The Myths

the Truth&

H E A R T D I S E A S E I N W O M E N

The Myths

the Truth& H E A R T D I S E A S E I N W O M E N

The Women’s Heart Program at Yale-New Haven Hospital is committed to the health

and welfare of women. That’s why we are pleased to present you with Heart Disease

in Women: The Myths & the Truth, a compilation of questions and answers covering

symptoms, risk factors and treatment options for women with heart disease.

The Women’s Heart Program at Yale-New Haven Hospital was launched in March 2001.

Since its inception, the mission of the program has been to promote the cardiovascular

health of women and continue to improve the overall outcomes for women with heart

disease by:

• Improving knowledge of women concerning their risks of cardiovascular disease

• Increasing early recognition of symptoms

• Changing behavior of women toward heart disease through action-oriented primary and secondary prevention

• Decreasing time from the onset of symptoms to receipt of rapid and appropriate care

We hope you enjoy this publication.

Sincerely,

Gail D’Onofrio, MD Lisa Freed, MD Janet Parkosewich, RN, MSN Medical Director Co-Director Co-Director

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TA B L E O F C O N T E N T S

Overview and Symptoms About the Disease 2

Symptoms 2

Identify Your Risk Factors “Know Your Numbers” 4

High Blood Cholesterol 4

High Blood Pressure 5

Obesity 7

Physical Inactivity 7

Diabetes 7

Smoking 8

Additional Risk FactorsFamily History 9

Menopause 9

Tests, Treatments and PreventionDiagnostic Tests, Procedures and Treatments 9

Medications 10

Primary Prevention 12

Secondary Prevention 15

The information contained within this booklet is intended for your general knowledge and is

not a substitute for medical advice or treatment for specific medical conditions. You should

seek prompt medical care for any specific health issues by consulting your physician. For a

Yale-New Haven Hospital physician referral, call toll-free 888.700.6543.

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O V E R V I E W A N D S Y M P T O M S

About the Disease

What is coronary artery disease?

Coronary artery disease (CAD) is the most common

form of heart disease. This condition occurs when

the coronary arteries, which are the blood vessels

that supply oxygen-rich blood to your heart muscle,

gradually become narrowed or blocked by plaque

deposits. Poor blood flow can “starve” the heart

muscle and lead to chest pain, also known as angina.

A heart attack occurs when an area of heart muscle is

completely deprived of blood and the heart muscle

cells die. This usually happens when a blood clot

forms over a ruptured plaque within a coronary artery.

What causes coronary artery disease?

CAD is caused by the buildup of plaque within an

area in one or more of the arteries supplying the heart

with nutrients and oxygen. These arteries are called

coronary arteries. Conditions such as high cholesterol,

high blood pressure, diabetes, and smoking damage

the artery walls and initiate plaque formation. Plaque

is made up of excess cholesterol and other substances

that float in your blood and, over time, become

lodged within the walls of the coronary arteries. This

disease process is called atherosclerosis, or hardening

of the arteries, and it can affect other arteries

supplying the brain and legs.

I thought coronary artery disease is a disease

that affects men. Does CAD affect men and

women equally?

Coronary artery disease is the leading cause of

death in the United States for men and women.

Approximately 500,000 women die each year due

to CAD. Unfortunately, the number of women dying

annually from coronary artery disease remains

constant compared to men, where the death rate is

declining. Younger women under 55 are twice as likely

to die after a heart attack and their risk of dying after

hospitalization is still about 50 percent higher than

men. Within six years of a heart attack 35 percent

of women, compared to 18 percent of men, will

experience another heart attack.

Symptoms

What are the symptoms of a heart attack?

According to the American Heart Association, heart

attack symptoms include:

Chest discomfort. Most heart attacks involve

discomfort in the center of the chest that lasts

more than a few minutes, or that goes away and

comes back. It can feel like uncomfortable pressure,

squeezing, fullness or pain.

Discomfort in other areas of the upper body.

Symptoms can include pain or discomfort in one or

both arms, the back, neck, jaw or stomach.

Shortness of breath. May occur with or without

chest discomfort.

Other signs. These signs may include breaking out

in a cold sweat, nausea or lightheadedness.

I have heard

doctors talk

about atypical

symptoms of

a heart attack.

What are atypical

symptoms?

A heart attack

can be preceded

by typical (usual) or atypical (unusual) symptoms.

Typical symptoms include chest pain felt under the

sternum (breast bone) or to the right or left of the

chest. People describe this pain as an uncomfortable

pressure, fullness, heaviness or squeezing feeling.

Often this chest pain or discomfort spreads to one

or both arms or shoulders, neck, jaw or upper back.

