June 2012 Issue

Young Women and Heart Attacks — Here’s What RDs Must Know to Reduce Risk in Female Clients
By Lenora Dannelke
Today’s Dietitian
Vol. 14 No. 6 P. 16

Jeanette, 38, attributed her acute onset of indigestion and nausea to the pizza and ice cream she ate for lunch. By the end of her workday, she felt fatigued and out of breath as she walked from her office building to her car. By the evening, her symptoms worsened, so her husband drove her to the emergency department where doctors confirmed she was having a heart attack. Jeanette was stunned.

“The last thing my husband and I thought was that I was having a heart attack,” she recalls. “I thought it was food poisoning.”

Unfortunately, Jeanette’s experience isn’t atypical among young women today. It’s been documented that heart attacks can occur in men and women of all ages, but younger women are facing greater danger because they often lack the classic symptom: chest pain.

Startling Research
A major study published in The Journal of the American Medical Association, which recently received much media attention, found that women under the age of 55 are less likely to experience hallmark chest pain during a heart attack and, as a result, are more likely than men to die due to lack of immediate medical attention. “Women who have atypical presentations are at the greatest risk of dying after a heart attack,” says lead researcher John Canto, MD, MSPH, of the Watson Clinic and Lakeland Regional Medical Center in Florida. “Chest pain, or even pressure, is by far the most common symptom in young or old heart attack patients. However, in younger women, that pain or discomfort may manifest in other areas, such as the jaw, neck, back, shoulder, arms, and the stomach, or they may have an unexplained shortness of breath. Other women complain of indigestion or say they just don’t feel well.”

What’s surprising is that less than 20% of all patients who report chest pain are, in fact, having a heart attack, Canto explains. “The art is figuring out who’s having a heart attack and who’s not. That’s the challenge.”

What’s unique about Canto’s study, which included more than 1 million patients, is that it accounts for age differences as well as gender differences. “It’s true that women may have a different symptom presentation—and that’s most pronounced in the younger age group—but those differences decline with each increasing age group. In the oldest age group, those gender differences go away,” he says. “The question is why do we see these differences? It’s largely unknown, though I suspect it has to do with the biology of the disease in younger women.”

Perils of Delayed Treatment
Because the difference in symptom presentation often causes delays in seeking treatment, it makes it more difficult for physicians to recognize a heart attack when a younger woman arrives at the hospital. In Jeanette’s case, the emergency department physician was aware of the different heart attack symptoms in women and men and ordered the right tests to make a timely and accurate diagnosis, but that’s not always the case. “Since young women shouldn’t be having heart attacks, and if they present with atypical symptoms, they may be less aggressively treated with medications or invasive cardiac procedures that are known to improve survival,” says Canto, who further notes that “it’s an uncommon scenario for patients to have a heart attack without key cardiovascular risk factors. The big five are family history, smoking, diabetes, hypertension, and high cholesterol.”

Minutes count in the treatment of heart attacks. “In our cardiology world, we say time is muscle,” explains Amy Ahnert, MD, of Lehigh Valley Health Network in Allentown, Pennsylvania, who notes the American Heart Association has mounted a campaign that stresses the importance of women calling 911 when there’s any suspicion of a heart attack. “The time between the development of symptoms of a heart attack and when we actually intervene and open up a blocked artery makes a huge difference in the eventual outcome and recovery. So we’re trying to spread the word about not delaying getting medical treatment.”

Adopting a Heart-Healthy Lifestyle
While women may not be able to change risk factors such as family history, there are other aspects of heart disease within their control. “The three most important things a patient can do are No. 1, lifestyle; No. 2, lifestyle; and No. 3, lifestyle,” Canto says. “So that means proper nutrition, exercise, and weight management.”

Ahnert also stresses the importance of taking preventive measures. “Probably 80% to 85% of heart events and attacks could be prevented if we were on top of risk factors,” she says. “I think the growing ‘size’ of our population, if you will, plays a role. Two-thirds of women are obese or overweight. With the obesity epidemic comes other risk factors because obesity has a direct relationship to diabetes, high blood pressure, and metabolic syndrome—a prediabetes state.”

Counseling women who have risk factors about proper heart-healthy nutrition also may benefit other family members. “The American diet at large leaves a lot to be desired: the fast foods, the fried foods, the portions. It’s really out of control, and we’re just seeing the tip of the iceberg now with statistics about the rising numbers for heart disease in young women,” Ahnert says. “There’s also a huge obesity epidemic in children. My biggest fear is what’s going to happen in 10 years when these obese adolescents come into adulthood. If you can get proper dietary and nutritional education to mothers, then they will hopefully translate that to good nutrition and healthful diets for their children. It’s never too early to think about nutrition in prevention of heart disease.”

For those patients with existing heart disease, Ahnert says dietitians can play a key role in secondary prevention. “What I often refer patients to is the DASH diet, which was developed primarily for blood pressure but has been looked at as a heart-healthy diet. In the Women’s Health Guidelines that were updated in 2011, in terms of heart disease, we’re to recommend a DASH-like diet,” she says.

Other resources recommended by Ximena Jimenez, MS, RD, LD, a consultant dietitian and national spokesperson for the Academy of Nutrition and Dietetics, include the books American Heart Association Healthy Family Meals: 150 Recipes Everyone Will Love; Delicious Food for a Healthy Heart; and Cooking Light Eat Smart Guide: Healthy Heart.

For additional ideas on heart-healthy food preparation, Jimenez suggests watching cooking shows on television or taking a cooking class at a community college. “Try different cooking methods, such as roasting or broiling,” she says. “If there’s a favorite dish in a restaurant you enjoy—for instance, green beans with pine nuts—try it at home.”

— Lenora Dannelke is an independent journalist and author based in Allentown, Pennsylvania, who writes about food, health, and travel topics.


Stocking a Kitchen That’s Heart Healthy
Clients who keep some essential foods in their kitchen pantry will find it easier to reach for healthier choices. Ximena Jimenez, MS, RD, LD, a consultant dietitian and national spokesperson for the Academy of Nutrition and Dietetics, offers these simple modifications women can make to improve their eating habits and heart health.

Wholesome Everyday Foods
Whole grains (eg, oatmeal, barley, corn): These foods are like having a custom-made medicine chest for a healthy heart. They’re good sources of vitamins, antioxidants, and fiber that keep the heart and blood vessels healthy and strong. These foods make a good breakfast or lunch and are also economical.

Walnuts: Tasty and versatile, suggest clients use walnuts in salads, baked goods, and stews. Because of their alpha-linolenic acid content—the omega-3s obtained from plants—they’re considered superstars of heart health.

Extra-virgin olive oil: This flavorful oil is mostly comprised of healthful fat that lowers LDL cholesterol, so it’s cardioprotective. Recommend clients drizzle it over salads stews, soups, and steamed vegetables.

Fruits (eg, figs, pomegranates, oranges, kiwi): They contain ample amounts of fiber, vitamins, and antioxidant flavonoids. Tell clients that those who eat large quantities of flavonoid-rich fruits are less likely to suffer a heart attack.

Foods to Eat Twice Per Week
Legumes (eg, garbanzo beans, lentils, red kidney beans): Inform clients these foods aren’t only budget friendly, they’re a great source of fiber and are nutrient packed with vitamin B6 and magnesium, all of which are cardioprotective. Suggest clients try adding kidney beans and lentils to soups and salads.

Oily fish (eg, salmon, tuna, mackerel, sardines): Recommend clients eat these varieties a few times per week. They’re rich in omega-3s, which provide several cardiovascular benefits.

— LD