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The Basics

What is cardiovascular disease?

Cardiovascular disease (CVD) refers to a diverse class of diseases that involve the heart and/or blood vessels (arteries and veins). Cardiovascular disease includes arteriosclerosis (arterial disease) that can lead to heart attacks and stroke, coronary artery disease (disease of the coronary arteries), heart valve disease, arrhythmias (abnormalities in the heart rhythm), heart failure, hypertension (high blood pressure), diseases of the aorta and its branches, disorders of the peripheral vascular system (otherwise known as peripheral artery disease), and congenital heart disease.

Coronary artery disease usually occurs when one or more of the coronary arteries are blocked. The coronary arteries run along the heart's surface and supply oxygen to the heart muscle. These arteries branch out from the main artery—the aorta—the body to help circulate oxygen-rich blood to all organs. Blockage of these arteries is usually caused by a process called atherosclerosis, which means a progressive build up of fatty material forming an occlusive or partially occlusive plaque in the inner lining of the artery. If the arteries are blocked, then there is a reduced blood supply to the heart muscle; this is when a heart attack can occur.

The same process can occur in other arteries. For example, an arterial blockage in the neck can reduce the blood supply to the brain and cause a stroke. In the legs, blockage of the arteries can cause calf pain while walking or, in more severe cases, even rest pain while lying down. The latter is called peripheral artery disease.

Hypertension or high blood pressure is also an important condition to understand. Blood pressure is the pressure of the circulating blood as it moves through the arteries to the different organs of the body. If this pressure is elevated there is added stress on the arterial walls and on the heart, which has to work harder to overcome this stress. This increased stress can contribute to arterial damage and atherosclerosis as described above. Blood pressure level is expressed with two numbers. An acceptable level is less than 140/90 or less than 130/80 for people with diabetes or chronic kidney disease

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What causes cardiovascular disease?

Some of the ways arterial disease develops is described in the section above. This section will describe risk factors that have been proven to be associated with the development of cardiovascular disease. These include:

Nonmodifiable risk factors (or risk factors that you can't alter)

• Age and gender. On average, women have their first heart attack at age 70, whereas men have their first heart attack at age 66. Estrogen (lack of it) plays an important role in postmenopausal high blood pressure.
• Genetic factors/family history of cardiovascular disease, especially a family history of premature cardiovascular disease (younger than 55 years of age in a male relative and younger than 65 years in a female relative)

Modifiable risk factors (risk factors that you can alter)

• Tobacco smoking. Fifty percent of heart attacks in middle age women are attributable to tobacco.
• Insulin resistance and diabetes mellitus. High cholesterol levels (high total cholesterol, high low-density lipoprotein, low high-density lipoprotein)
• Obesity, especially central obesity; apart from being linked to diabetes, this form of obesity independently increases cardiovascular risk.
• High blood pressure is a risk factor for all women; however, the mortality from hypertension is three times higher for African-American women.
• Physical inactivity/sedentary lifestyle

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What are the different symptoms and signs of cardiovascular disease?

There are many different symptoms and signs of cardiovascular disease and this depends on what specific organ is affected. Coronary artery disease affects the heart and its blood vessels; stroke affects the brain and nervous system; and hypertension (high blood pressure) affects the arteries and therefore multiple organs in the body (including the brain, eyes, heart, and kidneys).

Coronary artery disease can manifest as a "heart attack." Symptoms include chest pain, shortness of breath, sweating and possibly pain in other areas of the upper body such as in one or both arms, the back, neck, or jaw.

Stroke can cause sudden symptoms involving numbness or weakness of the face, arm, or leg, especially on one side of the body. It can also cause confusion and disorientation, difficulty with vision, coordination and speech.  If symptoms occur suddenly and then pass within 24 hours it usually means that a "mini stroke" or TIA (transient ischemic attack) has occurred.

People with hypertension usually feel well and have no symptoms. Many people have high blood pressure for years without actually knowing it. Only a healthcare professional can diagnose high blood pressure.