Atypical symptoms are ones that do not include

chest pain, such as: pain or discomfort in the upper

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abdomen or back between the shoulder blades; one

or both arms or shoulders; unexplained weakness

or extreme fatigue; or shortness of breath. People

describe atypical symptoms as indigestion or gas-like

fullness or burning. Both typical and atypical heart

attack symptoms can be accompanied by shortness

of breath, sweating, lightheadedness, nausea or

vomiting, or feelings of impending doom. Nearly

50 percent of women may experience atypical

symptoms, and chest pain may be absent.

I am 45-years-old with a strong family history

of heart disease. Lately I have been experiencing

vague symptoms including tiredness and

discomfort between my shoulder blades.

Should I be concerned?

You are right to be concerned. The symptoms you

describe are similar to the early warning signs of

a heart attack referred to as prodromal symptoms.

These vague symptoms come and go and are easily

attributed to stress or lack of sleep. They include

mild chest, shoulder or upper-back discomfort,

indigestion, shortness of breath, unusual fatigue

and sleep disturbances. In fact, 90 percent of women

experience prodromal symptoms in the days or weeks

preceding a heart attack. Make an appointment to see

your primary care physician, even if you think your

symptoms are vague and not serious ones.

What should I do if I experience symptoms that

could signal a heart attack?

Call 911 and get to the emergency room quickly

to minimize possible damage to the heart muscle.

Consider taking aspirin at the first sign of heart attack

symptoms.

I have had heartburn and indigestion for three

days now without any relief with antacids. The

pain goes all the way into my back. Although

I am only 29, I am concerned I may be having

heart attack warning symptoms, especially

because I smoke.

Sometimes it is very hard to tell the difference

between indigestion and heart attack symptoms

because they are so similar. This similarity occurs

because the stomach and esophagus lie so close to

the heart. Heartburn or indigestion is a feeling of

burning, warmth, heat or pain that often starts in the

upper abdomen just beneath the lower breastbone

and ribs. This discomfort may spread in waves upward

into the throat. A sour taste in the mouth may occur

with this burning sensation. You may also have

burping, nausea, bloating or difficulty swallowing. The

discomfort and pain of heartburn can last up to two

hours and sometimes

longer. Often these

symptoms are worse

after eating. Usually

the symptoms are

worse when lying

down or bending over

and are relieved by

sitting or standing up.

See your doctor to find

out if your symptoms

are from indigestion or

from another serious

medical condition such as coronary artery disease.

Quitting smoking is highly recommended, as it is not

only harmful to the heart but causes chronic lung

disease and many types of cancers.

I am 40-years-old and for the past few months

I have been waking up nearly every night with

a racing heart. I’m very anxious during the

episode, which lasts about 10-15 minutes. I also

experience slight stomach discomfort, which

soon passes. Could something be wrong with

my heart or is it anxiety?

Sometimes heart arrhythmias occur resulting in the

type of symptoms you describe. An arrhythmia is

a change in the regular beat of the heart. When an

arrhythmia occurs a number of sensations can be

experienced. The heart can feel like it is skipping a

beat or it can feel as if it is beating irregularly, very

fast or very slow. Many times, there is no recognizable

cause of an arrhythmia. Caffeine, tobacco, alcohol,

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cough and cold medicines, diet pills, lack of sleep and

stress are common culprits to consider. Heart disease

may cause arrhythmias too. You should discuss your

symptoms with your primary care physician.

My 65-year-old mother seems to get more tired

and out of breath doing routine activities over

the past six months. For the last two weeks, she

has also developed swelling in both her legs. Her

only medical problem is high blood pressure.

Could this be related to the heart?

These symptoms suggest that your mother may have

heart failure. Heart failure occurs when the heart

muscle is weakened and can no longer pump as much

blood as the body needs. Coronary artery disease

(CAD) and heart attack are common causes of heart

failure in men. In women, high blood pressure is the

most common cause. The body tries to compensate

for this reduced pumping ability by retaining salt

and water. This process increases the total amount of

blood returning to the heart and causes the heart to

enlarge. Unfortunately, if left untreated, heart failure

worsens over time. The first symptoms of heart failure

are due to insufficient blood supply to the body

leading to fatigue, weakness and lightheadedness.

Eventually, blood backs up in the blood vessels

leading to the heart and cause worsening signs of

heart failure. These symptoms are shortness of breath

with activity or at rest, awakening feeling short of

breath, weight gain and swelling of the feet, ankles

or abdomen. Your mother should see her physician

to determine the cause of her symptoms and begin

treatment right away.

I D E N T I F Y Y O U R R I S K FA C T O R S

“Know Your Numbers”

You will find six health conditions known to

increase the risk for coronary artery disease

listed below. All of these conditions can be

controlled. You can minimize your risk for CAD

by identifying your personal risk factors and take

action to control these risks. Your doctor will help

you design a treatment plan tailored to meet

your needs.

