Archive for April 2nd, 2009


It is true that women who develop heart attacks tend to be older than their male counterparts; and they are at more risk from heart attacks if they have high blood pressure and diabetes. So if you have one or the other, or both, of these conditions (they often go together), you must be particularly careful to keep it under good control.

For high blood pressure, that means

• Taking the correct antihypertensive drugs

• Having monthly blood pressure checks For diabetes, it means

• Strict control of weight—the BMI (Body Mass Index) should be strictly between 20 and 25, and preferably closer to the lower figure

• Frequent small meals containing large amounts of fiber

• Multiple injections of small amounts of insulin each day

• A daily diary of your blood glucose (booklets for keeping records of blood glucose, insulin doses, and food intake are available from your doctor)

• A monthly visit to your diabetic clinic

Hypertension among women has not been studied nearly as much as it has been among men. Some researchers question whether the findings about men apply directly to women. Several hypertension medications affect blood lipid levels and these effects may be different and perhaps counterproductive for women, possibly affecting their sex life. Potential changes in sexual response for women on certain blood pressure medications have been ignored by researchers and unquestioned by family doctors. These holes in research are rapidly being filled by current studies, so keep your eyes open for new information as it is released.

The female hormone estrogen appears to protect women against heart attacks—a protection that falls away after menopause. So why not try hormone replacement therapy (HRT) after your menopause to keep your heart attack risk low? In a large study of American nurses, HRT halved the risk of coronary disease in postmenopausal women. Worries that HRT might cause breast cancer appear to be unfounded, but there is very definite evidence that it greatly reduces the risk of ovarian cancer—and also, surprisingly, of rheumatoid arthritis. Nevertheless, women who have many close relatives with breast cancer should probably avoid HRT; there may be a very small risk that it can accelerate the development of an already existing growth.

The good news for women about heart disease is that the very strong risk in men with high cholesterol levels probably does not apply to women. Younger women naturally have higher blood cholesterol levels than men of the same age, but most of it is of the beneficial HDL type. Only if there is obvious hyperlipidemia, or a history of early deaths from heart attacks in women in the immediate family, should a high cholesterol level in a woman be taken as something to worry about, and needing a special diet or drugs.




The aim of a modern cardiology unit is to find the cause of your symptoms. Most of the time, in angina, this will be atheroma, affecting one, two, or all three of your coronary arteries. The tests to be performed in the clinic should identify the problem in sharp detail, so that any corrective treatment is planned for your own individual needs.

You will be asked to undergo exercise testing, special EKG tests, and X-ray investigations, including perhaps a radioisotope heart scan, an echocardiography, and finally a coronary angiogram.

The thought of all those tests, especially after you have been told you may have an at-risk heart, is daunting and frightening. Please do not let it worry you. In modern cardiology units, everything is done to make sure you are relaxed and calm. The staff are highly specialized, having concentrated on heart investigations for years, and know very well what entering such a unit means for their patients.

I have visited many such units, all of them staffed by cheerful, kind, and dedicated nurses and doctors, who can make even the most apprehensive patient feel relaxed. The atmosphere is never somber—there is no “gloom and doom.” The feeling is more of a professionalism dedicated to helping people back to a normal life, with much to look forward to. They have every reason to be cheerful, because they succeed in their aims with the vast majority of their patients, and since the development of coronary care units, the death rate from ischemic heart disease has dropped dramatically.

The first investigations aim to find the underlying cause of the symptoms. They will rule out such problems as heart valve disease (one clue being a heart murmur heard through the stethoscope), high blood pressure, an overactive thyroid, or anemia. If patients are found to have one of these problems, they will be given treatment and their angina should recede. Sometimes the heart clinic finds evidence of esophageal spasm (a form of cramp), and will refer you to a gastrointestinal specialist for treatment.

Most of the rest of the patients seen with angina in the cardiology unit have atheroma affecting the coronary arteries. The next aim is to find out how serious they are, and to estimate the risks of a fullblown heart attack in the near future. That means getting as many details as possible of how the heart is performing at the time of an angina attack. The two ways of doing this, initially, are to use a stress test or a Holter monitor.




