LISTEN TO YOUR HEART

The number of fit and healthy women suffering heart attacks is surprisingly high, so listen up

Affairs of the cardiovascular only concern men who consider a Ginsters pasty and a Fanta Fruit Twist a sound mid-morning snack, right? Well – them and women like you, too. Let us tell you why it pays to peel back the layers of misinformation around the medical issue you probably haven’t given a second thought

Knowing what’s set to be the biggest talking point in health and wellness is the Women’s Health team’s bread and (cashew) butter, so take it from us: in AW19, you’re going to be hearing a lot more chat about your heart. The powerful biological machine at the core of your existence is a grafter, beating three billion times during the average person’s lifetime. Bit odd, then, that the majority of women go about their days without giving it much thought – both in terms of how to help it operate optimally and, more importantly, what happens when something goes wrong. It’s an issue the British Heart Foundation (BHF) is on a mission to challenge. ‘There’s a visual that people have of the type of person you’d expect to suffer a heart attack: a man in middleto-later age, who might smoke, is a diabetes risk, doesn’t exercise and is overweight,’ explains Professor Chris Gale of the University of Leeds and spokesperson for the BHF. ‘But women are not immune to heart and circulatory disease – in fact, as many women as men are living with it in the UK.’ Each year, 28,000 women in the UK die from heart attacks, and coronary heart disease kills more than twice as many women as breast cancer. If that comes as a shock to you, all the more reason to read on.

Circulatory disease is arguably an even bigger deal for you than for the men in your life; according to heart health journal Circulation, mortality rates are worse for women within the first year of a heart attack than for men. It’s not a case of your female biology screwing you over – your heart health is in fact one area where your choices and actions can make a positive, formative difference. Instead, multiple cardiologists told WH that the problem is cultural; a complex melange of issues around selfreporting and diagnosis arising from the fact that the issue of female heart health appears to be locked in a cycle of false assumptions and missing information. So, to that point, let’s clear a few things up.

‘There are three primary ways in which the heart can go wrong,’ explains London-based cardiologist Dr Amanda Varnava. The first is with the heart muscle, which can become inflamed and struggle to pump as well as it needs to. ‘The second is an issue with the electricity of the heart, which causes it to beat too fast or too slow,’ she adds. ‘And the third and most common reason is a problem with the blood supply in the coronary artery.’ Unhealthy coronary arteries often occur, she explains, due to a process called atherosclerosis. That’s when the artery walls

‘fur up’, thanks to a build-up of fatty deposits and cholesterol called atheroma, which narrows the gap through which blood can travel. Gradual accumulation can cause angina (this may manifest as chest pains or breathlessness), or the atheroma can build up rapidly, becoming brittle and vulnerable to bits of the fatty substance breaking off. ‘In this instance, a clot may form around the dislodged area of cholesterol, blocking the artery,’ she explains.

When the coronary artery can’t do its job, the specific area of the heart muscle that artery supplies blood to dies and can no longer pump oxygenated blood around the body. That’s heart failure.

It’s complex stuff; hearts don’t malfunction nice and neatly, and those three primary causes of heart failure often intersect. For instance, the initial cause of the heart problem may be cholesterol build-up, not the muscle or its rhythm, but there will be a down-the-line effect. The heart will try to heal itself by changing dead or damaged heart muscle cells into scar tissue. But scar tissue can’t contract like heart muscle tissue can and, as a result, can’t help the heart to pump. ‘This can lead to rhythm problems and eventual collapse,’ adds Dr Varnava.

CHAMBERS OF SECRETS

Further complicating the state of play is the growing understanding that heart attacks show up differently for women. A sudden, crushing, clutch-your-chest pain? That’s more common in men; such indicators in women are more likely to include overwhelming fatigue, on-off pressure in the chest and pain in the back, neck or stomach. You probably don’t know this, and therefore wouldn’t link those symptoms to heart problems – worryingly, doctors don’t seem to do so either. In

2016, scientists at the University of Leeds highlighted that women are 50% more likely than men to receive the wrong diagnosis following a heart attack. Two years later, the same team discovered that women were a third less likely than

There’s a specific type of heart attack that disproportionately affects healthy young women

men to receive an artery-unblocking treatment and a quarter less likely to receive statin medication to prevent another heart attack. The absence of clarity around heart health in women plays out in a self-perpetuating cycle: women don’t believe themselves to be at risk and delay calling an ambulance. If a heart attack does strike, then there’s the chance that their immediate risk will be underestimated by medical professionals.