• High Blood Cholesterol

• High Blood Pressure

• Overweight or Obese

• Physical Inactivity

• Diabetes

• Smoking

The American Heart Association recommends

very specific treatment goals – that’s where

the saying “know your numbers” comes into

play. Because each of these risk factors can be

measured by using blood tests or other methods,

it will be easy for you to determine if your

treatment plan is working. All you have to do is

compare your current numbers, or the results

of these tests, to your goal numbers.

High Blood Cholesterol

What is cholesterol?

Cholesterol is a type of fat (lipid) and is an essential

nutrient your body needs for many important

functions, such as producing new cells. If you eat too

many foods high in saturated fat and cholesterol

or you have an inherited condition, the cholesterol

levels in your blood may climb to unhealthy levels.

This increases your risk for developing atherosclerosis

(hardening of the arteries) in the arteries supplying

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blood to the heart, brain and legs, and can lead to life-

threatening illnesses, such as heart attack or stroke.

Are cholesterol and triglycerides the same thing?

Cholesterol travels through your blood attached to a

protein. This cholesterol-protein package is called a

lipoprotein. Depending on how much protein there

is in relation to fat, lipoproteins are classified as:

• High-Density Lipoproteins

HDL is the “good” cholesterol, mostly protein

with only a small amount of fat

• Low-Density Lipoproteins

LDL is the “bad” cholesterol, mostly fat with

only a small amount of protein

• Very Low-Density Lipoproteins

VLDL is similar to LDL cholesterol in that it

contains mostly fat and not much protein

Triglycerides are a type of fat carried in the blood

by very low-density lipoproteins (VLDL). Only a

small amount of triglycerides are normally found

in the blood; most are stored in fat tissue. Women

tend to have higher triglyceride levels than men.

Cholesterol and triglyceride levels tend to rise with

age and obesity. Many people with heart disease

have high triglyceride levels in their blood, called

hypertriglyceridemia. High triglycerides may not

directly cause atherosclerosis but can be associated

with health conditions that hasten the process. High

triglyceride levels may result from other diseases

such as untreated diabetes mellitus. People with high

triglycerides often have high total cholesterol, high

LDL cholesterol and low HDL cholesterol level.

I have high cholesterol, but I don’t understand

what the numbers mean.

When distinguishing cholesterol numbers, you want

to know levels for your total cholesterol, LDL, HDL

and triglycerides. When you state you have “high

cholesterol,” you want to identify which one of these

levels is high.

Total cholesterol is a measure of the total amount

of cholesterol in the blood. Less than 200mg/dL is

desirable.

LDL, the “bad” cholesterol, is the main source of

cholesterol buildup and blockage in the arteries.

Levels of 70-100 mg/dL are optimal, especially if you

have a diagnosis of CAD or stroke.

HDL, the “good” cholesterol, helps keep cholesterol

from building up in the arteries and protects against

heart disease, so higher numbers are better. A level

less than 40 mg/dL is considered a major risk factor

for heart disease. Having an HDL level of 60 mg/dL

or more helps to reduce heart disease risk and is the

desired level.

Triglycerides are another type of fat and if elevated

can also increase your heart disease risk. Triglyceride

levels are considered borderline if between 150 and

199 mg/dL or high if greater than 200 mg/dL. The

desired level is less than 150 mg/dL.

In summary, it is important to know your cholesterol

numbers because lowering cholesterol reduces your

chance of developing heart disease.

High Blood Pressure

What is blood pressure?

Blood pressure is the amount of force exerted by the

blood against the walls of the arteries. This pressure

is produced by the beating of the heart to maintain

adequate blood flow to other parts of the body. When

the arteries are narrowed or damaged, they make it

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harder for blood to flow and the blood pressure will

rise. When high blood pressure continues untreated,

the heart becomes strained and blood vessels can

become damaged. High blood pressure is a major risk

factor for stroke, heart attack or kidney failure.

My blood pressure reading is 130/80. What do

these numbers mean?

Blood pressure is measured in two numbers – the top

number is the systolic reading, which measures the

pressure generated with each heartbeat. The bottom

number is the diastolic reading, which measures the

pressure when your heart is resting between beats.

These blood pressure readings will help you

interpret your blood pressure results.

• Normal (ideal): Lower than 120/80

• Prehypertension: Between 120/80 and 139/89

• Hypertension Stage I: Between 140/90 and

160/100

• Hypertension Stage II: Above 160/100

Are women at higher risk of developing high

blood pressure?

Women are particularly at risk of developing high

blood pressure if they are using birth control pills

(especially in combination with cigarette smoking),

during pregnancy, if they are overweight, after

menopause, if they are African American, or if they

have a family history of high blood pressure. As

women age, they have substantially increased risk

for hypertension.

