fast or very slow. Many times, there is no recognizable
cause of an arrhythmia. Caffeine, tobacco, alcohol,
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cough and cold medicines, diet pills, lack of sleep and
stress are common culprits to consider. Heart disease
may cause arrhythmias too. You should discuss your
symptoms with your primary care physician.
My 65-year-old mother seems to get more tired
and out of breath doing routine activities over
the past six months. For the last two weeks, she
has also developed swelling in both her legs. Her
only medical problem is high blood pressure.
Could this be related to the heart?
These symptoms suggest that your mother may have
heart failure. Heart failure occurs when the heart
muscle is weakened and can no longer pump as much
blood as the body needs. Coronary artery disease
(CAD) and heart attack are common causes of heart
failure in men. In women, high blood pressure is the
most common cause. The body tries to compensate
for this reduced pumping ability by retaining salt
and water. This process increases the total amount of
blood returning to the heart and causes the heart to
enlarge. Unfortunately, if left untreated, heart failure
worsens over time. The first symptoms of heart failure
are due to insufficient blood supply to the body
leading to fatigue, weakness and lightheadedness.
Eventually, blood backs up in the blood vessels
leading to the heart and cause worsening signs of
heart failure. These symptoms are shortness of breath
with activity or at rest, awakening feeling short of
breath, weight gain and swelling of the feet, ankles
or abdomen. Your mother should see her physician
to determine the cause of her symptoms and begin
treatment right away.
I D E N T I F Y Y O U R R I S K FA C T O R S
“Know Your Numbers”
You will find six health conditions known to
increase the risk for coronary artery disease
listed below. All of these conditions can be
controlled. You can minimize your risk for CAD
by identifying your personal risk factors and take
action to control these risks. Your doctor will help
you design a treatment plan tailored to meet
your needs.
• High Blood Cholesterol
• High Blood Pressure
• Overweight or Obese
• Physical Inactivity
• Diabetes
• Smoking
The American Heart Association recommends
very specific treatment goals – that’s where
the saying “know your numbers” comes into
play. Because each of these risk factors can be
measured by using blood tests or other methods,
it will be easy for you to determine if your
treatment plan is working. All you have to do is
compare your current numbers, or the results
of these tests, to your goal numbers.
High Blood Cholesterol
What is cholesterol?
Cholesterol is a type of fat (lipid) and is an essential
nutrient your body needs for many important
functions, such as producing new cells. If you eat too
many foods high in saturated fat and cholesterol
or you have an inherited condition, the cholesterol
levels in your blood may climb to unhealthy levels.
This increases your risk for developing atherosclerosis
(hardening of the arteries) in the arteries supplying
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blood to the heart, brain and legs, and can lead to life-
threatening illnesses, such as heart attack or stroke.
Are cholesterol and triglycerides the same thing?
Cholesterol travels through your blood attached to a
protein. This cholesterol-protein package is called a
lipoprotein. Depending on how much protein there
is in relation to fat, lipoproteins are classified as:
• High-Density Lipoproteins
HDL is the “good” cholesterol, mostly protein
with only a small amount of fat
• Low-Density Lipoproteins
LDL is the “bad” cholesterol, mostly fat with
only a small amount of protein
• Very Low-Density Lipoproteins
VLDL is similar to LDL cholesterol in that it
contains mostly fat and not much protein
Triglycerides are a type of fat carried in the blood
by very low-density lipoproteins (VLDL). Only a
small amount of triglycerides are normally found
in the blood; most are stored in fat tissue. Women
tend to have higher triglyceride levels than men.
Cholesterol and triglyceride levels tend to rise with
age and obesity. Many people with heart disease
have high triglyceride levels in their blood, called
hypertriglyceridemia. High triglycerides may not
directly cause atherosclerosis but can be associated
with health conditions that hasten the process. High
triglyceride levels may result from other diseases
such as untreated diabetes mellitus. People with high
triglycerides often have high total cholesterol, high
LDL cholesterol and low HDL cholesterol level.
I have high cholesterol, but I don’t understand
what the numbers mean.
When distinguishing cholesterol numbers, you want
to know levels for your total cholesterol, LDL, HDL
and triglycerides. When you state you have “high
cholesterol,” you want to identify which one of these
levels is high.
Total cholesterol is a measure of the total amount
of cholesterol in the blood. Less than 200mg/dL is
desirable.
LDL, the “bad” cholesterol, is the main source of
cholesterol buildup and blockage in the arteries.
Levels of 70-100 mg/dL are optimal, especially if you
have a diagnosis of CAD or stroke.