Don’t overdo the exercise. If you have started off at the normal weight for your height, and you find you are losing a pound or two, you are either doing too much or not eating enough to replace the lost energy. Don’t replace the heart attack risk with the problems of fad dieting. James Fixx wrote that the best runners looked too thin.

They may, but your objective is not to be one of the best runners. Your aim is to enjoy your exercise while getting your heart as fit as possible. Being a beanpole has disadvantages, and is not necessarily as good for you as being in the normal BMI range—that is, an average build. Of course, if you start by being overweight, losing the extra pounds through exercise is a bonus, provided that when you reach your ideal weight, you stay at it.

Another “don’t” is to get too obsessive about your weight. I don’t recommend regular weighing, as it tends to focus on that one aspect of health, to the exclusion of others. It can cause disappointment, sometimes even despair, if the pounds do not roll off quickly and steadily. That is a mistake, because the exercise will alter your body shape, making you leaner and trimmer, without necessarily causing your weight to change much. Your fat is being replaced by more muscle tissue, and that is more important than losing weight in itself.

So instead of focusing on your weight, follow your progress by looking in a long mirror once in a while. You will know better from your shape and your muscle tone that you are improving, and that will boost your confidence rather than undermine it.




Lowering a particular population’s cholesterol level by advice on health alone can be done, if it is approached with enthusiasm. In a study of London civil servants aged forty to forty-nine years, half were given simple dietary recommendations aimed at lowering blood cholesterol. Over only four months, the average blood cholesterol level fell by 10 percent, but, more importantly, the percentage of men with a blood cholesterol over 240mg/dl changed from 53 percent to 25 percent. After eighteen months, only 23 percent of them had blood cholesterol figures above 240mg/dl.

This must have greatly reduced their potential for a premature heart attack. When the cholesterol levels were divided up into five equal blocks from the lowest to the highest, it turned out that only 7 percent of the heart attacks occurred in people in the lower two-fifths. Thirty-one percent of the heart attacks occurred in the top one-fifth for cholesterol level. This is a strong argument for lowering a high cholesterol level into the normal range by changing your lifestyle.




The first clues to the causes of heart disease came from Norway. Before the Second World War, Norwegians enjoyed a very high standard of living—and a very high rate of angina and deaths from heart attacks. Then came the Nazi occupation.

From 1940 onwards, Norwegians no longer had tobacco. Many were forced into jobs that were physically hard. Their milk, cheese, and beef were exported to Germany, and they had to rely much more on fish as a staple food. As a nation, they lost weight and their blood pressures fell. At the same time, Norwegians were under great stress. For four years, they lived constantly with such fear and anxiety as we can hardly imagine today.

What happened to the heart attack rate under such conditions? It fell .. . steeply! There was also an even steeper drop in the numbers of hospital patients who had thromboses (blood clots) after surgery.

By 1947, only two years after the war ended, with the return of abundant food and cigarettes, and despite the immense relief from stress, the heart attack rates were rising again to the pre-war levels.

However, that Norwegian natural experiment, which was probably mirrored in countries such as the Netherlands, also occupied by the Nazis, has lessons for people today.

The first is that, even when the answers are obvious, it is almost impossible for people to accept them if it means having to adopt a completely new approach to life. It took until the 1980s for the medical profession to accept the implications of the Norwegian experience, and only then after many other studies had confirmed them. For nonmedical people, the message has still not penetrated, or it is not heeded, until they are suddenly faced with the possibility of their own mortality!

The second, and more encouraging, lesson from Norway is that it takes only a short time, less then a year, for a change in lifestyle to improve your chances of avoiding a heart attack and early death from heart disease. It does not seem possible that the lifestyle change could have reversed years of atheroma, but it may have made other differences to the supply-demand equation in the workings of the heart—such as making it much less easy for clots to form within the affected arteries.