My blood pressure is 133/84 and I am a smoker.

Am I more at risk of getting high blood pressure?

Nicotine, found in tobacco of any form, will

temporarily increase the blood pressure and the

heart rate with each use. It also causes constriction in

the arteries of the arms and legs, which will increase

an individual’s blood pressure. In time, smoking

combined with other risk factors significantly

increases the chance of developing coronary

artery disease.

I am 58-years-old and always had blood pressure

readings of 110/70. For the past two years, my

automated blood pressure readings at the

grocery store have been fluctuating – 150/73,

145/76, 135/76, the highest being 156/76. Do I

have high blood pressure?

You will be diagnosed with hypertension if your blood

pressure measurements are above 140/90 mm Hg on

three or more separate occasions. They are usually

measured one to two weeks apart. Except in very

severe cases, the diagnosis is not based on a single

measurement. High blood pressure screening tests

and programs vary widely in reliability. Results from

automated blood pressure testing, commonly found

at grocery stores or pharmacies, may not be accurate.

Any high blood pressure measurement discovered

during a blood pressure screening program needs

to be confirmed by a health professional.

I do not have

any symptoms

from high

blood pressure.

Is it necessary

to continue

treatment?

High blood

pressure can

damage your

arteries, heart

and kidneys, and lead to atherosclerosis and stroke.

Hypertension is called a “silent killer” because it does

not cause symptoms unless it is severely high and,

without your knowing it, causes major organ damage

if not treated.

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Obesity

I am 40 pounds overweight. My weight is

mostly around my abdomen. What is my risk

of developing coronary artery disease?

Women with excess body fat are at higher risk of heart

disease, even if they don’t have other risk factors. The

exact risk is still a matter of some debate, but it is

known that increased weight raises your chances of

developing high blood pressure, diabetes and high

cholesterol, all of which are major risk factors for CAD.

Fat deposits, especially around the abdomen, are an

important independent risk factor for developing

coronary artery disease. The ideal waist circumference

for women is 35 inches or less.

An additional method to determine if you are at your

goal weight is to use the body mass index, or BMI.

BMI is a calculation that considers the relationship

between a person’s height, weight and body fat. The

desired BMI is 18.5- 25. To calculate your BMI, use the

chart to the right.

Physical Inactivity

I am 63-years-old and have high cholesterol

and high blood pressure. My doctor said I should

exercise but I’ve never done that. Will it really

help?

Lack of exercise is a risk factor for developing

coronary artery disease. It can indirectly increase

the risk of CAD because it also increases the risk of

diabetes and high blood pressure. Regular exercise

can help reduce your risk of CAD by helping you

control cholesterol and blood pressure, regulate

blood sugar (important for people with diabetes),

and lose weight. Regular exercise is essential not

only for preventing CAD but also for improving your

overall cardiovascular health. Check with your doctor

first before starting an exercise program if you have

diagnosed CAD, have been sedentary for a long

period of time, or have other heart, lung or metabolic

diseases, such as diabetes.

Diabetes

Is heart disease directly related to diabetes?

If so, in what way?

People with diabetes are more prone to heart disease

and stroke. Long-term complications from diabetes

develop because of persistent high blood sugar

levels and progression of atherosclerosis in arteries

throughout the body including arteries to the eyes,

kidneys, heart, brain and legs. Diabetes damages

the lining of blood vessels, causing them to become

clogged with plaque, which is made up of cholesterol,

white blood cells, calcium and other substances

that collect under the inner lining of an artery. This

damage narrows the vessels, decreasing the blood

supply, which eventually causes injury to the affected

area. It also increases the pressure in the blood vessels,

resulting in high blood pressure. When blood vessels

that supply the brain and heart are affected, a heart

Body Mass Index (BMI)To calculate your exact BMI value, multiply weight in

pounds by 705, divide by height in inches, then divide

again by height in inches.

Find your height in the left column below, then find your

weight range in the corresponding categories to the right.

Minimal Risk (normal): BMI less than 25

Moderate Risk (overweight): BMI 25 to 29

High Risk (obese): BMI greater than 30

Sample Weight Risk Factory Categories

Height Minimal Risk Moderate Risk High Risk

5’1” 131 or less 132-157 158 or more

5’3” 140 or less 141-168 169 or more

5’5” 149 or less 150-179 180 or more

5’7” 158 or less 159-190 191 or more

5’9” 162 or less 169-196 197 or more

5’11” 172 or less 179-208 209 or more

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attack or stroke may occur. About three-quarters of

people with diabetes die of some form of heart or

blood vessel disease. A person with diabetes has the

exact same risk for a heart attack as a person of the

same age who has already had a heart attack. People

with diabetes who experience a heart attack have

an unusually high death rate immediately or in the

long term.