HDL, the “good” cholesterol, helps keep cholesterol
from building up in the arteries and protects against
heart disease, so higher numbers are better. A level
less than 40 mg/dL is considered a major risk factor
for heart disease. Having an HDL level of 60 mg/dL
or more helps to reduce heart disease risk and is the
desired level.
Triglycerides are another type of fat and if elevated
can also increase your heart disease risk. Triglyceride
levels are considered borderline if between 150 and
199 mg/dL or high if greater than 200 mg/dL. The
desired level is less than 150 mg/dL.
In summary, it is important to know your cholesterol
numbers because lowering cholesterol reduces your
chance of developing heart disease.
High Blood Pressure
What is blood pressure?
Blood pressure is the amount of force exerted by the
blood against the walls of the arteries. This pressure
is produced by the beating of the heart to maintain
adequate blood flow to other parts of the body. When
the arteries are narrowed or damaged, they make it
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harder for blood to flow and the blood pressure will
rise. When high blood pressure continues untreated,
the heart becomes strained and blood vessels can
become damaged. High blood pressure is a major risk
factor for stroke, heart attack or kidney failure.
My blood pressure reading is 130/80. What do
these numbers mean?
Blood pressure is measured in two numbers – the top
number is the systolic reading, which measures the
pressure generated with each heartbeat. The bottom
number is the diastolic reading, which measures the
pressure when your heart is resting between beats.
These blood pressure readings will help you
interpret your blood pressure results.
• Normal (ideal): Lower than 120/80
• Prehypertension: Between 120/80 and 139/89
• Hypertension Stage I: Between 140/90 and
160/100
• Hypertension Stage II: Above 160/100
Are women at higher risk of developing high
blood pressure?
Women are particularly at risk of developing high
blood pressure if they are using birth control pills
(especially in combination with cigarette smoking),
during pregnancy, if they are overweight, after
menopause, if they are African American, or if they
have a family history of high blood pressure. As
women age, they have substantially increased risk
for hypertension.
My blood pressure is 133/84 and I am a smoker.
Am I more at risk of getting high blood pressure?
Nicotine, found in tobacco of any form, will
temporarily increase the blood pressure and the
heart rate with each use. It also causes constriction in
the arteries of the arms and legs, which will increase
an individual’s blood pressure. In time, smoking
combined with other risk factors significantly
increases the chance of developing coronary
artery disease.
I am 58-years-old and always had blood pressure
readings of 110/70. For the past two years, my
automated blood pressure readings at the
grocery store have been fluctuating – 150/73,
145/76, 135/76, the highest being 156/76. Do I
have high blood pressure?
You will be diagnosed with hypertension if your blood
pressure measurements are above 140/90 mm Hg on
three or more separate occasions. They are usually
measured one to two weeks apart. Except in very
severe cases, the diagnosis is not based on a single
measurement. High blood pressure screening tests
and programs vary widely in reliability. Results from
automated blood pressure testing, commonly found
at grocery stores or pharmacies, may not be accurate.
Any high blood pressure measurement discovered
during a blood pressure screening program needs
to be confirmed by a health professional.
I do not have
any symptoms
from high
blood pressure.
Is it necessary
to continue
treatment?
High blood
pressure can
damage your
arteries, heart
and kidneys, and lead to atherosclerosis and stroke.
Hypertension is called a “silent killer” because it does
not cause symptoms unless it is severely high and,
without your knowing it, causes major organ damage
if not treated.
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Obesity
I am 40 pounds overweight. My weight is
mostly around my abdomen. What is my risk
of developing coronary artery disease?
Women with excess body fat are at higher risk of heart
disease, even if they don’t have other risk factors. The
exact risk is still a matter of some debate, but it is
known that increased weight raises your chances of
developing high blood pressure, diabetes and high
cholesterol, all of which are major risk factors for CAD.
Fat deposits, especially around the abdomen, are an
important independent risk factor for developing
coronary artery disease. The ideal waist circumference
for women is 35 inches or less.
An additional method to determine if you are at your
goal weight is to use the body mass index, or BMI.
BMI is a calculation that considers the relationship
between a person’s height, weight and body fat. The
desired BMI is 18.5- 25. To calculate your BMI, use the
chart to the right.
Physical Inactivity
I am 63-years-old and have high cholesterol
and high blood pressure. My doctor said I should
exercise but I’ve never done that. Will it really
help?
