One out of three women will die from a heart attack or related condition. Will you be one of those three? Most women probably don’t spend much time thinking about this, especially when they are younger and their focus is on their family, their jobs, and all that is going on in the world. But as women transition past menopause, heart disease becomes a big issue and the risk of being diagnosed with it rises dramatically. The unfortunate fact is that many women first find out that they have a heart problem when they land in the emergency room or the hospital.
So predicting if you are at risk for heart disease is a good idea, as there may be an opportunity to avoid, or at least delay, the consequences of it.
What is heart disease?
Before going further, let’s define what we mean when we say heart disease. Basically we are talking about coronary artery disease (CAD). This is the condition where a gunky substance called plaque builds up on the lining of the arteries. As these deposits enlarge, blood flow is impaired and eventually the artery completely blocks and this causes a heart attack. When this occurs part of the heart muscle dies and this can cause sudden death, or leave you with a poorly functioning heart.
The process of plaque development is a slow one and many factors contribute to it. We have identified these and if a person has any of them, we say that person has risk factors for heart disease. The more risk factors a person has, the more likely they are to have a heart attack. So, since the purpose of this article is to help you assess your risk, let’s go over these factors.
Traditional risk factors
For years there has been a list of risk factors that are clearly associated with an increased risk of heart disease. These include: smoking, having high cholesterol, having high blood pressure, and having diabetes. There are also a number of genetic factors that people inherit that promote the development of plaque. Many of the standard questionnaires that evaluate one’s risk for a heart attack look primarily at these factors.
There are also other risk factors that many people may not realize. This includes having kidney disease or having an autoimmune condition – such as rheumatoid arthritis, lupus, or psoriasis. Chronic severe stress also increases the probability of having a heart attack. Childhood trauma, PTSD, and other major emotional experiences increase the likelihood of heart disease.
Risk factors unique to women
There are two periods of time in a woman’s life that can have a great impact on her risk of heart disease. Interestingly they both have something to do with reproduction. The first involves events that may occur during pregnancy; the second period occurs later in life when a woman no longer can become pregnant – which is menopause.
The pregnancy-related risks have just recently been receiving attention. It is now clear that women who develop hypertension or diabetes while pregnant have an increased risk of future heart disease. In addition, the risk of heart disease is increased if a woman delivers less than 37 weeks, has a low birth weight baby, or if her pregnancy is complicated by preeclampsia or eclampsia – two serious conditions that cause high blood pressure, seizures and health risks for both mother and baby. Even though these pregnancy-related conditions may resolve after the pregnancy, they remain issues that can affect her risk of heart disease down the line.
It is unclear if these pregnancy-related problems cause some low-grade damage to the arteries, or actually are early warning signs that a woman’s arteries are at increased risk for plaque. Nonetheless it is being realized that doctors should be paying attention to these historical events when evaluating patients, even though they happen years before a heart attack is likely to occur.
At the other end of the spectrum is menopause. Before menopause, women have lower rates of heart disease than men, but after menopause the rate increases significantly. And this is not just an age issue. Studies looking at women who go through menopause at a young age, either from surgery or natural reasons, show an accelerated rate of the onset of heart disease.
Is menopause a risk factor?
This chart, taken from the Harvard Health newsletter, indicates that prior to age 60, women are at considerably lower risk than men for heart disease. However ten to twenty years past menopause, women catch up, and then surpass men!
Despite that this strongly suggests that menopause is a risk factor for heart disease, major medical organizations, like the American Heart Association remain vague about classifying natural menopause, per se, as a risk factor. This reflects a continued reluctance to acknowledge that the loss of estrogen promotes heart disease. Odds are, however, this will be appreciated more in the future, because there has been a trove of research that would explain why the lack of estrogen plays a role.
Let’s review what we know.
- After menopause, the “bad” type of cholesterol, known as LDL cholesterol increases. LDL attaches to the lining of the arteries and is a main component of plaque. Estrogen therapy helps prevent the rise in LDL.
- Low levels of estrogen cause fat to deposit around the abdomen (belly fat) as well as around the heart. Fat in these areas causes problems. The fat cells in the belly affect how our insulin works, thus increasing the risk of diabetes – a major risk factor. Fat around the heart is believed to cause inflammation, which is damaging to the heart cells as well as the arteries on the heart.
- Estrogen has anti-inflammatory and anti-oxidant properties that help keep the lining of the arteries healthy. As the estrogen level falls, the lining of the arteries become increasingly susceptible to being damaged. This initiates the development of plaque and also impairs blood flow to the cells.