At what age do people with diabetes begin to

develop heart disease?

There is no specific timeframe for developing CAD

if you have diabetes. In many circumstances, people

who are newly diagnosed with Type 2 diabetes have

had abnormally high blood sugars long before the

diagnosis was made. Therefore, it is difficult to know

exactly how long the heart has been exposed to the

effects of diabetes. However, diabetes is frequently

associated with other risk factors. Rather than focus

on a person’s age at time of diagnosis, it is more

important to keep the blood sugar under good

control or modify other cardiac risk factors, such as

quitting smoking, increasing activity, and working

to get weight, blood pressure and cholesterol to

goal levels.

Are women with diabetes at higher risk of heart

disease?

Diabetes eliminates any survival advantage that a

woman has over a man of the same age. A woman

with diabetes has the same risk of dying from heart

disease as a man her same age. Women with diabetes

have 2- 4 times higher risk of heart disease compared

to women without diabetes. As women age, diabetes

is more common and diabetes affects more women

than men over 60. If a woman has diabetes, she

should aim to achieve near-normal fasting plasma

glucose (blood sugar) of less than 100 mg/dL and

near normal HbA1c of less than percent. (Hemoglobin

A1c measures average blood sugar over the course of

three months and a physician can order this test.)

Smoking

I have been smoking a pack of cigarettes daily for

the last five years. Does smoking affect the heart?

Cigarette smoking is one of the most powerful risk

factors for CAD in women. It is associated with 50

percent of all cardiovascular events in women. The

incidence of a heart attack increases sixfold in women

vs. threefold in men who smoke. When combined with

other factors such as oral contraceptive use, it greatly

increases the risk. In addition, smoking increases the

blood pressure, decreases exercise tolerance, increases

the tendency for the blood to clot, increases LDL

cholesterol and decreases HDL cholesterol.

I recently quit smoking. How long will it take

to reduce my risk of heart disease to that of a

non-smoker?

The risk of CAD and stroke begins to drop

immediately after quitting smoking. It becomes half

after one year without smoking and continues to

decline thereafter to a nonsmoker’s risk.

My husband is a smoker. Am I at increased risk

of heart disease due to secondhand smoking?

Constant exposure to other people’s tobacco smoke,

called passive smoke, does increase your risk for CAD.

After spending just 30 minutes in a smoky room,

oxygen in the blood decreases, blood pressure rises

and blood is more likely to clot.

Cigarette smoking is one of the

most powerful risk factors for

heart disease in women. It is

associated with 50 percent of all

cardiovascular events in women.

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A D D I T I O N A L R I S K FA C T O R S

Family History

I am a healthy 50-year-old woman. I do not

have high blood pressure or diabetes and my

lipid profile is in the normal range. However, my

father had a heart attack at age 70 and two of

his brothers had heart attacks in their late sixties.

Does this mean I have a family history of heart

disease? Do I need to be concerned?

Family history is an important determinant of risk,

particularly premature CAD in a family member.

Premature family history of CAD means that you

have a first-degree male relative under 55 with

CAD or a first-degree female relative (mother, sister)

under 65 with CAD. Age and gender are contributory

risk factors. Males have a greater lifetime risk of

developing CAD.

Menopause

Does menopause increase the risk of heart

disease?

Many women seem to be protected from heart

disease before menopause. As women age, their risk

of heart disease rises. The loss of natural estrogen as

women age may contribute to the increased risk of

CAD after menopause.

I’ve read so much in the news lately about

hormone replacement therapy and heart disease.

What are the latest recommendations?

Based on recent clinical trials showing no benefit of

postmenopausal hormone therapy for cardiovascular

disease prevention and possible adverse effects, the

American Heart Association does not recommend

postmenopausal hormone therapy for the prevention

of cardiovascular disease in women with or without

existing CAD. Combined estrogen plus progestin

hormone therapy should not be initiated or continued

to prevent cardiovascular disease in postmenopausal

women. Other forms of menopausal hormone therapy

(e.g., unopposed estrogen) should not be initiated

or continued to prevent cardiovascular disease in

postmenopausal women pending the results of

ongoing trials. Although hormone therapy is not

recommended for cardiovascular disease prevention,

women and their healthcare providers should weigh

the potential risks of therapy against the potential

benefits for menopausal symptom control.

T E S T S , T R E AT M E N T S A N D P R E V E N T I O N

I have been experiencing mild chest pain after

exercise for the past six months. My EKG was

normal. Do I need further testing?

An electrocardiogram (EKG, ECG) may show evidence

of heart enlargement, signs of insufficient blood

flow to the heart, signs of a new or previous heart

attack, heart rhythm problems, changes in the

electrical activity of the heart caused by an electrolyte

imbalance and signs

of inflammation of

the sac around the

heart (pericarditis).