Lack of exercise is a risk factor for developing
coronary artery disease. It can indirectly increase
the risk of CAD because it also increases the risk of
diabetes and high blood pressure. Regular exercise
can help reduce your risk of CAD by helping you
control cholesterol and blood pressure, regulate
blood sugar (important for people with diabetes),
and lose weight. Regular exercise is essential not
only for preventing CAD but also for improving your
overall cardiovascular health. Check with your doctor
first before starting an exercise program if you have
diagnosed CAD, have been sedentary for a long
period of time, or have other heart, lung or metabolic
diseases, such as diabetes.
Diabetes
Is heart disease directly related to diabetes?
If so, in what way?
People with diabetes are more prone to heart disease
and stroke. Long-term complications from diabetes
develop because of persistent high blood sugar
levels and progression of atherosclerosis in arteries
throughout the body including arteries to the eyes,
kidneys, heart, brain and legs. Diabetes damages
the lining of blood vessels, causing them to become
clogged with plaque, which is made up of cholesterol,
white blood cells, calcium and other substances
that collect under the inner lining of an artery. This
damage narrows the vessels, decreasing the blood
supply, which eventually causes injury to the affected
area. It also increases the pressure in the blood vessels,
resulting in high blood pressure. When blood vessels
that supply the brain and heart are affected, a heart
Body Mass Index (BMI)To calculate your exact BMI value, multiply weight in
pounds by 705, divide by height in inches, then divide
again by height in inches.
Find your height in the left column below, then find your
weight range in the corresponding categories to the right.
Minimal Risk (normal): BMI less than 25
Moderate Risk (overweight): BMI 25 to 29
High Risk (obese): BMI greater than 30
Sample Weight Risk Factory Categories
Height Minimal Risk Moderate Risk High Risk
5’1” 131 or less 132-157 158 or more
5’3” 140 or less 141-168 169 or more
5’5” 149 or less 150-179 180 or more
5’7” 158 or less 159-190 191 or more
5’9” 162 or less 169-196 197 or more
5’11” 172 or less 179-208 209 or more
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attack or stroke may occur. About three-quarters of
people with diabetes die of some form of heart or
blood vessel disease. A person with diabetes has the
exact same risk for a heart attack as a person of the
same age who has already had a heart attack. People
with diabetes who experience a heart attack have
an unusually high death rate immediately or in the
long term.
At what age do people with diabetes begin to
develop heart disease?
There is no specific timeframe for developing CAD
if you have diabetes. In many circumstances, people
who are newly diagnosed with Type 2 diabetes have
had abnormally high blood sugars long before the
diagnosis was made. Therefore, it is difficult to know
exactly how long the heart has been exposed to the
effects of diabetes. However, diabetes is frequently
associated with other risk factors. Rather than focus
on a person’s age at time of diagnosis, it is more
important to keep the blood sugar under good
control or modify other cardiac risk factors, such as
quitting smoking, increasing activity, and working
to get weight, blood pressure and cholesterol to
goal levels.
Are women with diabetes at higher risk of heart
disease?
Diabetes eliminates any survival advantage that a
woman has over a man of the same age. A woman
with diabetes has the same risk of dying from heart
disease as a man her same age. Women with diabetes
have 2- 4 times higher risk of heart disease compared
to women without diabetes. As women age, diabetes
is more common and diabetes affects more women
than men over 60. If a woman has diabetes, she
should aim to achieve near-normal fasting plasma
glucose (blood sugar) of less than 100 mg/dL and
near normal HbA1c of less than percent. (Hemoglobin
A1c measures average blood sugar over the course of
three months and a physician can order this test.)
Smoking
I have been smoking a pack of cigarettes daily for
the last five years. Does smoking affect the heart?
Cigarette smoking is one of the most powerful risk
factors for CAD in women. It is associated with 50
percent of all cardiovascular events in women. The
incidence of a heart attack increases sixfold in women
vs. threefold in men who smoke. When combined with
other factors such as oral contraceptive use, it greatly
increases the risk. In addition, smoking increases the
blood pressure, decreases exercise tolerance, increases
the tendency for the blood to clot, increases LDL
cholesterol and decreases HDL cholesterol.
I recently quit smoking. How long will it take
to reduce my risk of heart disease to that of a
non-smoker?
The risk of CAD and stroke begins to drop
immediately after quitting smoking. It becomes half
after one year without smoking and continues to
decline thereafter to a nonsmoker’s risk.
My husband is a smoker. Am I at increased risk
of heart disease due to secondhand smoking?
Constant exposure to other people’s tobacco smoke,
called passive smoke, does increase your risk for CAD.
After spending just 30 minutes in a smoky room,
oxygen in the blood decreases, blood pressure rises
and blood is more likely to clot.
Cigarette smoking is one of the
most powerful risk factors for
heart disease in women. It is
associated with 50 percent of all
cardiovascular events in women.