According to a study published in April in the journal Heart, women are more likely than men to experience the types of heart attacks that arrive unannounced by typical risk factors (such as obesity, diabetes and high blood pressure – but more on these later); heart attacks like myocardial infarction with non-obstructive coronary arteries (or Minoca for short). ‘Unlike in classic coronary heart attacks [remember: where arteries fur up with cholesterol and lipids that block blood flow], the arteries that supply the heart are only minimally obstructed, if at all,’ explains Professor Gale. So why does this lead to a heart attack? Simple answer: we don’t know yet. Another is SCAD, which stands for spontaneous coronary artery dissection. ‘It occurs when a coronary artery near the heart develops a tear or bruise, which ends up blocking the blood flow,’ explains Professor Gale. The exact number of women who experience this specific type of heart attack is hard to get at, but experts believe the women affected are disproportionately young, fit and generally healthy.

RISKY BUSINESS

To reiterate: excepting the rogue outliers, there’s so much you can do for your ticker. According to the BHF, being mindful of all the risk factors that might increase your vulnerability to heart problems is a healthy start. If you have a family history of cardiovascular disease, you have an increased risk of developing coronary heart disease or angina, or suffering a heart attack, heart failure or a stroke. ‘If anyone in your family has suffered heart failure under the age of

50, raise that with your GP, no matter your age,’ says Dr Varnava. Your ethnic origin can play into specific heart health concerns, too. ‘People of South Asian descent are more vulnerable to heart disease, while those of African origin are disproportionately affected by high blood pressure and associated problems,’ she adds. Regardless of family history, getting a cholesterol and blood pressure check before you turn 40 is advised.

‘Women who have gone through the menopause – either naturally or because they’ve had their ovaries removed – before the age of 45 face an increased risk,’ explains Dr Varnava. ‘It’s thought to possibly be because these women have spent a longer time living without oestrogen, which is known to be protective.’ That’s not the only period of hormonal upheaval during which cardiologists want women to be mindful of cardiovascular warning signs – pregnancy and birth bring their own complications.

‘The hormonal changes can cause a heart attack, so even if you’re fit and well you need to pay attention to the classic warning symptoms – particularly breathlessness,’ says Dr Varnava. ‘It’s very rare, but the progesterone of pregnancy loosens your body’s tissues to enable you to dilate your cervix in order to deliver a baby; but it also means that arteries can tear more easily than in a non-pregnant state and cause a heart attack that way.’

High blood pressure and diabetes both independently increase your risk of heart attack. The former by driving the build-up of cholesterol in the coronary arteries and placing strain on the heart, the latter by making your body a more fertile ground for a process called glycosylation to take place. ‘That’s when glucose molecules [which are more prevalent in the bloodstreams of diabetics] attach to molecules and structures, such as proteins and cell membranes, within the arterial wall, promoting atherosclerosis – that “furring up”,’ explains Dr Varnava. She adds that being obese exacerbates all these processes and increases

their severity. There are also reports, she explains, of obesity-specific cardiac death, and warns that outcomes of different surgical interventions – transplants, pacemakers, etc – are far poorer for a patient who’s severely obese.

It follows that eating in a way that compounds these problems should be curtailed. We’re referring to processed foods and those high in saturated fat or sugar, which spike blood sugar, further raise blood pressure and contribute to excess body weight. It’s not simply about what you consume, either: oral hygiene matters, according to Dr Melissa Caughey, cardiology researcher at University of North Carolina School of Medicine. She explains that people who have inflammation of the gums (also known as peritonitis) are two to three times more likely to have a heart attack or other serious cardiac event – though, again, scientists are yet to identify a direct connection.

PROTECT AND SERVE

All things considered, it pays to get wise to the myriad ways your lifestyle can impact your heart – and to level up any elements you find wanting. Authors of a worldwide study, published in The Lancet, found poor diet to be a more prolific contributor to cardiac death than smoking. ‘It’s important to remember that there are two components to a heart-healthy diet,’ explains Dr Ali Khavandi, consultant cardiologist and founder of The Cardiologist’s Kitchen, an initiative that aims to help people at risk of cardiovascular disease make food and lifestyle changes (cardiologistskitchen.com). ‘The first is avoiding damaging foods and the second is getting enough of actively protective foods.’ His three rules of thumb: eat more plant-based fibre (such as whole grains and cruciferous vegetables), factor in regular servings of unsaturated fats (which you’ll find in olive oil, nuts and oily fish, such as mackerel) and get plenty of variety – within each meal and across your diet as a whole.