However, a normal

electrocardiogram

does not necessarily

mean that your

chest pain is not

cardiac in origin. An

electrocardiogram

cannot predict whether

you are at a risk of having a heart attack. You may

need further evaluation of your symptoms and stress

testing to determine the cause of your chest pain.

What is a nuclear stress test?

A nuclear scan is a test used to estimate the amount

of blood reaching the heart muscle during rest

and exercise. It is typically done for people with

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unexplained chest pain or to determine the location

and amount of injured heart muscle after a heart

attack. For this test, a radioactive substance (tracer)

is injected into a vein and a special camera is used

to view the amount of tracer that reaches the heart

at rest and when stressed (through exercise or

medication). As the tracer moves through the heart

muscle, areas that have good blood flow absorb the

tracer. If an area of heart muscle does not adequately

absorb the tracer, it means either that the blood flow

is severely reduced or there has been a previous

heart attack. An abnormal nuclear stress test may be

consistent with a blocked artery and you may be at

risk for a heart attack.

I recently had

an abnormal

stress test.

My doctor

recommended

coronary

angiography.

How will this

test help?

Angiogram,

or cardiac

catheterization,

is an appropriate follow-up test to examine the

inside of your arteries. A special dye is injected into

the coronary arteries to trace the movement of

blood through the arteries. The purpose of this test

is to pinpoint the size and location of plaque that

may have built up in your coronary arteries due to

atherosclerosis.

What is angioplasty? Is it different from stenting?

Angioplasty is a procedure to reopen narrowed

coronary arteries. During the angioplasty procedure,

a thin, flexible tube (catheter) is inserted through an

artery in the groin or arm and carefully guided into

the artery that is narrowed. Once the tube reaches

the narrowed artery, a small balloon at the end of

the tube is inflated. The pressure from the inflated

balloon presses fat and calcium deposits (plaque)

against the wall of the artery to improve blood flow. If

necessary, a small, expandable wire tube called a stent

is inserted into the artery to hold it open. Stents may

be medicated to decrease scar formation on the stent,

which increases the likelihood of the artery remaining

open over a longer time. Reclosure (restenosis) of the

artery is less likely to occur after angioplasty followed

by stenting than after angioplasty alone.

My father has CAD that has been worsening

despite medical management. What treatment

options are available?

There are several treatment options available.

Angioplasty (with or without stent placement) and

atherectomy (shaving the plaque from the inside of

the coronary arteries) are nonsurgical procedures to

reopen narrowed coronary arteries. Coronary artery

bypass surgery involves bypassing the blocked artery

with a graft fashioned from a leg vein or chest or

arm artery (mammary or radial artery). The choice

between angioplasty with or without stent placement

and bypass surgery depends on a number of factors

including the artery blocked, the number of vessels

blocked, the location and severity of blockage and

other heart problems.

Medications

I’ve heard that these cholesterol drugs cause bad

side effects that can kill people. I’m concerned

since I recently started taking Lipitor.

The most widely used cholesterol-lowering drugs

are called statins. They are effective in lowering

cholesterol and along with it the risk of dying from

heart disease and/or having recurrent heart attacks.

In general, statins have very few side effects. In a few

cases there may be some liver abnormalities along

with muscle tenderness and weakness. From time to

time your doctor may order liver function tests if you

take statins. The incidence of serious muscle injury

and progression to life-threatening rhabdomyolysis

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(muscle breakdown) is very rare, but it’s essential to

report any muscle pain, weakness and/or tenderness

to your doctor.

I have chronic stable angina for which I take a

long-acting nitrate and atenolol. How do these

medications work?

Nitrates are a first-line therapy for the treatment of

acute anginal symptoms. Nitrates open (dilate) the

arteries to the heart. This action increases blood flow

to the heart, relieving chest pain (angina). Nitrates

also dilate veins throughout the body so that they can

hold more blood. This action reduces the amount of

blood going back to the heart, reducing the heart’s

workload. Beta blockers reduce the workload on the

heart by slowing the heart rate and reducing the

blood pressure, which allows the heart to pump more

efficiently. As a result, beta blockers can help relieve

or prevent chest pain (angina).

I do not like to take a nitroglycerin tablet

because it gives me a headache.

Nitroglycerin and other nitrates relax the arteries

(vasodilatation) and improve the blood flow to the

heart. The major side effects associated with nitrate

use are headache, lightheadedness and flushing,

which are due to the vasodilatation and tell you

that the medication works. These symptoms tend to

improve with time. Since the nitroglycerin evaporates

from the pills once the bottle is opened, you need a

new prescription every six months.

