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Signs of heart attack are different in women

April 24, 2017
heart health

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Jane Fendl has spent a lifetime mindful of the deadly impact of heart disease.

She was just 8 years old when her father died at age 43 from his second heart attack. Fendl also lost her paternal grandfather and aunt to cardiac issues.

“I’ve been aware and careful all my life,” says the 59-year-old Neptune resident. “I was home with my dad the day he had his heart attack and it made a big impression on me.”

Which is why the clinical project manager has been been an active walker, swimmer, biker and weightlifter since her early teens, and opted to have her first stress test in her 40s.

But two years ago, Fendl began experiencing acid reflux, treating what she thought was “a bad stomach” with over-the-counter medication. Then, several mornings of severe esophageal spasms finally prompted her to get a checkup.

“My EKG and blood pressure were both normal, and though I’ve had high cholesterol (over 200) all my life, my ‘good cholesterol’ (HDL) level was high enough that my previous doctors felt it had a protective effect and didn’t insist that I go on a statin,” she says.

Sangeeta Garg. MD

Perhaps no one was more shocked than Fendl at the results of the nuclear stress test prescribed by Sangeeta Garg, director of the Gloria Saker Women’s Heart Program at CentraState Medical Center in Freehold.

A nuclear stress test, which involves injecting a radioactive dye to track circulation, is more telltale than an EKG and traditional treadmill tests.

“The images and a subsequent cardiac catheterization showed that I had a lack of blood flow to the bottom portion of my heart and two blockages — one that was 70 percent blocked and one that was 90 percent blocked,” Fendl says. “I couldn’t believe it, because I’d had no symptoms — no pain or shortness of breath. In fact, I’d felt fine and had even been exercising the morning of the catheterization.”

Kristina Burke, an educator from High Bridge, was similarly caught off guard when she experienced a full-blown heart attack in July 2015. She was just 33 years old.

“I was driving home from work and felt nauseous. My arms and jaw were aching, and my heart started palpitating,” she recalls. “I’d had a similar experience the day before, but it had gone away, so I just passed it off.” This time, however, she says an “alarm bell” went off and she decided to stop at the emergency room of the local hospital that she drove past every day on her way home from work.

“No one was more surprised than me to find out that I’d suffered a heart attack, which had cut off blood supply to my heart and left scar tissue,” Burke says. A coronary artery spasm had led to her myocardial infarction and she was hospitalized for the next three days.

“It wasn’t a chest-clutching, dramatic thing. It was more subtle and I’d just thought it was indigestion,” Burke says. Though her father and grandfather had both dealt with heart issues, “there was no evidence that I’d been affected. I was healthy, active, thin and had low cholesterol. I never thought I’d be in that situation.”


According to the Centers for Disease Control, 1 in 3 women die each year from cardiovascular disease, the leading cause of mortality among women in the United States, more than all cancers combined.

However, while statistics show that between 1984 and 2015 more women in the United States died from heart disease than did men (likely the result of an increase in diabetes, obesity, inactivity and stress), a recent study by the American Heart Association revealed that only about 30 percent of women surveyed knew that it was the biggest threat to female mortality.

“People believe that it’s a man’s problem or a condition related to older age, or driven by family history,” says CentraState’s Garg. “Awareness about heart disease among women has definitely increased in the last 15 years, but women still often don’t think it’s their issue.”

Claire Boccia Liang

Heart disease manifests itself through a range of conditions, from electrical malfunctions (arrhythmias such as atrial fibrillation) to valvular conditions (narrow or leaky valves), as well as heart failure caused by a virus.

But nearly half of all heart disease cases fall under the category of coronary artery disease, “a process by which small cholesterol particles collect under the surface of the artery and cause inflammation,” says Claire Boccia Liang, director of the women’s heart program at the Gagnon Cardiovascular Institute at Morristown Medical Center.

“The body calls in white blood cells to fight the inflammation, which causes the area to become more inflamed, and the cholesterol particles and dead white blood cells combine to form a substance known as ‘plaque,’ ” says Boccia Liang. “In the event of a perforation, cholesterol can leak into the bloodstream and form a clot, which closes off the artery and blocks blood flow to the region.”

This precarious condition can remain undetected for some time. “A 10, 20 or 30 percent narrowing of the artery, which could lead to the sudden formation of a clot, may not be picked up by a standard stress test,” she adds. “You could have non-obstructive coronary disease and feel totally normal.”

“The reality is that 50 to 60 percent of women who die from a heart attack had no prior symptoms,” says Garg, noting that women, often more stoic by nature, have a tendency to ignore or pass off their symptoms as something less troubling that will correct itself in time.

This is exacerbated by the fact that the symptoms of a heart attack in women can be more random than in men. While an attack may involve the characteristic chest pain, shortness of breath and tingling in the arm(s) that is often seen in men, it can also manifest itself in far more subtle and vague ways, which makes an attack more difficult to diagnose.

However, modern technology offers a number of ways to detect a problem early. Stress tests, nuclear stress tests and low-dose CAT scans (known as coronary calcium scoring) can identify the presence of calcium in areas of coronary inflammation and plaque deposits.


Once identified, medications such as cholesterol-lowering statins can reduce the risk of arteries clogging and rupturing. A regimen of baby and/or chewable aspirin is often prescribed to help stop a clot from solidifying in the event of rupture.

“In addition, for those who can’t take statins because of their side effects, a new class of drugs called PCSK9 inhibitors, which dramatically reduce levels of LDL, or bad cholesterol, is now available,” Boccia Liang says, “and their ability to reduce cardiovascular events is currently being investigated.”

For many women, it comes down to awareness. “At CentraState, our nurse practitioners routinely conduct lectures in the community, promoting women’s health,” Garg says. She also says women are regularly referred to the services of the hospital’s Health Awareness Center, including its smoking cessation program, wellness/fitness center and its diabetic center for counseling on nutrition and exercise.

Fendl and Burke have taken control of their recoveries following their health scares. After Fendl had stents inserted to expand her blocked arteries, she started taking a statin and a platelet inhibitor to prevent her stents from clogging.

“Everything is clear and this is my new baseline,” she says. “Today, I feel great and am very active, but I tell women that they need to be vigilant about heart disease because your symptoms won’t necessarily slam you in the face.”

Burke agrees. “I consider myself lucky that my heart attack wasn’t fatal and now it’s under control.” She remains on beta and calcium channel blockers to keep her arteries relaxed and open.

“I feel good that I understand my condition and have a plan in place to address it,” Burke says. “I advise all women to trust their instincts if they feel something is wrong and to get it checked out.”

Unfortunately, women have reached parity with men for the first time when it comes to cardiovascular disease, says Boccia Liang. But it remains to be seen if the trend will continue. “We often take care of everyone but ourselves,” she says. “But if we turn that attention on ourselves, it’s incredible what we can do.”

Garg encourages women to go on the offensive and take control of the risk factors. At the same time, “we encourage women to live life well and to make good choices.”


Article courtesy of Susan Bloom for Inside Jersey.