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Cardiovascular disease and women: the statistics

Heart disease is the leading cause of death in women, who are twice as likely to die from the disease than from all cancers combined. Thirty-nine percent of women do not survive their first heart attack. The age-adjusted rate of heart disease for African-American women is 72% higher than for Caucasian women. Also, African-American women ages 55 to 64 are twice as likely as Caucasian women to have a heart attack and 35% more likely to suffer from coronary artery disease.

• Within 6 years of surviving a heart attack, women are more likely to suffer heart failure, and only half of all women with high blood pressure are treated for the condition.
• Women who smoke risk having a heart attack 19 years earlier than nonsmoking women.
• Women with diabetes are two to three times more likely to have heart attacks.
• Women tend to develop heart disease about 10 to 15 years later than men, because of the protective effect of female hormones such as estrogen.
• Women with heart disease have different symptoms than men and respond differently to methods of treatment. The most common symptoms of a heart attack are chest pain that may radiate to the neck, the jaw, or down the left arm, as well as shortness of breath and sweating.
• Women are less likely than men to feel chest pain during a heart attack. Studies suggest that more women than men experience so-called "atypical" symptoms, such as back pain, nausea, or fatigue. Shortness of breath has been found to be more common in women, whereas sweating is more common in men.

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Diagnosis and Treatment

Diagnosis

Your healthcare professional will need to talk to you about your individual risk for developing cardiovascular disease. The recommendations for prevention and treatment will be different depending on your level of risk.

You may be at high risk for developing cardiovascular disease if you have:

• Established coronary artery disease
• A history of stroke
• Peripheral artery disease
• Been diagnosed with an abdominal aortic aneurysm
• Advanced or chronic kidney disease
• Diabetes, or
• If your Framingham cardiovascular disease risk is greater than 20%

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Prevention and Treatment

All women should follow these lifestyle recommendations to reduce the chances of developing cardiovascular disease:

• Stop smoking
• Eat healthfully
• Exercise regularly
• Control your weight and maintain it within the normal range for your height

Diet
In scientific studies, a Mediterranean diet has been shown to increase survival among older people. A Mediterranean diet also reduces the risk of heart disease recurrences.

The Mediterranean diet includes eating the following:

• Plenty of fruits, vegetables, bread, and cereals, beans, nuts, and seeds
• Olive oil
• Dairy products, fish, and poultry in low to moderate amounts
• Red meats in small amounts
• Wine in low to moderate amounts

Research shows that people who eat more fruits and vegetables have lower rates of heart disease. A healthy diet should include five or more servings per day of a variety of fruits and vegetables. A typical serving of fruit is one medium fruit; a quarter cup of dried fruit; or half cup of fresh, frozen, or canned fruit. A typical serving of vegetables is one cup of raw leafy vegetables or a half cup of cooked vegetables.

Eating a diet rich in fish oils can reduce the risk of a heart attack or the risk of dying from heart disease in people who have already had a heart attack. Omega-3 fatty acids found in cold water fish (salmon, mackerel, sardines, and herring) and in fish oils (EPA and DHA) may also reduce the risk of heart disease and lower the risk of heart problems, particularly in people who do not eat much fish.

Although the total amount of fat in your diet doesn't increase your LDL (bad) cholesterol level, it is best not to get more than 35% of calories from fat, even from mostly good fats. Fat has more calories per gram than protein or carbohydrates making it likely that you will take in too many calories (and gain weight) if you eat a lot of fat. It is also difficult to stay within the limits for saturated fat and dietary cholesterol when you eat a high-fat diet. Saturated fat is found mostly in meats and dairy products (unless they're nonfat) and tropical oils (coconut and palm oil). Trans fats, a type of unsaturated fat, should also be avoided because it increases the risk of heart disease. Trans fats are found in foods that contain hydrogenated/partially hydrogenated vegetable oils, such as cookies, crackers, other baked goods, commercially prepared fried foods, and some margarines. To see if a food is truly trans-fat-free, check ingredients labels for hydrogenated/partially hydrogentated fats and oils. It is always important to read your food labels to learn about exactly what is in the food you eat.

