Cardiovascular disease, including coronary heart disease, is one of the leading causes of death and disability in the U.S. Myocardial infarction — heart attack — accounts for 780,000 coronary incidents each year. One person every 40 seconds suffers heart attack. The male to female ratio experiencing a heart attack is three men to every two women. The median age is 68 years old.
It is important to recognize the presentation (the appearance of sign or symptom) of coronary artery disease as presentation may be typical, atypical and may differ in special subsets including females and diabetics.
Who is at risk for coronary artery disease? Almost everyone — 60% of adults in the U.S. will have a myocardial infarction, stroke or heart failure in their lifetime. Risk factors include smoking, hypertension, diabetes mellitus, family history and hyperlipidemia.
The ASCVD, atherosclerotic cardiovascular disease risk calculator, assesses the 10-year risk for atherosclerotic cardiovascular disease http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate.
Other risk markers including ankle-brachial index, high-sensitivity C-reactive protein and coronary calcium score are also considered.
Coronary heart disease is present due to inadequate supply of blood to the heart muscle. Presentation of coronary heart disease could be stable angina, usually chest pain with activity. Acute coronary syndromes, heart failure, arrhythmias and sudden cardiac death are also presentations. Initial presentation due to incidental findings/abnormal EKG or echocardiogram, though rare are also important especially in the diabetic population.
Chest pain is the most common angina symptom and may present as heaviness, chest pressure that radiates to the arm, jaw or neck associated with numbness of the fingers, generalized fatigue, nausea and sweating, is rather typical.
Women in general present with coronary heart disease 10 years later than men do. While chest pain is usually precipitated by activity or exertion in men, women may experience chest pain that is precipitated by rest or mental stress rather than physical activity. Women may present with just shortness of breath or generalized fatigue rather than chest pain especially if they are diabetic. Women more frequently present with symptomatic heart failure as compared to men and this is mainly due to left ventricular diastolic dysfunction. Women may also have coronary spasm and typically present with on and off chest pain at rest rather than with activity. Younger females may present with coronary artery dissection especially during the childbearing period or peripartum.
Broken heart syndrome or Takotsubo cardiomyopathy is another entity that is more commonly seen in females. Typically the presentation is similar to a heart attack but with normal epicardial coronary arteries. There is ballooning of the left ventricle on imaging studies. This typically occurs in females ages 58 to 75 years old. They may present with chest pain, shortness of breath typically after stress. EKG mimics a heart attack. The good news is that recovery usually occurs within 1 month with treatment.
The metabolic syndrome is another entity that deserves special attention in both males and females. Metabolic syndrome is present in 25% of the U.S. population. It doubles the risk of cardiovascular disease. It accounts for half of the cases of atherosclerotic cardiovascular disease. It is characterized by three or more of the following: abdominal obesity, waist circumference in males more than or equal 40 inches, waist circumference in females more than or equal 35 inches; triglycerides more than or equal 150 mg/dL or on treatment; HDL less than 40 mg/dL in males and less than 50 mg/dL in females; blood pressure more than or equal 135/85 mmHg or on treatment; fasting glucose more than or equal 100 mg/dL or on treatment.
Hyperlipidemia deserves a special attention because it may be secondary to underlying causes like thyroid problems, liver disease, kidney disease, diabetes mellitus, or due to medications. Adequate treatment depends on treating the underlying cause.
Atherosclerosis is a rather systemic process affecting the whole body but in different degrees. Therefore, screening for atherosclerosis may include peripheral vascular disease screening ankle-brachial index, carotid artery disease, and evaluation for renal artery stenosis/atherosclerotic disease especially in patients with resistant hypertension.
Early screening and preventive measures are the keys for ensuring good health. Avoid smoking; ensure adequate blood pressure control and blood sugar control. Ensure adequate cholesterol control. Stay active and eat healthy. Early screening by stress testing preferably with imaging studies to improve accuracy in females, coronary calcium score are important measures.
Taking 81 mg of aspirin a day is controversial, but agreement is on its benefit for secondary prevention rather than primary prevention.
About the author
Dr. Mona Youssef is board certified in Internal Medicine, Cardiovascular Diseases, Interventional Cardiology and Nuclear Cardiology. She is on staff at Banner Payson Medical Center and Banner Heart Hospital.