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A D D I T I O N A L R I S K FA C T O R S
Family History
I am a healthy 50-year-old woman. I do not
have high blood pressure or diabetes and my
lipid profile is in the normal range. However, my
father had a heart attack at age 70 and two of
his brothers had heart attacks in their late sixties.
Does this mean I have a family history of heart
disease? Do I need to be concerned?
Family history is an important determinant of risk,
particularly premature CAD in a family member.
Premature family history of CAD means that you
have a first-degree male relative under 55 with
CAD or a first-degree female relative (mother, sister)
under 65 with CAD. Age and gender are contributory
risk factors. Males have a greater lifetime risk of
developing CAD.
Menopause
Does menopause increase the risk of heart
disease?
Many women seem to be protected from heart
disease before menopause. As women age, their risk
of heart disease rises. The loss of natural estrogen as
women age may contribute to the increased risk of
CAD after menopause.
I’ve read so much in the news lately about
hormone replacement therapy and heart disease.
What are the latest recommendations?
Based on recent clinical trials showing no benefit of
postmenopausal hormone therapy for cardiovascular
disease prevention and possible adverse effects, the
American Heart Association does not recommend
postmenopausal hormone therapy for the prevention
of cardiovascular disease in women with or without
existing CAD. Combined estrogen plus progestin
hormone therapy should not be initiated or continued
to prevent cardiovascular disease in postmenopausal
women. Other forms of menopausal hormone therapy
(e.g., unopposed estrogen) should not be initiated
or continued to prevent cardiovascular disease in
postmenopausal women pending the results of
ongoing trials. Although hormone therapy is not
recommended for cardiovascular disease prevention,
women and their healthcare providers should weigh
the potential risks of therapy against the potential
benefits for menopausal symptom control.
T E S T S , T R E AT M E N T S A N D P R E V E N T I O N
I have been experiencing mild chest pain after
exercise for the past six months. My EKG was
normal. Do I need further testing?
An electrocardiogram (EKG, ECG) may show evidence
of heart enlargement, signs of insufficient blood
flow to the heart, signs of a new or previous heart
attack, heart rhythm problems, changes in the
electrical activity of the heart caused by an electrolyte
imbalance and signs
of inflammation of
the sac around the
heart (pericarditis).
However, a normal
electrocardiogram
does not necessarily
mean that your
chest pain is not
cardiac in origin. An
electrocardiogram
cannot predict whether
you are at a risk of having a heart attack. You may
need further evaluation of your symptoms and stress
testing to determine the cause of your chest pain.
What is a nuclear stress test?
A nuclear scan is a test used to estimate the amount
of blood reaching the heart muscle during rest
and exercise. It is typically done for people with
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unexplained chest pain or to determine the location
and amount of injured heart muscle after a heart
attack. For this test, a radioactive substance (tracer)
is injected into a vein and a special camera is used
to view the amount of tracer that reaches the heart
at rest and when stressed (through exercise or
medication). As the tracer moves through the heart
muscle, areas that have good blood flow absorb the
tracer. If an area of heart muscle does not adequately
absorb the tracer, it means either that the blood flow
is severely reduced or there has been a previous
heart attack. An abnormal nuclear stress test may be
consistent with a blocked artery and you may be at
risk for a heart attack.
I recently had
an abnormal
stress test.
My doctor
recommended
coronary
angiography.
How will this
test help?
Angiogram,
or cardiac
catheterization,
is an appropriate follow-up test to examine the
inside of your arteries. A special dye is injected into
the coronary arteries to trace the movement of
blood through the arteries. The purpose of this test
is to pinpoint the size and location of plaque that
may have built up in your coronary arteries due to
atherosclerosis.
What is angioplasty? Is it different from stenting?
Angioplasty is a procedure to reopen narrowed
coronary arteries. During the angioplasty procedure,
a thin, flexible tube (catheter) is inserted through an
artery in the groin or arm and carefully guided into
the artery that is narrowed. Once the tube reaches
the narrowed artery, a small balloon at the end of
the tube is inflated. The pressure from the inflated
balloon presses fat and calcium deposits (plaque)
against the wall of the artery to improve blood flow. If
necessary, a small, expandable wire tube called a stent
is inserted into the artery to hold it open. Stents may
be medicated to decrease scar formation on the stent,
which increases the likelihood of the artery remaining
open over a longer time. Reclosure (restenosis) of the
artery is less likely to occur after angioplasty followed
by stenting than after angioplasty alone.
My father has CAD that has been worsening
despite medical management. What treatment
options are available?
There are several treatment options available.