I am taking aspirin, atenolol, lisinopril and

simvastatin for medical management of CAD.

What are their benefits?

Platelets are responsible for forming blood clots.

Aspirin reduces platelet function and the risk of

having a heart attack or stroke from a blood clot

forming in the arteries of the heart or brain. Beta

blockers (atenolol) reduce the heart rate and blood

pressure and

therefore

decrease the

workload on

the heart. ACE

inhibitors

(lisinopril)

decrease the

blood pressure

and reduce the

workload on

the heart by

preventing the

formation of the

hormone angiotensin, which narrows arteries. Statins

(simvastatin) block an enzyme that the body needs

to form cholesterol. All these medications have been

shown to decrease the chance of another heart attack

and lengthen life in patients with CAD.

I was started on an ACE inhibitor after I suffered

a heart attack. For the past few weeks, I’ve had

a cough that I was told could be related to the

medicine. Should I continue the medicine?

ACE inhibitors are recommended immediately after

a heart attack to reduce the risk of death associated

with a heart attack and prevent the development of

heart failure.

Cough occurs in 20 percent of patients on ACE

inhibitors. If coughing is a severe problem, consult

your doctor, as other medications such as ARBs

(angiotensin receptor blockers) can be tried.

Nitrates are a first-line therapy

for the treatment of acute anginal

symptoms. Nitrates open (dilate)

the arteries to the heart.

12

Primary Prevention

What is primary prevention?

Primary prevention is early identification of

cardiovascular risk factors and taking action to reduce

these risks before cardiovascular disease develops.

Primary prevention strategies are aimed at helping

people make lifestyle changes, such as quitting

smoking or losing weight, before they are diagnosed

with a heart attack or stroke.

My most recent cholesterol test numbers are:

208 total cholesterol; HDL 67; triglycerides 96;

LDL 126. Because I have rheumatoid arthritis it is

difficult for me to do strenuous exercise, however

I do practice Tai Chi. What suggestions do you

have for lowering my LDL?

Ways in which a person could help reduce a high

cholesterol level are to start and maintain a low-

saturated-fat, low-cholesterol diet and lose weight if

overweight. Meat, cheese and dairy products are the

major sources of saturated fat. Increase your intake

of fiber, which can lower cholesterol. Fiber is found in

legumes (beans), whole-grain breads and cereals and

fresh vegetables. Exercise and being physically active

plays an important role in helping reduce cholesterol

– in doing Tai Chi, you are doing a good job in helping

yourself be active. One should aim for 20 to 30

minutes of moderate exercise (walking, gardening,

easy bicycling) at least 5 days a week. Exercise can

help control cholesterol, blood pressure and blood

sugar (important if you have diabetes or a family

history of diabetes). It would be wise to discuss these

levels, along with any other risk factors you may have,

with your physician to set your target cholesterol

goals and create the best plan of care to reach them.

My recent lipid profile was abnormal and my

doctor wants me to work on improving it in part

through more exercise and in part through diet.

The American Heart Association recommends

a low-saturated fat, low-cholesterol diet. My

doctor says not to worry about eggs or shrimp,

and instead to eliminate sugar, alcohol and

refined wheat flour from my diet as much as

possible. How and where can I find some credible

discussion of this conflicting advice?

One good resource for you to get this information

is from your doctor since he suggested the dietary

changes. The Therapeutic Lifestyle Changes (TLC)

diet is recommended by the National Cholesterol

Education Program of the National Institutes of

Health. You may want to work with a registered

dietitian or nutritionist to help you follow the

TLC eating plan, which is low in saturated fat and

cholesterol. According to this eating plan, less than

7 percent of your daily calories will come from

saturated fat, and cholesterol should be limited

to 200 milligrams (mg) per day. Also, the TLC plan

recommends increasing soluble fiber and adding

plant stanols and sterols to your diet. Plant sterols

and stanols are found in small quantities in many

fruits, vegetables, nuts, seeds, cereals, legumes and

other plant sources. Vegetable oils, for example,

contain both plant sterols and stanols. Plant stanols

and sterols are available in salad dressings and

margarines, such as Benecol and Take Control.

How can I increase my good cholesterol?

The “good” cholesterol is known as HDL (high density

lipoprotein) cholesterol. You can increase your

good cholesterol in several ways. First, increase your

exercise activity to 30-60 minutes a day on most days

of the week. Also, losing weight and not smoking will

increase HDL levels. A level of HDL less than 40 mg/dL

is considered a risk factor for heart disease, whereas

a level of 60 mg/dL is considered protective against

heart disease. Medications such as fibrates and niacin

also raise HDL levels.

Exercise and being physically

active plays an important role in

helping reduce cholesterol.

13

My total cholesterol is 230. My internist says that

it’s okay for me but I am concerned. What should

I do?

