Margaret thought of herself as fit, despite carrying a few extra pounds. She worked full time and was active in various community projects. When she felt a heaviness in her chest as she walked on the beach, she wondered at first if it was an oncoming cold, or perhaps indigestion from the lunch she just ate. She slowed down her pace and continued walking. Only when this situation repeated itself three times, each sensation of heaviness worse than the previous, did she think to consult me. When she answered yes to further questions about shortness of breath and sweating, we arranged for a prompt cardiology evaluation, even though she was a non-smoker with normal blood pressure. She turned out to have a single coronary artery that was almost completely blocked and after the appropriate surgery, she was restored to her prior fitness.
Now it became time to address her less-than-obvious cardiac risk factors, so that her cardiac event turns out to be a timely rescue that protects her from future events.
This article is for all women who have any reason to be concerned about heart disease, whether it is a history of high blood pressure (or pre-eclampsia), a family history of heart disease, or concerns about possible diabetes.
First, some important definitions:
Angina (or angina pectoris)—chest pain due to inadequate blood flow to the heart muscle. Often felt as a heaviness in the chest extending to OR just felt in the jaw (men tend left, women tend right), shoulder or arm. Often accompanied by nausea or sweating.
Atherosclerosis—narrowing of the arteries caused by fatty deposits and aggravated by the additional deposit of calcium into “plaques”, which can deteriorate and obstruct flow in the artery where they sit.
Cardiac—pertaining to the heart
Cerebrovascular disease—obstruction (partial or complete) of the tiny arteries within the brain, resulting in impaired function by the part of the brain affected.
Congestive Heart Failure—weakening of the pumping action of the heart, resulting in shortness of breath or swelling of the ankles. A result of prolonged high blood pressure or a complication of a heart attack, in the short- or long-term.
Coronary Artery Disease—obstruction (partial or complete) or narrowing of the tiny arteries carrying nutrients and oxygen to the heart muscle.
Heart Attack or Myocardial Infarction—death occurring in a portion of the heart muscle, caused by obstruction in one of the coronary arteries.
Hypercholesterolemia—elevation above “normal” of one or more of the cholesterol values appearing on a standard lipid panel.
Peripheral Vascular Disease—obstruction (partial or complete) of the large ateries, particularly to the legs, resulting in pain and/or alteration of the skin of the area involved.
Now, what do we know about all these terms?
Coronary Heart disease, cardiovascular disease, cerebrovascular disease, coronary artery disease are terms that refer to the various conditions – high blood pressure, angina, heart attacks, congestive heart failure, atherosclerosis – that can lead to premature disease and death associated with the heart and blood vessels. Although one might think such conditions would be gender neutral, there are indeed quite marked differences between men and women. Looking at current statistics reported in the Journal of Family Practice Supplement, February 2014, women overall have about 2/3 the heart disease rates as men, affecting 5.1% of women compared to 7.9% of men. Even after menopause women’s heart disease risk runs about 10 years behind that of men. Not so sweet for women, however, if we read further. Women generally fare more poorly after a cardiac event than men do. Following a heart attack, 19% of men but 26% of women die within the first year, with 36% and 45%, respectively, dying within 5 years. Women also develop congestive heart failure at greater rates after a heart attack, 18% vs 8% for those aged 45-60. And finally, women are more likely to be symptomatic with some form of angina.
The most important “WARNING” is that angina in women can be quite different than angina in men. Any new appearance of angina, any change in a pain pattern, or any pain that could be angina requires a trip to the Emergency Room right now! not the doctor’s office next week.
The causes of coronary heart disease include some well established and some hotly debated risk factors. By universal consensus it is recognized that high blood pressure, abdominal obesity, diabetes mellitus (types 1 and 2), and smoking raise a woman’s risk of developing coronary disease. It is not generally agreed, however, how to evaluate a woman’s lipid panel. Is it LDL? The statin advertisements focus on LDL (low-density lipoprotein, the so-called “bad cholesterol”, and one aspect of the lipid profile that statins can affect.) However, repeated studies have shown that statins can lower LDL, but that in and of itself does not lower cardiac risk. Particularly in women the benefit is suspect, particularly so because, according to the Norwegian HUNT 2 study (52,000 participants over 10 years), “Among women, serum cholesterol had an inverse association with all-cause mortality as well as cardiovascular disease or CVC .”