Angioplasty (with or without stent placement) and
atherectomy (shaving the plaque from the inside of
the coronary arteries) are nonsurgical procedures to
reopen narrowed coronary arteries. Coronary artery
bypass surgery involves bypassing the blocked artery
with a graft fashioned from a leg vein or chest or
arm artery (mammary or radial artery). The choice
between angioplasty with or without stent placement
and bypass surgery depends on a number of factors
including the artery blocked, the number of vessels
blocked, the location and severity of blockage and
other heart problems.
Medications
I’ve heard that these cholesterol drugs cause bad
side effects that can kill people. I’m concerned
since I recently started taking Lipitor.
The most widely used cholesterol-lowering drugs
are called statins. They are effective in lowering
cholesterol and along with it the risk of dying from
heart disease and/or having recurrent heart attacks.
In general, statins have very few side effects. In a few
cases there may be some liver abnormalities along
with muscle tenderness and weakness. From time to
time your doctor may order liver function tests if you
take statins. The incidence of serious muscle injury
and progression to life-threatening rhabdomyolysis
11
(muscle breakdown) is very rare, but it’s essential to
report any muscle pain, weakness and/or tenderness
to your doctor.
I have chronic stable angina for which I take a
long-acting nitrate and atenolol. How do these
medications work?
Nitrates are a first-line therapy for the treatment of
acute anginal symptoms. Nitrates open (dilate) the
arteries to the heart. This action increases blood flow
to the heart, relieving chest pain (angina). Nitrates
also dilate veins throughout the body so that they can
hold more blood. This action reduces the amount of
blood going back to the heart, reducing the heart’s
workload. Beta blockers reduce the workload on the
heart by slowing the heart rate and reducing the
blood pressure, which allows the heart to pump more
efficiently. As a result, beta blockers can help relieve
or prevent chest pain (angina).
I do not like to take a nitroglycerin tablet
because it gives me a headache.
Nitroglycerin and other nitrates relax the arteries
(vasodilatation) and improve the blood flow to the
heart. The major side effects associated with nitrate
use are headache, lightheadedness and flushing,
which are due to the vasodilatation and tell you
that the medication works. These symptoms tend to
improve with time. Since the nitroglycerin evaporates
from the pills once the bottle is opened, you need a
new prescription every six months.
I am taking aspirin, atenolol, lisinopril and
simvastatin for medical management of CAD.
What are their benefits?
Platelets are responsible for forming blood clots.
Aspirin reduces platelet function and the risk of
having a heart attack or stroke from a blood clot
forming in the arteries of the heart or brain. Beta
blockers (atenolol) reduce the heart rate and blood
pressure and
therefore
decrease the
workload on
the heart. ACE
inhibitors
(lisinopril)
decrease the
blood pressure
and reduce the
workload on
the heart by
preventing the
formation of the
hormone angiotensin, which narrows arteries. Statins
(simvastatin) block an enzyme that the body needs
to form cholesterol. All these medications have been
shown to decrease the chance of another heart attack
and lengthen life in patients with CAD.
I was started on an ACE inhibitor after I suffered
a heart attack. For the past few weeks, I’ve had
a cough that I was told could be related to the
medicine. Should I continue the medicine?
ACE inhibitors are recommended immediately after
a heart attack to reduce the risk of death associated
with a heart attack and prevent the development of
heart failure.
Cough occurs in 20 percent of patients on ACE
inhibitors. If coughing is a severe problem, consult
your doctor, as other medications such as ARBs
(angiotensin receptor blockers) can be tried.
Nitrates are a first-line therapy
for the treatment of acute anginal
symptoms. Nitrates open (dilate)
the arteries to the heart.
12
Primary Prevention
What is primary prevention?
Primary prevention is early identification of
cardiovascular risk factors and taking action to reduce
these risks before cardiovascular disease develops.
Primary prevention strategies are aimed at helping
people make lifestyle changes, such as quitting
smoking or losing weight, before they are diagnosed
with a heart attack or stroke.
My most recent cholesterol test numbers are:
208 total cholesterol; HDL 67; triglycerides 96;
LDL 126. Because I have rheumatoid arthritis it is
difficult for me to do strenuous exercise, however
I do practice Tai Chi. What suggestions do you
have for lowering my LDL?
