Published in Panorama
When women need to heed their heart
World Heart Federation statistics reveal that 37/100 women and 35/100 men above the age of 50, die of heart disease, annually. The incidence of CHD in women is 8 times more than breast cancer and it is topping the list as a prime cause of death in them, particularly in the menopause period, reveals Dr.N.P.Sivadas, Specialist Cardiologist, Dr.Moopen’s Poly Clinic, Deira. “And most of these deaths are preventable since they are caused due to lack of awareness, even among the educated lot of women!” The medical fraternity which hitherto believed that coronary heart disease (CHD) is the bastion of males, is faced with ample evidence to prove this is not so. The World Heart Foundation has started intensive campaigns in 90 countries to make people aware of this fact, so that they may take timely preventive steps.
Contrary to popular belief, CHD can be present much prior to menopause in women who indulge in smoking, alcoholism, those who are on oral contraceptives and the hereditarily predisposed who are genetically prone to diabetes and hypertension. This is so because their hormonal protection is blunted, reveals Dr.Siva Das.
Menopause, explains Dr.Saleena Moiddin Kutty, Gynaecologist and Obstetrician, Dr.Moopen’s Poly Clinic Deira, “is a natural part of aging and occurs when the ovaries stop making the estrogen hormones. The average age when a woman attains menopause is around 51 years, though it is not uncommon to see young girls of 17 years or thereabout having menopause as a result of disease like leukemia where she is undergoing chemotherapy. Also, some women may attain menopause before 35 years of age, when for some unknown reason, their ovaries stop functioning, or are surgically removed.”
While the symptoms of menopause last for a relatively short time, the low estrogen levels can have far reaching consequences for the women from the long term point of view, admits Dr.Saleena. “These chronic symptoms associated with menopause are more dangerous and can affect the life of the women. These problems include osteoporosis, increased risk for heart disease, increased risk of embolism and stroke, deep vein thrombosis, enhanced risk of certain types of cancer, particularly breast & uterine cancers and Alzheimer’s Disease”.
Estrogen stimulates skeletal growth and helps maintain healthy bones. Similarly, it also has protective effect on the heart and veins in that it increases the 'good cholesterol' or high-density lipoprotein (HDL) and lowers 'bad cholesterol' which is the low-density lipoprotein (LDL).
What is CHD and how does it affect menopausal women? Dr.Das explains, “CHD is a disease spectrum. In the early stages, they start becoming symptomatic, that is, they start getting chest pain while walking. This particular entity is known as angina. This implies that the blood vessel which carries blood to the muscles of the heart, is partially blocked. When it becomes 100% blocked, it is the heart attack stage. This is the second presentation of CHD. The 3rd presentation of CHD is when the person drops dead, without giving any chance for the doctors to treat the patient. This is because of a massive heart attack and abnormal beating of the heart, leading to a sudden arrest of the heart. A fourth manner in which CHD may present itself is when patients have small episodes of ischemic attacks which go unnoticed and is often attributed to gas. But actually these may be small attacks in the heart. The heart muscles become weak and dilated and present as heart failure when the heart fails in its proper pumping action.”
At what point of time can the heart problems begin in women of menopausal age? Dr.Das is forthright: “It may begin any time after menopause. The women may be actually having heart disease initiated much prior to this. But they become symptomatic when the hormonal protection is withdrawn. Sometimes, some women, even prior to menopause, start manifesting symptoms much earlier, especially the ones in the high risk categories as mentioned earlier.”
What about women who do not have any of these risk factors, as smoking, drinking, familial tendency, et al? “We see several variations,” explains Dr.Das. “Some women show up symptoms immediately after menopause, some exhibit symptoms as old as 60, 70 and even after 70 years. But what we notice is that, if CHD develops later, the damage to the heart is much more and the reversibility after the episode and after the treatment, sometimes even after angioplasty and bypass surgery, is less, compared to the males.”
Why is this so? Dr.Das clarifies, “The male heart as such, is a little more conditioned to stress than the female heart. So when an insult occurs, the implications and ramifications are much more in women than in men.”