What is agreed upon is that certain risk factors are particularly worrisome for women:
- Elevated triglycerides (>150 Mg/dL) or Triglyceride/HDL ratio > 2
- Low HDL is more worrisome for women, and the standards are higher: for women HDL should be >50 mg/dL
- Compared to diabetic men, who have a two-fold to three-fold increased risk of coronary heart disease, diabetic women are reported to have a three-fold to seven-fold increased risk.
- Poor sleep is known to be a cardiac risk factor; sleep problems are more hazardous for women’s hearts.
- There are various hormonal risk factors (birth control pills, pregnancy, hormone replacement therapy) in which excessive estrogen increases the blood’s tendency to clot and can become problematic. Estrogen is most problematic in its oral form; well-monitored topical hormone replacement therapy can be safely added to a healthy lifestyle.
- A history of hypertension or pre-eclampsia in pregnancy raises a woman’s risk for later hypertension and warrants regular evaluation and counseling good choices for a healthy lifestyle!
- Family history is relevant only if family members had premature heart disease, i.e., if a man had a heart event under the age of 50 or a woman under the age of 60.
It is not well understood why women do more poorly than men if they do sustain a heart attack. One theory is that the symptoms are often atypical or present in the absence of familiar risk factors, and the heart attack is not recognized by the woman or her physician until it has done more damage than it would have in a man, in whom the first thought might be of a heart attack. Physicians have been well schooled in the atypical presentations of women’s heart pain, and women themselves would be wise to pay particular attention to all the preventive suggestions listed below so that they never experience a serious cardiac event.
The evolution of the plaque of atherosclerosis offers several opportunities for intervention. A plaque forms at an area of irritation in the blood vessel, enhanced by inflammation; lower levels of inflammation, particularly measured by the hs-CRP (highly sensitive C-reactive protein) test, are associated with a lower cardiac risk. Calcification of the plaque occurs in the abundance of calcium and the relative deficiency of vitamin K2, the “traffic cop” that directs calcium toward teeth and bones and away from blood vessels and kidneys. High blood pressure also aggravates the problem.
- Keep a normal weight and use the same strategy to normalize any tendency to high blood pressure. See our Weight Loss Eating Plan.
- Normalize your blood pressure. See Hypertension
- Breathe only clean air, avoid cigarette smoking or other nicotine exposures, including second-hand smoke
A comprehensive program involves many areas in which action steps can be taken, gradually or all at once. You will be your own most valuable health manager. Some of the suggestions below include flexibility: balance gentleness and honesty with yourself!
Start by following the basic nutrition and healthy lifestyle guidelines, with the following modifications:
Savor Helpful Foods
- Protein: Eat to satiety and always accompany with healthy fat to enhance nutrient absorption. Seafood should be wild-caught; look for omega-3-rich varieties such as wild Alaskan salmon and salmon roe (avoid farmed), herring, anchovies, sardines, and cooked or smoked oysters. To enhance nutrient absorption, add butter or cream sauce to fish and sour cream to roe. Red meat is healthy, particularly wild or pasture-raised meats. Eat as many eggs as you like! Try some organ meats; they are incredibly rich in nutrients.
- Dairy can be healthy for you if it’s full fat, unpasteurized if possible, and collected from cows fed on grass and pasture. Avoid milk that comes from grain-fed cows.
- Fats: Essential for nutrient absorption, adequate fat also provides satiety in a carbohydrate-cautious diet. Restricting fat is hazardous as it causes fat-soluble vitamins to be lost and protein content to increase to dangerous levels for the kidneys.
- Vegetables are valuable sources of fiber (for a healthy population of probiotics living in your colon), as well as minerals and phytonutrients. Eat them with butter or cream.
- Fruit: Although over-indulgence in fruit can stymie weight loss, it is well shown, and particularly in women that berries are very healthy fruits. Include at least half a cup of darkly colored berries every day if you can.
- Fermented foods: Naturally fermented foods enhance digestion and immune function as well as providing valuable vitamin K2. Choose from sauerkraut, kimchi, fermented pickles, cultured vegetables, miso, yogurt, and kefir; eat at the beginning of meals two to three times a day.