Ways in which a person could help reduce a high
cholesterol level are to start and maintain a low-
saturated-fat, low-cholesterol diet and lose weight if
overweight. Meat, cheese and dairy products are the
major sources of saturated fat. Increase your intake
of fiber, which can lower cholesterol. Fiber is found in
legumes (beans), whole-grain breads and cereals and
fresh vegetables. Exercise and being physically active
plays an important role in helping reduce cholesterol
– in doing Tai Chi, you are doing a good job in helping
yourself be active. One should aim for 20 to 30
minutes of moderate exercise (walking, gardening,
easy bicycling) at least 5 days a week. Exercise can
help control cholesterol, blood pressure and blood
sugar (important if you have diabetes or a family
history of diabetes). It would be wise to discuss these
levels, along with any other risk factors you may have,
with your physician to set your target cholesterol
goals and create the best plan of care to reach them.
My recent lipid profile was abnormal and my
doctor wants me to work on improving it in part
through more exercise and in part through diet.
The American Heart Association recommends
a low-saturated fat, low-cholesterol diet. My
doctor says not to worry about eggs or shrimp,
and instead to eliminate sugar, alcohol and
refined wheat flour from my diet as much as
possible. How and where can I find some credible
discussion of this conflicting advice?
One good resource for you to get this information
is from your doctor since he suggested the dietary
changes. The Therapeutic Lifestyle Changes (TLC)
diet is recommended by the National Cholesterol
Education Program of the National Institutes of
Health. You may want to work with a registered
dietitian or nutritionist to help you follow the
TLC eating plan, which is low in saturated fat and
cholesterol. According to this eating plan, less than
7 percent of your daily calories will come from
saturated fat, and cholesterol should be limited
to 200 milligrams (mg) per day. Also, the TLC plan
recommends increasing soluble fiber and adding
plant stanols and sterols to your diet. Plant sterols
and stanols are found in small quantities in many
fruits, vegetables, nuts, seeds, cereals, legumes and
other plant sources. Vegetable oils, for example,
contain both plant sterols and stanols. Plant stanols
and sterols are available in salad dressings and
margarines, such as Benecol and Take Control.
How can I increase my good cholesterol?
The “good” cholesterol is known as HDL (high density
lipoprotein) cholesterol. You can increase your
good cholesterol in several ways. First, increase your
exercise activity to 30-60 minutes a day on most days
of the week. Also, losing weight and not smoking will
increase HDL levels. A level of HDL less than 40 mg/dL
is considered a risk factor for heart disease, whereas
a level of 60 mg/dL is considered protective against
heart disease. Medications such as fibrates and niacin
also raise HDL levels.
Exercise and being physically
active plays an important role in
helping reduce cholesterol.
13
My total cholesterol is 230. My internist says that
it’s okay for me but I am concerned. What should
I do?
In order to determine whether this level of cholesterol
is appropriate, you need to determine your LDL
and HDL levels and whether other coronary artery
disease risk factors are present. Your number of
risk factors and your 10-year risk of having a heart
attack will determine whether your treatment begins
with lifestyle changes alone or whether it includes
cholesterol-lowering medications. Generally, unless
you have CAD or are at high risk for CAD, therapeutic
lifestyle changes will be tried first, for at least three
months.
You will need to be assertive about your health
and not accept a borderline total cholesterol as
okay without further assessment of LDL and HDL
cholesterol.
For the past six months, I have tried to manage
my high cholesterol by dietary modification and
exercise. My recent LDL cholesterol was 180 and
HDL was 30. My internist wants me to try losing
more weight before considering medication.
If your LDL cholesterol is still 180 after six months
of strict adherence to a trial of therapeutic lifestyle
changes and you have mentioned that you have
at least one coronary risk factor (low HDL), you will
likely need medication to lower your LDL cholesterol.
You should be evaluated for the major risk factors
that modify LDL goals – cigarette smoking, high
blood pressure, low HDL cholesterol, family history of
premature CAD and age. Your LDL goal will be based
on the risk category you fall in:
<160 mg/dL – Zero to one risk factor
<130 mg/dL – Multiple (2+) risk factors
<70-100 mg/dL – CAD or CAD equivalent
If your internist is not willing to make a treatment
plan that includes a dietitian consult, an exercise
regimen and medications, then consider getting
a second opinion.
How often should I exercise? What are the
benefits of physical activity?
It is important to try to incorporate physical activity
for 30 minutes on most, if not all, days. Physical activity
gives you strength and energy; helps you handle
stress, sleep better, look good and feel positive; helps
control weight and blood pressure; and strengthens
your heart, lungs, bones and muscles. Regular
moderate physical activity lowers the risk of heart
disease, stroke, diabetes, high blood pressure, obesity,
high total cholesterol and low HDL cholesterol.
What kind of exercises should I do?