Eating foods rich in soluble fiber (such as oatmeal) and plant sterols/stanols (added to some margarines and spreads) may help lower cholesterol levels because they inhibit cholesterol absorption from the intestines. In order to gain a beneficial effect, the recommended intake is 2 grams of plant sterol esters per day. There are some dietary supplements useful in the prevention and treatment of cardiovascular disease. Supplementation with niacin can also improve levels of "the good cholesterol" called HDL (high-density lipoprotein) cholesterol. Some scientific studies suggest that supplementation with coenzyme Q10  may be beneficial in the treatment of heart failure symptoms.

The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure in people with and without high blood pressure. This diet is rich in potassium (largely from fruits and vegetables), and you can choose a plan with either a moderate (2400 milligrams or lower) or low (1500 milligrams or lower) amount of sodium.

Salt is sodium chloride. There is scientific evidence to suggest that a diet low in sodium and high in fruit and vegetables and lower high blood pressure, particularly if you are an African-American woman over the age of 45. Lowering blood pressure will contribute to lowering your risk of cardiovascular diseases overall.

Although alcohol intake for women should be limited to one standard drink per day, alcohol consumed at least once a week is protective against heart disease in women.

Weight loss and dealing with obesity
The statistics for obesity in the US show that over 65% of adults over the age of 20 are obese and about 16% of all teens and children are overweight or obese. This is the result of people eating too much (large portions), eating too few natural and unrefined foods, and eating more processed foods containing sugar and fat, as well as leading a less-active lifestyle.

The correct weight for your height is calculated with your body mass index (BMI), which is your weight divided by your height squared (W/H X H). However your waist-to-hip ratio measurement (otherwise known as waist circumference) is also important. Your waist to hip ratio is an independent risk factor for developing cardiovascular disease. If you are a woman with a waist circumference of more than 88 cm or 35 inches then you are at risk of developing cardiovascular disease.

Obesity is defined as having a BMI greater than 30 and being overweight is defined as a BMI between 25 and 30. A normal body weight reflected in a BMI will be between 20 and 25, reducing your chances of developing cardiovascular disease and improving your overall health. Being overweight is a risk for other diseases, such as certain cancers, sleep apnea, CVD, and osteoarthritis.

The key to weight loss is taking in fewer calories than the energy you burn during physical activity. A dietician or nutritionist can help you to devise a plan to eat less and help you to choose foods that will reduce excess weight but help you maintain your ideal weight. He/she will tailor the plan to your individual goals, food likes and dislikes, activity levels, and medical conditions. No single food plan is going to work for everyone who needs to loose weight.

Exercise and physical activity
All adults should get a minimum of 30 minutes of moderate-intensity physical activity, such as brisk walking, on most or preferably all days of the week. Studies suggest that active women have a 50% risk reduction in developing heart disease. Exercise will enable you to maintain your weight more easily.

In addition, exercise lowers your risk for certain cancers (particularly colon cancer). Weight-bearing exercise such as walking, aerobics, or lifting weights helps prevent osteoporosis or bone thinning by keeping your bones strong. Exercise can also help you cope with stress. Being active keeps you mobile and independent into old age, and it can ease the joint swelling and pain from arthritis.

Exercise doesn't have to mean a trip to the gym. Such physical activities as gardening, household chores, or walking for leisure can be included.

Other lifestyle modifications

• Limit alcohol. Drinking too much alcohol can raise blood pressure, cause heart failure, and lead to stroke. Excess alcohol intake can contribute to high triglycerides, produce irregular heartbeats, and affect cancer and other diseases. Alcohol contributes to obesity, alcoholism, suicide, and accidents. The risk of heart disease in people who drink moderate amounts of alcohol (an average of one drink per day for women, two drinks for men) is lower than in nondrinkers.
• Reduce stress. Some scientists have noted a relationship between coronary heart disease risk and stress in a person's life that may affect his/her risk factors for heart disease and stroke. For example, a person under stress may overeat, start smoking, or smoke more than they otherwise would. Research has even shown that stress reaction in young adults predicts middle-age blood pressure risk.
• Stop smoking. If you smoke, quit. If someone in your household smokes, encourage them to quit. It is difficult to quit smoking, but it's harder to recover from a heart attack or stroke or to live with chronic heart disease if you smoke. Commit to quit. We're here to help if you need it.