- Celtic sea salt: This provides valuable trace minerals, and as insulin levels are lowered, you will excrete increasing levels of salt in your urine. Salt to taste.
Avoid Problematic Foods
- Sugar: No sugar, honey, maple syrup, corn syrup, rice syrup, high-fructose corn sweeteners, agave, fruit juices or sodas. Juice and soda are equally powerful in markedly increasing your risk of diabetes. Avoid non-caloric sweeteners with the exception of stevia powder (the green powder only, not the white extract).
- Added Sugars, AKA desserts, sodas, and juice! A 2014 study showed an association between a modest amount of added sugars and nearly doubled risk of heart disease.
- Alcohol: Eliminate alcohol if you are overweight and diabetic. If you have normal weight and blood pressure, you will probably benefit from one, no more than 2, drinks daily. Red wine has the best reputation for heart healthy alcohol.
- Soy: The only acceptable soy products are fermented tempeh, miso, and tamari. Limit tempeh to one serving per week.
- Vegetable oils and GMO oils: Genetically modified oils include canola, corn, soy, and cottonseed. Also avoid sunflower and safflower oils, margarine, and all trans fats.
- Restaurant and processed foods: As metabolic numbers improve, a wise eater may be able to find healthy meals at “slow-food” restaurants. Fast-food options should become a relic of the past.
- Low-fat, nonfat, or pasteurized dairy products: These highly processed foods aggravate a tendency toward diabetes, which greatly increases women’s risk of heart disease.
- Begin Barleans Omega Swirl, 1 Tbsp daily, or Designs for Health OmegAvail, 1 or 2 softgels daily.
- Dr. Ron's Ultra Pure Liver: For those unwilling to eat liver, supplement with liver pills (6 daily).
- Cardiovascular Research Magnesium Taurate: Magnesium levels are often low throughout the population, and adequate magnesium levels are protective in general to the cardiovascular system.
- Vitamin D: Obtain vitamin D from the sun with 20 minutes of full-body (not just hands and ankles) exposure to midday sun (May to September in northern latitudes). With direct UV exposure, the body can generate up to 20,000 units or more of vitamin D daily. Test your blood level of vitamin D3: the ideal range for healthy people is 40-65 ng/ml; those with health challenges may benefit from higher levels. If sun exposure is not giving you adequate vitamin D3 levels, take Pure Encapsulations Vitamin D3. Take as needed to normalize blood levels. For most adults that amount is approximately 4000 i.u., daily, or consult your healthcare professional for individual requirements.
- Vitamin K2 as MK7: If you are taking a vitamin D3 supplement to normalize D blood levels, you will increase your assimilation of calcium. Supplement with a modest amount (100-200 mcg daily) of vitamin K2 as MK7 to help your internal “traffic cop” send the calcium to your bones and teeth, not your arteries.
- CoQ10: A vital anti-oxidant, CoQ10 is most frequently seen and sold as ubiquinone. For your body to use it effectively, it should be in the ubiquinol form, such as Integrative Therapeutics UBQH, taking 1 capsule, once or twice daily. CoQ10 can help lower levels of inflammation, increase your energy, and is an absolute MUST for anyone taking a statin drug, which decreases CoQ10 levels right along with cholesterol.
- Folate and vitamin B6 have both been found to be protective against heart disease in women, primarily when taken in the form of a multi-vitamin. High levels of dietary folate were particularly protective for women who consumed up to 1 alcoholic beverage daily. Extra benefits of these vitamins include reduced risk of breast cancer (folate) and improved sleep (B6). It is important to take folate (and not to take folic acid), and to include food sources of both of these nutrients (organ meats, a wide variety of animal protein and vegetables).
- Avoid all cigarette smoke, first-, second- or even third-hand!
- If you are overweight, normalize your weight with a low-carbohydrate eating plan so that you prioritize lowering your triglyceride levels.
- If you have diabetes, or pre-diabetes, also follow a low-carbohydrate therapeutic plan to return to normal blood sugars.
- If you have high blood pressure, your greatest benefit will derive from the discovery of natural means to lower your blood pressure. If those interventions are unsuccessful, there are many medications that your physician can choose to prescribe to lower your blood pressure. All medications have side effects, but effective medications, even with their side effects, are better for you than unresolved high blood pressure!