Moderate activities such as pleasure walking,
gardening, yard work, dancing, home exercise and
moderate to heavy housework can reduce your risk
of heart disease if done on most or all days. More
vigorous exercises such as brisk walking, jogging, stair
climbing, hiking, swimming, rowing, bicycling, aerobic
dancing and cross-country skiing can improve the
fitness of your heart and lungs. If you haven’t been
active and want to start exercising, you should discuss
with your doctor an exercise program that is right
for you. You can also add more activity to your daily
routine such as taking stairs instead of elevators/
escalators and taking a walk during your lunch break.
14
What is the ideal body weight to reduce the risk
of heart disease?
A body mass index (BMI) between 18.5 and 24.9 Kg/
m2 is considered ideal (see chart on page 8). General
recommendations are to achieve and maintain
the ideal weight by restricting calories in diet and
increasing the caloric expenditure by exercising.
Overweight or obese persons should reduce 10
percent of their body weight in the first year of
therapy.
I know I should quit smoking – it’s bad for my
heart and my lungs – but I’ve tried everything
and nothing works. Any suggestions?
The more attempts you make to quit smoking
the greater your chances are of succeeding.
Counseling or smoking cessation programs also
increase your chances of quitting for good. Nicotine
replacement therapy, in the form of nicotine
transdermal patches and nicotine gum, are more
effective in helping you quit smoking when used as
part of a more comprehensive smoking cessation
program. Medication called bupropion may help you.
Consider talking with your doctor about the best
option for you.
How can I avoid gaining weight after I quit
smoking?
People do not automatically gain weight after they
quit smoking. However, if they start eating more once
they quit smoking, their weight will increase. If you
watch what you eat and stay physically active, you
may not gain any weight. The benefits of quitting
smoking on your cardiovascular health outweigh the
risk of gaining a few pounds, which can be controlled
if you are cautious with diet and exercise.
I continue to read about red wine’s health
benefits. Is this proven?
More research regarding red wine consumption
and possible cardiovascular benefits needs to be
conducted. Some studies have indicated possible
cardioprotective effects of red wine due to the
flavonoids present in the red grape seeds and skin.
These flavonoids are identified as antioxidants,
which may possibly reduce the risk of heart disease.
However, according to a recent American Heart
Association science advisory, drinking red wine or
any other alcoholic beverage cannot replace effective
conventional measures of reducing a person’s risk
for heart disease. Conventional measures include
controlling weight, lowering cholesterol and lowering
blood pressure.
Recently my sister and I were diagnosed with
hypertension. I was started on medications,
whereas she has only been advised lifestyle
changes. I would like to avoid medications
as well.
Your treatment will depend upon how high your
blood pressure is, whether you have other medical
conditions, such as diabetes, and whether any
organs have already been damaged. Your risk of
developing other diseases, especially heart disease,
will be another important factor your doctor will
consider. If you fall into the pre-hypertension range
(120-139/80-89 mm Hg), your doctor will likely
recommend lifestyle modifications, including losing
excess weight, exercising, limiting alcohol, cutting
back on salt, quitting smoking and following the
Dietary Approaches to Stop Hypertension (DASH)
diet – an eating plan that is a low-sodium, low-fat
and low-saturated fat diet that emphasizes eating
The more attempts you make
to quit smoking the greater
your chances are of succeeding.
Consider talking with your doctor
about the best option for you.
15
more fruits, vegetables, whole grains and low-fat
dairy foods.
Drug therapy is not recommended for pre-
hypertension patients with the exception of patients
with diabetes who have blood pressure readings over
130/80 mm Hg. Combination drug therapy in addition
to aggressive lifestyle changes is usually necessary for
those with hypertension.
How can I reduce high blood pressure?
You can reduce your blood pressure by making some
changes in your lifestyle and taking proper treatment.
Lose weight if you’re overweight. Eat a healthy diet
low in saturated fat, cholesterol and salt. Be more
physically active. Limit alcohol to no more than one
drink per day for women or two drinks a day for men.
Take medicine the way your doctor tells you and
know what your blood pressure should be and work
to keep it at that level.
I have diabetes and am on Metformin. What can
I do to prevent the complications of diabetes?
Diabetes is a disease that can be controlled. Careful
monitoring of diet, daily blood sugars and a blood
test called hemoglobin A1c will all help to reduce
complications. The hemoglobin A1c measures
average blood sugar over the course of three months
and your physician can order this test for you. An ideal
hemoglobin A1c result for people with diabetes is less
than 7 percent. Studies have demonstrated that tight
control over diabetes reduces the risk for subsequent
heart attack and stroke. You should aim to achieve
near-normal fasting plasma glucose (blood sugar)
of less than 110 mg/dL and near-normal hemoglobin
A1c of less than 7 percent. Other cardiac risk factors
associated with diabetes need to be treated more
aggressively. For example, change your blood
pressure goal to less than 130/80 mm Hg and your
LDL cholesterol goal to less than 70 mg/dL.
