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Journalism of Courage
When a 32-year-old marketing executive walked into the emergency room of Fortis Hospital, Mohali, complaining of severe fatigue, mild chest discomfort and shortness of breath, she thought her blood pressure was fluctuating once again. As the staff decided to do a routine electrocardiogram (ECG), Dr Arun Kochar, additional director, cardiology, immediately ordered a troponin test, which indicates damage to the heart muscle. It showed she had already suffered a heart attack.
“Her symptoms were atypical as she did not have chest pain but her test results suggested acute myocardial infarction. An angiography revealed that she had severe blockage in major heart arteries. We had to do an emergency bypass surgery. Two years later, she is on a regular follow-up and her heart is functioning absolutely normally. Heart disease can affect any woman, regardless of age, even with the cardio-protective properties of estrogen in their reproductive years. A cocktail of smoking, alcohol, stress and birth control pills is the new trigger,” says Dr Kochar.
Women’s heart health is now a matter of concern across India as the age of patients keeps getting younger. Nobody knows it better than Dr Neelam Dahiya, assistant professor, department of cardiology, PGIMER, Chandigarh, which was among the first government hospitals to open a preventive heart clinic. “We did a study which shows that 44 per cent of women who suffered cardiovascular disease were obese with only one per cent of them having adequate fruits and vegetables in their daily diet. Higher body fat and lesser physical activity are red flags. High sugar, salty foods and an unhealthy diet can tip you over the edge,” she says.
Data from the last three years at PGIMER shows that 13-15 per cent of women who suffered from cardiovascular diseases (CVD) were under 50 years of age. Not only that, the study found risk factors of heart disease were much more common in women, who were likely to have worse outcomes than men in terms of mortality, by as much as 50 per cent. “Often women mistake their chores to be an indicator of physical activity. What they do not understand is that while they may tire you out, they are low-impact and do not burn calories,” Dr Dahiya adds.
Prof (Dr) Rajesh Vijayvergiya of the Advanced Cardiac Center, PGIMER, Chandigarh, says that heart attack is the leading cause of death in women, though it has a lower age-specific risk compared to men. “Risk factors like diabetes and abnormal cholesterol are more strongly associated with heart disease in women in comparison to men. Diabetic men have a two to three-fold increased risk of heart disease, while diabetic women have a three to seven-fold increased risk. Diabetes eliminates a gender advantage for women at any age,” he says. Which means women’s markers on hypertension, cholesterol and diabetes should preferably be on the lower side of the healthy range.
Dr Vijayvergiya and his team treat about five young premenopausal women with heart disease every month. In fact, PGIMER’s pilot-scale study in north India, which was published in Molecular and Cellular Biochemistry, found risk factors such as hypertension in 75 per cent patients, diabetes in 36 per cent and metabolic syndrome (a cluster of conditions that precede a heart attack) in 75 per cent respectively. “The metabolic syndrome is very easy to track with numbers. Your waist circumference should not be more than 85 cm, triglycerides should not be more than 150 mg/dL, HDL or good cholesterol should not dip below 50 mg/dL, blood pressure should not be more than 130/85 mmHg and fasting blood sugar should no way go higher than 110 mg/dL,” says Dr Vijayvergiya.
Smoking and birth control pills can increase the risk of heart attack in women because they both affect the blood in different ways. The first restricts blood vessels and leads to rapid clot formation. Nicotine in cigarettes also increases blood pressure and heart rate. Birth control pills can thicken the blood and increase blood pressure. “Combining the two substances can increase the risk of cardiovascular issues like heart attacks and strokes,” says Dr Kochar. “Smoking has a greater influence on cardiovascular health in women compared to men, in whom it is one of the prime causes of high mortality and morbidity. Smoking erodes the cardio-protective effect of estrogen. The risk increases with the number of cigarettes smoked daily,” he explains.
A lesser talked about risk factor is stress cardiomyopathy, commonly known as the broken heart syndrome, which occurs when a person experiences sudden acute emotional stress that can rapidly weaken the heart muscle. This manifests in middle-aged women faster than other age groups. A woman’s risk of developing the condition increases five times after the age of 55.
“Loss of estrogen may also play a part in the higher risks of heart disease after menopause. But we need to focus on heart health from our 20s,” says Dr Dahiya. The early onset of menopause and fast-dipping estrogen levels, sometimes before the age of 40, is a key reason for the rising incidence of heart attacks. Emerging heart disease risks for women include pregnancy-related complications, autoimmune diseases, mental health factors, breast cancer treatments and sleep disorders, she adds.
Of course, the biggest disadvantage for women is that they have very atypical symptoms — usually severe fatigue, shortness of breath, chest discomfort (not typical angina), light-headedness, nausea and vomiting. They may have neck, back or jaw pain with more nausea and less perspiration. A higher incidence of atypical symptoms results in delays in seeking medical care. “The discomfort in the upper abdomen, pain in the shoulders or jaw, or a sensation that radiates through both arms are often brushed off as indigestion or stress,” says Dr Kochar.
In some cases, high uric acid can be a red flag. Difficulty getting to sleep or waking up unusually may be a sign of a heart attack. Watch out for the unexplained cough.
All these risk factors are modifiable and controllable if we discipline ourselves on diet, exercise, stress and adequate sleep. While everybody should screen their blood markers from their 20s, after 40, everyone should be evaluated for heart disease using ECG, echocardiogram and treadmill test (TMT) as per the advice of a physician. These should be repeated depending upon the underlying risks of every individual. “With checks and balances, we have even managed pregnancy in a few young women who had angioplasty in the past,” says Dr Dahiya.
Dr Vijayvergiya suggests a simple diet formula that can take care of all markers. “Increase vegetables (>200 gm), fruits (>200 gm), cereals, and fibre (> 20 gm/d) in your daily diet. Salt intake should be < 5 gm/d. Avoid foods with a high saturated fat content like red meat, dairy products, coconut and palm oils. Cut out high trans fats like deep-fried fast foods, bakery products, packaged snack foods and margarine. All healthy adults should do 30 to 45 minutes of moderate to vigorous exercise, five days a week. Maintain a blood pressure <140/90 mmHg and a fasting blood sugar <110 mg/dL. Give up smoking,” he advises.