- Sleep is vital to a healthy heart. Sleep quality matters both in terms of quantity (7-9 hours best) and quality (deep sleep, from which you wake rested).
- Exercise keeps your heart healthy. Find an “intentional” exercise that you will enjoy doing: walk, dance, tennis, hike, swim, row, what else? Lifting weights and high intensity intervals are both particularly valuable for maintaining strength on all levels, mental, hormonal, and muscular. Additionally, it’s important to spend more time walking and standing and less time sitting. We are learning that this non-intentional exercise may be even more influential on our heart health than what we have been calling exercise.
- Perceived stress definitely influences our blood pressure, as well as many markers of general health. When we are stressed, we generate higher levels of stress hormones which act on their own to prepare us for a long winter, with food cravings, fat storage, and all of that achieved by sacrificing immunity and general health.
- If you are considering birth control pills or estrogen therapy of any sort, be sure you have normal blood pressure and no excessive tendency to blood clotting, which your physician can check.
- Medications. Anti-hypertensives: although I have said it is preferable to lower blood pressure naturally, I do believe there is a good use for anti-hypertensive medications when the natural means are ineffective. Statins are another story: they are associated with an increased risk for diabetes, breast cancer, and possibly dementia. The only women for whom some definite benefit has been shown are probably those women who have recently had a “stent” procedure to bypass an obstructed coronary vessel or are recovering from a heart attack. They do nothing for high triglycerides, which are the greater risk for women. Be sure to consult a physician who understands the pros and cons of statins before you agree to take one.
Laboratory Tests and Interventions
- Hypercholesterolemia: elevated total cholesterol is not a risk factor for women in the absence of other risk factors. The most significant laboratory tests for women are triglycerides (you want them under 100 mg/dL) and HDL (which you want to see over 50 mg/dL).
- Elevated fasting sugar or Hemoglobin A1C indicates a tendency to diabetes, which markedly raises a woman’s risk for diabetes.
- Hs-CRP: elevated levels of inflammation raise the risk of heart disease in men and women. Avoidance of processed foods, vegetable oils, consumption of nutrient dense foods and supplementation with CoQ10 and possibly vitamin E can be helpful in lowering hs-CRP.
- Homocysteine: elevated homocysteine is associated with increased risk of heart disease as well as dementia. Inadequate levels of vitamin B12 and/or folate should be checked for. If those levels are adequate, you might have the MTHFR (Methyl-tetra-hydro-folate-reductase) gene abnormality. Some of those abnormalities indicate that you absorb but cannot “activate” (i.e., methylate) your own B vitamins and need to take them in a pre-methylated form. Worthy of an entire article in itself!
- Ferritin: women don’t usually have this problem but abnormally high levels of Ferritin (over 100 ng/mL) have been implicated as agents of inflammation and part of the reason men have higher heart disease rates than women. Menopausal women who tend to accumulate high Ferritin levels can donate blood (the Red Cross will thank you) to bring their levels back to normal.
Margaret, from the introduction to this article, required a bit more collaboration after the surgeon nicely restored circulation to her heart muscle. Her blood pressure was not the usually low-normal blood pressure it had been. She had a reading of 160/100 at her dentist, and purchased a cuff of her own to monitor it more closely; it was staying above normal.
She came in for an exam and lab tests, and although she appeared completely recovered and healthy, it seemed she was under some additional job-related stress that was affecting her sleep and she showed evidence of diminished thyroid function. She has a family history of heart disease, as her high-powered father took up yoga and stopped smoking when he had a minor heart attack at the age of 50.
Despite starting some thyroid support (iodine, selenium, organ meats, and tyrosine), her thyroid numbers continued to show underactive thyroid function, so we started her with a prescription for Armour (dessicated) thyroid. Normalizing her thyroid resolved the blood pressure problem.
Our collaboration continues however, for now she is a woman over 60, with a history of heart disease and a family history: 3 risk factors to keep in mind as we chart a course with diet, exercise, and stress reduction to keep all those factors in the “history” part of her chart, and away from the “active problem list”. She continues to do well with only a prescription for thyroid – and a determination to keep living the healthy lifestyle that makes her coronary artery problem a thing of the past.