My doctor recommended that I start aspirin as
I am at high risk for coronary artery disease. I
thought aspirin is for people who have angina
or who have had a heart attack.
Aspirin is definitely recommended for patients who
have had a myocardial infarction (heart attack),
unstable angina, ischemic stroke (caused by blood
clot) or transient ischemic attacks (TIAs or “little
strokes”), in the absence of contraindications. This
recommendation is based on sound evidence from
clinical trials showing that aspirin helps prevent
the recurrence of such events as heart attack,
hospitalization for recurrent angina, second strokes,
etc., known as secondary prevention. Studies show
aspirin also helps prevent these events from occurring
in people at high risk, known as primary prevention.
The American Heart Association recommends low-
dose aspirin in high-risk people.
Secondary Prevention
What is secondary prevention?
Secondary prevention is aimed at identifying and
treating people with established disease and those at
very high risk of developing cardiovascular disease. It
also includes treating and rehabilitating patients who
have had a heart attack or stroke to prevent another
similar event.
16
I had a heart attack two months ago. I am on
aspirin, metoprolol, Pravachol and lisinopril. How
long will I need to be on these medications?
Aspirin, beta blocker (metoprolol), ACE inhibitors
(lisinopril, accupril or monopril) and statins such as
Lipitor, Zocore or Crestor have been shown to reduce
the risk of future heart attack in people with known
CAD. The American Heart Association recommends
to continue aspirin, beta blockers and ACE inhibitors
indefinitely for patients who have had a heart attack,
unless contraindicated.
I am overweight and I have diabetes, high
blood pressure and high cholesterol for which
I am taking medications. I also had a heart attack
and a mini-stroke one year ago. What can I do
to reduce my risk of having another heart attack
or stroke?
Aggressive lifestyle changes in addition to
medications will lower your risk for a future heart
attack or stroke. Complete cessation of smoking,
weight control, 30 minutes of physical activity on
most days, alcohol moderation, moderate sodium
restriction and emphasis on fruits, vegetables and
low-fat dairy products are some of the changes you
need to consider. Your blood pressure should be less
than 130/80, LDL cholesterol should be less than 100
(less than 70 being the optimal) and hemoglobin
A1c should be less than seven. You will benefit from
working with a dietitian or nutritionist to help you
achieve your dietary goals. Ask your doctor to help
you make a plan of care that includes a dietitian and
an exercise program, in addition to medications. You
may also want to discuss whether you are a candidate
for cardiac rehabilitation.
I am a 50-year-old woman who recently
underwent bypass surgery. Will a cardiac
rehabilitation program benefit me?
Cardiac rehabilitation is a medically supervised
program that includes exercise, lifestyle changes,
education and emotional support for people who
have had a heart attack, bypass surgery or have
other heart problems. It is individually designed
to enhance your quality of life by improving your
physical and emotional health. It can stabilize or
reverse CAD. Benefits include enhanced exercise
tolerance, less depression and anxiety, controlled
CAD symptoms and most importantly, lower risk
for future cardiac events. Attending a cardiac
rehabilitation in your community is strongly
recommended by the American Heart Association.
This booklet was developed by Suman Tandon, MD, Gail D’Onofrio, MD, MS, Lisa Freed, MD,
and Janet Parkosewich, RN, MSN.
S T E E R I N G C O M M I T T E E M E M B E R S
Mariane Carna, RN, MSNExecutive Director, Heart & Vascular Center, Yale-New Haven Hospital
Gail D’Onofrio, MD, MS, Medical DirectorChief, Section of Emergency Medicine, Yale-New Haven Hospital
Lisa Freed, MD, FACC, Co-DirectorAttending Cardiologist, Yale-New Haven Hospital
Clinical Assistant Professor, Yale University School of Medicine
Basmah Safdar, MDCo-Director, Chest Pain Center, Yale-New Haven Hospital
Assistant Professor, Yale University School of Medicine
Janet Parkosewich, RN, MSN, FAHA, Co-DirectorCardiac Clinical Nurse Specialist, Yale-New Haven Hospital
Charlotte Hickey, RN, MSClinical Coordinator, Yale-New Haven Hospital
Women’s Heart Program at
Yale-New Haven Hospital
Women’s Heart Program at Yale-New Haven Hospital
20 York Street
New Haven, CT 06510
203.688.4373
www.ynhh.org