New views on heart disease
Dr. Ross Feldman is leading various teams as the principal investigator for women’s health at the Institute of Cardiovascular Sciences at the city’s St. Boniface Hospital. (photo from Dr. Ross Feldman)
Many of us are under the impression that heart disease mainly affects men. But researchers have been trying for the last few decades to change this skewed view. One such researcher, Dr. Ross Feldman, recently found his way to Winnipeg. Feldman is leading various teams as the principal investigator for women’s health at the Institute of Cardiovascular Sciences at the city’s St. Boniface Hospital.
According to Feldman, “Most of what we know in terms of risk and benefit and treatment of those factors that contribute to heart disease initially came from studies of younger people with more advanced risk factors – be it cholesterol, high blood pressure, [etc.] – and what the benefit was from the treatment of those problems, in terms of reducing risk of heart attacks or strokes. Women tended not to be included in those studies, because premenopausal heart disease risk is so much lower. So, in the earlier days, we developed guidelines that were mostly based on findings in younger men. It really wasn’t appreciated that women had accelerating risk after menopause.”
This new understanding about the connection between post-menopause and heightened risk of heart disease has only come to light in the past 10 to 15 years. The Heart and Stroke Foundation is only now, within the last year, opting to make the topic a priority.
“I think it’s taken even longer for it to register on the psyche of healthcare professionals … that women are at an increased risk post-menopause,” Feldman told the Independent. “They’re also much less likely to be diagnosed appropriately, less likely to get appropriate treatment, and they are more likely to have complications with trying to fix blood vessel problems. They’re less likely to be sent out following a cardiac event on all the right medications. And then, ultimately, a little more likely to die of heart disease.”
Feldman believes this lag time – for women to get the correct diagnostics and treatments – will not change anytime soon, unfortunately, as the training provided in medical schools is still based on past knowledge about women and heart disease. Medical students are still being taught that women are more likely to present with atypical chest pain, with no further explanation, said Feldman.
“If women are most likely to present that way, why are you calling it atypical chest pain?” he asked. “It gives you an idea of how male-centric our whole approach to heart disease has been. What we get out of it is, you often see a dichotomy, that sometimes you’ll see premenopausal women at risk of being over-treated.
“A woman, premenopause with hypertension, probably doesn’t need blood pressure-lowering therapy unless their blood pressure is greater than 160 over 100. Whereas, a post-menopausal woman with multiple smaller elevations in individual risk factors – a little bit higher blood pressure, a little bit higher cholesterol – will often get overlooked…. Yet, she is at a much greater risk than will be projected, based on consideration of any individual risk factor.
“There needs to be a sex-specific approach to management of the risk factors of heart disease and the presentation for heart disease,” he said. “The guidelines for that approach are still in flux.”
As medical practitioners are lagging behind the latest findings about women and heart disease, Feldman said that premenopausal women don’t need to be as concerned about risk factors that may be a little out of whack, such as LDL cholesterol or blood pressure. However, he said, post-menopausal women need to be advocates for more aggressive treatment for even seemingly marginal elevations in risk factors.
“The problem is that primary care professionals, a lot of them, will tend to underestimate the risks,” said Feldman. “There are reasonable calculators that will tell people, if you add up several small risks for a post-menopausal woman, that translates into an overall risk level that mandates more aggressive therapy. Generally, blood pressure and cholesterol are the most important factors to look at, but it’s the whole aggregate risk based on the calculation that tells you how aggressively you need to treat, regardless of the extent of the elevation.”
While researchers like Feldman are working on sex-specific therapies, women can help themselves by reducing their degree of risk via exercise, maintaining a healthy weight and a healthy diet, keeping hydrated and finding ways to keep stress and anxiety levels down.
“As women age, as with men, excessive salt intake increases blood pressure and often that excessive salt doesn’t primarily come from the salt shaker, but from processed foods,” said Feldman. “When shopping, shop the rim of grocery stores. Stay away from the aisles. Maybe shop in the frozen food sections, but probably not.
“To date, there is no real sex-specific preventative approach. That is, exercise, as far as I know, is as effective in blood pressure reduction and weight reduction for men as it is for women … maybe a little more effective in women, but likely marginal differences. I think it’s important for women to know that weight gain and a more sedentary lifestyle are bigger risks for them than for men. Men tolerate being couch potatoes a little better than women do.
“The slope of the line for weight gain in men is pretty linear,” he said. “In women, there’s an increase in slope of weight gain after menopause. Women’s systems are less tolerant of the kinds of changes that occur with age than men’s.
“We know there are ethnic differences in risk tolerance,” he added. “We know that Asians are less tolerant to weight gain than Caucasians. That is a genetic difference. We hadn’t appreciated that sex differences work the same way, although we should have, as, ultimately, a sex difference is a genetic difference.”
Rebeca Kuropatwa is a Winnipeg freelance writer.