 

The risk of having a heart attack begins to decline within months of smoking cessation, reaching the level of persons who have never smoked within 3 to 5 years.

Medical treatment
Medications are often required to lower a patient's blood pressure if it remains high despite changing his/her lifestyle in the ways discussed above. In fact, most people with high blood pressure will require more than one medication to ultimately bring their blood pressure to within normal limits. Even taking medication to bring blood pressure down by 20 mm Hg (systolic blood pressure) will translate to a reduced risk of dying from cardiovascular disease.

 

The benefits of medication to lower blood pressure must be balanced against the risk of side effects. Some medications will be more suitable for certain individuals; for example, the elderly will have a greater risk of side effects, such as constipation and edema, with calcium channel blockers, whereas people with CVD or COPD (chronic obstructive pulmonary disease) may not be able to take beta-blockers.

 

If you have high blood pressure you will probably not have any symptoms, and so it may come as a surprise to you that your healthcare professional recommends medication to lower it. You may need to take blood pressure medication on a daily basis—usually for the rest of your life. It is very important not to miss even a few doses of your medication as this may lead to elevation of your blood pressure.

 

You may have what's called "white coat hypertension"; that means your blood pressure goes up when you're at the healthcare professional's office. Monitoring your pressure at home with a log will help you measure your true level, which you can share with your healthcare professional. This is helpful in diagnosing and preventing potential health problems.

 

People who have high cholesterol levels and do not meet their cholesterol targets with lifestyle modifications alone, will usually require medications. Different anticholesterol medications are available depending on which of three types of cholesterol is elevated: high high-density lipoprotein, high low-density lipoprotein, or low high-density lipoprotein with high low-density lipoprotein.

 

Aspirin is used to thin the blood in patients with a high risk of cardiovascular disease and in patients who've had a myocardial infarction (heart attack), unstable angina, ischemic stroke (caused by blood clot) or transient ischemic attacks (TIAs or "little strokes"). Blood thinning is required in order to reduce the chance of forming blood clots in the arteries, such as in the coronary arteries of the heart, which is an almost inevitable consequence of atherosclerosis.

 

Experts agree that aspirin has value in preventing a second heart attack. However, it is less clear whether taking aspirin reduces the risk in people, particularly women, who have never had a heart attack.

 

The American Heart Association recommends aspirin use for patients who have had a myocardial infarction (heart attack), unstable angina, ischemic stroke (stroke caused by blood clot), or transient ischemic attacks (TIAs or "mini strokes"), if not contraindicated. 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 (secondary prevention).  Studies show aspirin also helps prevent these events from occurring in people at high risk (primary prevention).

You should not start aspirin therapy without first consulting your clinician. The risks and benefits of aspirin therapy vary for each person.

 

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Empower Yourself

Reducing your risk of cardiovascular disease involves understanding the risks and setting goals and (in consultation with your healthcare provider).

Assessing your risk for heart disease

Talk to your healthcare professional about your risk factors. He/she will perform a thorough medical history, physical examination, and lab tests. Unfortunately, nearly one third of people with high blood pressure and nearly half with high cholesterol do not know their risk. According to current guidelines, all adults should be checked for cardiovascular risk factors commencing at age 20. You should have your blood pressure, weight, and waist measurements recorded every 2 years, and your fasting blood sugar and cholesterol levels should be tested every 5 years. A Framingham risk score should be calculated for all adults 40 years and older.