- Low levels of estrogen lead to symptoms such as hot flashes, sleep disturbance, and mood changes. These symptoms cause stress, poor sleep, and depression – conditions known to promote heart disease.
All of these effects mediated by the loss of estrogen promote plaque development and plaque buildup. So it seems logical that menopause should be considered a risk factor for heart disease.
Calculating risk
As noted, the more risk factors a woman has, the higher her risk of developing a heart attack. Calculators have been devised to quantify this risk and the calculator used most was created jointly by the American Heart Association and American College of Cardiology. This calculator takes into account one’s age, sex, ethnicity and weight, plus the presence or absence of the traditional risk factors. Once these values are entered into an online form, a number is generated that estimates the risk of having a heart attack in the next ten years.
If it is determined that a person’s 10-year risk of a heart attack is less than 5%, this is considered a low risk. For these individuals doctors encourage patients to do as much as they can to stay at low risk – emphasizing lifestyle measures such as maintaining an ideal weight, exercising, and following a healthy diet. The blood pressure should not exceed 130/80 and the blood sugar should be kept within the normal range.
If a person’s risk is over 10% doctors emphasize all of the above measures and it is strongly recommended that these patients take a high-dose statin drug (a drug that lowers the LDL cholesterol) along with a baby aspirin. Taking these medications has been shown to lessen the risk of a heart attack.
If a patient is determined to be intermediate risk – with a score that falls between 5% and 10% – doctors recommend certain interventions, such as lower dose statins, based on the person’s unique health status and situation.
Using a calculator like the AHA’s has become standard practice, but one issue that is emerging is that they underestimate women’s risk. Part of this is due to the fact some of the risk factors unique to women may not be factored in. The consequences of this is that women may not be accurately diagnosed and thus not receive the optimal preventative treatment. This puts them at increased risk of developing heart disease and may be a factor why women end up having a higher risk of dying from heart disease than men, once they are diagnosed.
What you can do
Doing an assessment of your ten-year risk of having a heart attack seems a prudent thing to do. This helps identify if you have risk factors and will motivate you to be more proactive in decreasing your future risk.
There are obviously some things you can’t control, such as your family history or whether you did have a complication during pregnancy years ago. However, there are measures to take that can lessen your risk. Some of the steps are fairly straightforward. This includes
avoiding cigarettes, maintaining a normal weight, eating a healthy diet, and 
exercising regularly. These measures can combat the risk of diabetes, lower blood pressure, and improve cholesterol. If these conditions do develop or persist despite your efforts, the next step would be to consult your doctor to determine if you should be on medications to get these conditions under control.
What about estrogen?
If you are entering menopause, the question you may have is whether taking estrogen in the form of HRT is advisable. Unfortunately, this is a controversial issue. Up until the last twenty years, doctors did recommend it. This was because from 1950 to 2000 multiple studies assessing the health status of women taking HRT revealed an almost 50% reduction in the risk of having a heart attack. However these were not randomized, controlled, studies, but rather studies that observed the outcomes of thousands of women either taking HRT or not.
It wasn’t until 2003 that a large-scale randomized study (the Women’s Health Initiative or WHI) came out – which is the type of study considered to give the most valid and reliable results. In this study over 25,000 women were placed either on a sugar pill or HRT and followed for about 5 years. Unexpectedly, the WHI concluded that taking HRT actually increased the risk of heart disease. Much has been written about the shortcomings of the WHI (see my article on the WHI) but the main issue is that the average age of the women in the study was 63, which is ten to 15 years beyond the age when women typically would start on HRT. It is now apparent that estrogen does not exert its beneficial effects on the heart if it is not started within ten years of menopause. In fact, it may cause some detrimental effects. So, although the WHI results should only be applied to this older age group of women initiating HRT later in life, its conclusions have been inappropriately extrapolated to women younger than 60.
This has led to the current guidelines, which do not recommend that women take estrogen solely to prevent heart disease. However, if women are having hot flashes and other menopausal symptoms, estrogen therapy is approved and these women undoubtedly will get the added benefit of lowering their cardiovascular risk. In addition, it should also be noted that all of the major menopause societies recommend that women who undergo surgical menopause, or go through premature menopause strongly be advised to take estrogen therapy until at least age 50-52.
The bottom line
We are all at risk for heart disease, but for some individuals the risk will be higher and they may not realize it. This is particularly true for women, whose unique risk factors may fall under the radar when it comes to the standard evaluations. 
It behooves women to educate themselves about this subject and thus be empowered to improve their long-term health. If you want to learn more, I devote considerable time explaining how estrogen has many benefits on heart health in my book, The Estrogen Question: Know Before You Say “No” to HRT.
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