Is CHD towards the onset of menopause, preventable? Here comes the importance of prior checkups, to menopause, emphasizes Dr.Das. “Age-related checkup should be done after the age of 40, every year. This includes basic blood tests as sugar test and lipid profile test – these are the minimum tests that must be undertaken. If the woman has diabetes or hypertension, then even the kidney function test should be done. Also, in these cases, the blood test may even have to be done monthly, after the age of 40. As a minimum, once a year, an ECG should be taken. If the ECG shows abnormality, then definitely, without delay, the person should go in for other objective testing like treadmill test. If the treadmill changes are significant, the woman should go in for an angiography.”
Dr.Das emphasizes, “The awareness of testing according to age, without the symptoms of CHD getting manifested, is important. Because by the time symptoms emerge, the disease may have come to a sufficiently advanced level and some damage would have already occurred to the heart muscles. Preventive checkup is the most important aspect of cardiac treatment in menopausal women. At this time suppose we detect a problem in the heart muscles, we can reverse it 100% and bring it to normalcy, provided it is diagnosed on time. Once the myocardium is damaged, that portion, whatever be the extent of damage, it is irreversible.”
Is it possible that an ECG misses to pick a problem? Yes, this can happen sometimes, agrees Dr.Das. “But this can be counterchecked with a blood test called Cardiac Injury Enzyme Test. We have about three to four enzymes Enzymes released by injury to the muscle of the heart. If we suspect a cardiac problem which the ECG does not pick up, we have this test done and it will yield a positive result while ECG still shows normal heart condition.”
At what point of time would an Echo cardiogram be indicated? Dr.Das explains, “Suppose we feel that the pumping action of the heart is not sufficient, then we post the patient for Echo. Secondly, diabetic and patients who have hypertension, there is another entity which may predispose them to heart problems and attack. This is known as thickening of the left ventricular muscles, termed left ventricular hypertrophy. This has been identified today as a separate risk factor for CHD. The sugar levels in diabetics are high and this stimulates hypertrophy of the left ventricles. This is picked up by the Echo cardiogram. Thirdly, if there are any leaking valves, they can induce other complications later in life, like infective endocarditis. A fourth indication for Echo cardiogram is when the patient’s left ventricular function is sub-optimal, she may not even be fit to undergo an operation. We can stratify the operative outcome of the patient on the basis of a simple Echocardiogram. Those who are having very good left ventricular output before surgery, their post-surgical healing will be very quick and morbidity, much less.”
Once examination is done and the woman shows up cardiac symptoms, what is the next course of action? “She is first put on medication,” explains Dr.Das. “The most important parameters, the heart rate and blood pressure should be kept to the minimum, as close as possible to the normal. We do this by giving beta-blockers. We also use vaso-dilators and veno-dilators so that the demand on the heart becomes less. If the person has hypertension, we also give drugs to combat this. Similarly medication is given for control of diabetes and high cholesterol.”
Dr.Das adds, “It has been very conclusively proved that even a normal cholesterol level can give rise to heart attack. So in patients who show up CHD, we keep the cholesterol level to less than 80% of normal, both total cholesterol and the bad cholesterol or LDL. Similarly, Triglycerides have been found to show an increased incidence of heart attacks, though not to the proportion of LDL. Yet, high triglyceride levels can trigger cardiac problems by increasing the level of VLDL (very low density lipoproteins) which in turn increases the risk of CHD.”
HDL, reveals Dr.Das, is conducive to the wellbeing of the heart. “It mobilizes the LDL from the body tissues and excretes it through the liver. Therefore it is important to increase the HDL level in the body, through exercise and certain medications.”
Dr.Das enlists certain other preventive measures also, which is equally applicable to both sexes, particularly those with risk factors for CHD.
1. Cut down on the fat content of the food, especially dairy products.
2. For cooking, it is preferable to use monounsaturated oils, like olive oil.
3. Lifestyle modifications and regular exercises must be undertaken..
4. Eat plenty of fresh fruits and vegetables, particularly green vegetables.
5. Avoid red meat, mutton, beef, yellow of the egg and pork.
6. Fish and chicken may be taken; in fact, fish is effective in bringing down LDL levels.
7. Avoid shelled sea foods, lobsters, mollusks, crabs and prawns since they contain good amounts of LDL.
8. Avoid addictions like smoking and alcohol.
9. Maintain optimum weight.