The Framingham risk calculator measures your risk of developing heart disease in the next 10 years using a scoring system that includes measures of age, sex, total and low-density lipoprotein (bad) cholesterol levels, smoking, and blood pressure. Low risk means there is a less than 10% chance of developing heart problems within 10 years. Intermediate risk means a 10% to 20% chance, and high risk means a greater than 20% chance. The Framingham risk calculator can underestimate the risk in some women, so you should always use this calculator in consultation with your healthcare professional.

Find out from your healthcare professional your blood pressure and cholesterol levels in order to reduce your risk of cardiovascular disease. Also, know your weight, your waist measurement, and how much exercise you should be doing on a daily basis.

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Dealing with cardiovascular disease

Prevention of cardiovascular disease is key. Although there are many nonmodifiable risk factors (having cardiovascular disease in your family or being over 50 years old), there are many modifiable risk factors that you can change.

Stop smoking: This is probably the most important part of prevention and perhaps the most challenging of all. Many people have the intention to stop but fail with their first few attempts. This does not mean that you should give up. In order to succeed, you need to feel ready to change your habits and recognize the advantages of quitting as well as having a plan to deal with cravings and relapse.

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Frequently asked questions

What are the common symptoms of a heart attack?
The most common symptoms of a heart attack are chest pain, left arm pain, shortness of breath, and sweating. As well as these common symptoms, some people can experience less common or "atypical symptoms" that may be mistaken for a sign of another condition.

What are some "atypical symptoms" of a heart attack?
"Atypical symptoms" include symptoms other than the ones mentioned above; however, the term "atypical" is misleading because these symptoms are actually relatively common. "Atypical" symptoms include:

• Back, neck, or jaw pain
• Nausea
• Vomiting
• Indigestion
• Weakness
• Fatigue
• Dizziness
• Lightheadedness

Women experience more "atypical" symptoms than men at the time of a heart attack.

How will menopause affect my risk of developing heart disease?
Heart disease rates in women after menopause are two to three times that of premenopausal women of the same age. This is related to the hormone estrogen which has protective effects on the cardiovascular system.

Should I consider hormone therapy to reduce my risk of developing heart disease?
No. Hormone therapy is no longer recommended for heart disease prevention. A large, multicenter heart disease prevention study, part of the Women's Health Initiative (WHI), found that estrogen-alone hormone therapy had no effect on coronary heart disease risk but did increase the risk of stroke for postmenopausal women. The estrogen-alone study involved 40 clinical centers and more than 10,000 healthy postmenopausal women ages 50 to 79 who did not have a uterus.

Should women at low risk for heart disease take aspirin?
Many research studies on aspirin and its use in cardiovascular disease prevention did not include women. Therefore the benefits of aspirin for cardiovascular disease prevention are less established for healthy women than they are for healthy men.

In the Women's Health Study, healthy women 45 years or older were given 100 mg of aspirin or a placebo pill every other day for several years. It was found that this regimen did not significantly reduce the risk of having a heart attack or dying from cardiovascular disease except in women older than 65 years. There are other studies that have tested aspirin for use in cardiovascular disease prevention, however, it is still unclear which women should take aspirin.

If you have risk factors for cardiovascular disease you should talk to your healthcare professional about the benefits and risks of taking aspirin.

What are the risks of aspirin use?
Aspirin can cause side effects. One of the more serious side effects is ulceration and bleeding in the stomach. Aspirin causes thinning of the blood and can cause serious bleeding in the case of injury, such as a fall. This risk of serious bleeding is higher for people older than 70. Minor side effects, including upset stomach and nausea, are more common. Your healthcare professional can advise you on whether the benefits of taking aspirin outweigh the risks.

How do I quit smoking?
It is not easy to quit smoking; however the first and essential step is feeling ready and motivated to quit. It is important to realize that many women try a few times before they succeed. If you quit smoking once and then relapse, don't give up, give yourself another chance. Talk to your healthcare professional about the different medical options, such as nicotine patches, nicotine gum, and certain tablets. He/she can help you to devise a plan for dealing with cravings.

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Glossary of cardiovascular disease terms

Aorta: The largest artery in the human body, bringing oxygenated blood from the heart to all parts of the body.