‘A lack of dietary diversity could lead to a wasteland of a microbiome in the gut, which very early research suggests could have a negative effect on long-term heart health,’ adds Dr Khavandi. As for the notorious heart health saboteur, salt? It’s a good rule of thumb to avoid jar sauces and frozen meals packed with it, but he says you needn’t make it a priority to lower your intake unless you have existing issues with high blood pressure. Save your more stringent exercising of moderation for booze. ‘Alcohol’s effect on heart health is like a J-shaped curve,’ explains Dr Khavandi. ‘Drinking a small glass of wine – Mediterraneanstyle with dinner – is probably protective, but go over that minimal amount and all alcohol becomes rapidly damaging. It’s energy-dense and if you drink more than you should, that’s a clear driver for visceral fat storage, type-2 diabetes and high blood pressure,’ he warns.

On to movement; it’s not exactly news that exercise is a cardiovascular health essential. More noteworthy are results of a 2018 Iowa State University study that looked at the impact of resistance training on heart health, independent of aerobic activity (definition: brisk, breath-quickening exercise that promotes circulation of oxygen through the blood) and found that weight training alone is enough to lower your risk of having a heart attack or other cardiovascular event. Big news for spinning refuseniks. Speaking of cardio, a study published earlier this year in JAMA Cardiology offered up baffling results; participants who did over five hours of vigorous cardio each week were less likely to die from a cardiovascular event, and yet they developed an ominous build-up of atheroma (that blockage-causing mix of lipids and cholesterol) in their arteries. Does that mean that, where your heart is concerned, you can have too much of a good thing? Not really. ‘These early signs of heart disease never got to the point where they blocked people’s arteries,’ explains Dr Varnava. ‘So, though there may have been some early signs on the CT scans, the end result is good.’ Her conclusions are solidified by a paper she’s just finished marking, in which

super-endurance athletes – women who do over 12 hours of intense weekly training – didn’t show any early signs of heart disease. ‘Basically, exercise is good for heart health – no matter how much you do.’

While chronic stress (a response to emotional pressure over a prolonged period of time) is generally understood to raise blood pressure and heart rate, putting extra strain on the cardiovascular system, research on stress has been negligible compared with other physiological risk factors, and multiple UK cardiologists contacted by WH were reluctant to draw a line between the two. Most believe that rather than being a cause of heart problems in and of itself, stress plays a supporting role: by raising blood pressure or causing individuals to slack on eating well, sleeping and exercising. But a new wave is challenging this view, pushing for health authorities to list emotional stress as a key modifiable risk factor. Among them, Dr Sandeep Jauhar, US cardiologist and author of Heart: A History (£9.99, Oneworld), in which he argues that, from the first big study of cardiovascular risk factors in the mid-20th century, scientists have overlooked the role of emotional and social disruption because cholesterol levels are easier to measure.

Results from a 2017 US study back him up. Researchers measured activity in the amygdala – the brain’s almond-shaped threat detector system – to determine whether its activity can predict someone’s risk of suffering a cardiovascular event. Turns out that it can. The scientists theorised that the amygdala may sense danger and signal to the bone marrow to produce extra white blood cells (to help fight infection and hasten repair in the event of a physical attack), which causes the arteries to develop the atheroma plaques and become inflamed. While these results alone aren’t enough to influence national or global health policy, the Harvard cardiologist who led the study is now referring his patients for stress-management programmes.

TICK TOCK

At the crux of the matter is the need to bump heart health up your personal health priorities list. According to a recent survey by the American Medical Association, women in their twenties are more concerned about their mental health than that of their heart. Dr Caughey, whose work has highlighted the increasing number of heart attacks among young women in the US (no equivalent data is available in the UK), isn’t surprised – nor does she believe that such an ordering of priorities is limited to women over the pond, or those of the stereotypically emotionally attuned late-millennial demographic. ‘Anxiety and depression cause uncomfortable symptoms that can be felt, sometimes on an everyday basis, while risk factors for heart disease, such as high blood pressure, are usually symptom-free,’ she explains. But just as mentally ‘well’ people know they need to nurture their minds to stave off depression, preventing a heart attack requires a similar cumulative, long-game effort.

We don’t need you to be excited about it, but we do want you to know that it’s an effort worth making. While those in labs and consulting rooms may not have all the answers, they’re united on one thing: a body that’s nourished, well-worked-out and feeling the benefits of stress-relieving activities is a body that’s stronger and more capable – it’s a body that’s statistically less likely to experience a serious cardiac event and one that, should the worst happen, will be more resilient in its recovery. The bottom line? Playing by the heart-healthy rules detailed above doesn’t equate to watertight insurance against things going wrong. However, paying due care and attention to one of the hardest-working bits of your body amounts to one of the smartest investments in your health you’ll probably ever make. You know what to do.

‘Exercise is good for heart health – no matter how much you do’