Arrythmia: Disorders of the heart's rhythmic beating.

Abdominal Aortic Aneurysm: Occurs when a weak area in the aorta expands or bulges.

Atherosclerosis or Arteriosclerosis: Process in which fatty deposits of cholesterol, calcium, or other products build up in the lining of an artery.

BMI (Body Mass Index): Measure of body fat based on height and weight.

Coronary Artery Disease: Occurs when the arteries that supply blood to the heart become hardened and narrowed.

Coenzyme Q10: A vitamin-like nutrient, occurring naturally in food, and also manufactured by cells in the body. A large concentration can be found in the heart muscle cells. Heart failure (from a wide variety of causes) has been strongly correlated with significantly low blood and tissue levels of coenzyme Q10.

Congenital Heart Disease: In the newborn; includes structural defects of the heart and occurs when the heart or blood vessels near the heart do not develop properly.

Diabetes Mellitus: Characterized by hyperglycemia (high blood sugar); serious complications include cardiovascular disease, blindness, and chronic renal failure.

Diastolic Blood Pressure: Bottom number on a blood pressure reading, representing the pressure in the arteries when the heart is at rest.

Framingham Cardiovascular Risk: When the blood supply to the heart is interrupted, causing potential damage and death of heart tissue.

Heart Failure: Structural or functional cardiac disorder that impairs  the heart's ability to pump blood throughout the body.

Heart Valves: Maintain the unidirectional flow of blood by opening and closing, ensuring blood flows in one direction.

High-Density Lipoprotein (HDL): Class of lipoprotein that carries cholesterol from the body tissues to the liver.

Hypertension: Commonly referred to as high blood pressure; a medical condition in which blood pressure is chronically elevated.

Insulin Resistance: Condition whereby normal amounts of insulin are inadequate to produce a normal insulin response from fat, muscle, and liver cells.

Iscahemic Stroke: Ischemic Stroke: The result of an obstruction within a blood vessel supplying blood to the brain.

Low-Density Lipoprotein (LDL): A class of lipoprotein that transport cholesterol from the liver.

Myocardial Infarction: See heart attack.

Niacin: Also known as nicotinic acid or vitamin B3, a water-soluble vitamin that plays an essential role in energy metabolism and removal of toxic chemicals from the body.

Obesity:  Stored fatty tissue in human and in other mammals; associated with certain health conditions and increased mortality.

Omega-3 Fatty Acids: Considered healthy essential fatty acids shown to reduce cardiovascular disease.

Osteoarthritis: A joint disease caused by the breakdown and loss of cartilage between the bones.

Peripheral Artery Disease: Occurs when plaques build up on the inside walls of the arteries that carry blood throughout the body.

Placebo: Pharmacologically inert preparation administered via ingestion, injection, inhalation, or topically.

Sleep Apnea: A sleep disorder characterized by pauses in breathing during sleep.

Stroke: Occurs when blood flow to the brain stops, potentially causing permanent neurological damage.

Systolic Blood Pressure: The top number on a blood pressure reading, representing the maximum pressure exerted when the heart contracts.

TIA (Transient Ischemic Attack): Also known as a "ministroke," occurring when a blood clot temporarily clogs an artery. These symptoms occur rapidly and last a short time—less than 5 minutes.

Unstable Angina: Occurs when a blood clot forms on a plaque, suddenly increasing the degree of blockage in a coronary artery.

Waist Circumference/Waist-to-Hip Ratio Measurement: A measurement taken by placing a tape measure around your body at the level of the uppermost part of your hipbone, usually at the level of your navel.

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References

1. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99:779-785. (Lyon Diet Heart Study)

2. Whelton PK, He J, Cutler JA,et al. Effects of oral potassium on blood pressure. Meta-analysis of randominzed controlled clinical trials. JAMA. 1997;277:1624-1632 (sodium restriction study)

3.Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293-1304. 

4. Anderson GL, Limacher M, Assaf AR. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004;4291:1701-1712.

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