In order to determine whether this level of cholesterol

is appropriate, you need to determine your LDL

and HDL levels and whether other coronary artery

disease risk factors are present. Your number of

risk factors and your 10-year risk of having a heart

attack will determine whether your treatment begins

with lifestyle changes alone or whether it includes

cholesterol-lowering medications. Generally, unless

you have CAD or are at high risk for CAD, therapeutic

lifestyle changes will be tried first, for at least three

months.

You will need to be assertive about your health

and not accept a borderline total cholesterol as

okay without further assessment of LDL and HDL

cholesterol.

For the past six months, I have tried to manage

my high cholesterol by dietary modification and

exercise. My recent LDL cholesterol was 180 and

HDL was 30. My internist wants me to try losing

more weight before considering medication.

If your LDL cholesterol is still 180 after six months

of strict adherence to a trial of therapeutic lifestyle

changes and you have mentioned that you have

at least one coronary risk factor (low HDL), you will

likely need medication to lower your LDL cholesterol.

You should be evaluated for the major risk factors

that modify LDL goals – cigarette smoking, high

blood pressure, low HDL cholesterol, family history of

premature CAD and age. Your LDL goal will be based

on the risk category you fall in:

<160 mg/dL – Zero to one risk factor

<130 mg/dL – Multiple (2+) risk factors

<70-100 mg/dL – CAD or CAD equivalent

If your internist is not willing to make a treatment

plan that includes a dietitian consult, an exercise

regimen and medications, then consider getting

a second opinion.

How often should I exercise? What are the

benefits of physical activity?

It is important to try to incorporate physical activity

for 30 minutes on most, if not all, days. Physical activity

gives you strength and energy; helps you handle

stress, sleep better, look good and feel positive; helps

control weight and blood pressure; and strengthens

your heart, lungs, bones and muscles. Regular

moderate physical activity lowers the risk of heart

disease, stroke, diabetes, high blood pressure, obesity,

high total cholesterol and low HDL cholesterol.

What kind of exercises should I do?

Moderate activities such as pleasure walking,

gardening, yard work, dancing, home exercise and

moderate to heavy housework can reduce your risk

of heart disease if done on most or all days. More

vigorous exercises such as brisk walking, jogging, stair

climbing, hiking, swimming, rowing, bicycling, aerobic

dancing and cross-country skiing can improve the

fitness of your heart and lungs. If you haven’t been

active and want to start exercising, you should discuss

with your doctor an exercise program that is right

for you. You can also add more activity to your daily

routine such as taking stairs instead of elevators/

escalators and taking a walk during your lunch break.

14

What is the ideal body weight to reduce the risk

of heart disease?

A body mass index (BMI) between 18.5 and 24.9 Kg/

m2 is considered ideal (see chart on page 8). General

recommendations are to achieve and maintain

the ideal weight by restricting calories in diet and

increasing the caloric expenditure by exercising.

Overweight or obese persons should reduce 10

percent of their body weight in the first year of

therapy.

I know I should quit smoking – it’s bad for my

heart and my lungs – but I’ve tried everything

and nothing works. Any suggestions?

The more attempts you make to quit smoking

the greater your chances are of succeeding.

Counseling or smoking cessation programs also

increase your chances of quitting for good. Nicotine

replacement therapy, in the form of nicotine

transdermal patches and nicotine gum, are more

effective in helping you quit smoking when used as

part of a more comprehensive smoking cessation

program. Medication called bupropion may help you.

Consider talking with your doctor about the best

option for you.

How can I avoid gaining weight after I quit

smoking?

People do not automatically gain weight after they

quit smoking. However, if they start eating more once

they quit smoking, their weight will increase. If you

watch what you eat and stay physically active, you

may not gain any weight. The benefits of quitting

smoking on your cardiovascular health outweigh the

risk of gaining a few pounds, which can be controlled

if you are cautious with diet and exercise.

I continue to read about red wine’s health

benefits. Is this proven?

More research regarding red wine consumption

and possible cardiovascular benefits needs to be

conducted. Some studies have indicated possible

cardioprotective effects of red wine due to the

flavonoids present in the red grape seeds and skin.

These flavonoids are identified as antioxidants,

which may possibly reduce the risk of heart disease.

However, according to a recent American Heart

Association science advisory, drinking red wine or

any other alcoholic beverage cannot replace effective

conventional measures of reducing a person’s risk

for heart disease. Conventional measures include

controlling weight, lowering cholesterol and lowering

blood pressure.

Recently my sister and I were diagnosed with

hypertension. I was started on medications,

whereas she has only been advised lifestyle

changes. I would like to avoid medications

as well.

Your treatment will depend upon how high your

blood pressure is, whether you have other medical

conditions, such as diabetes, and whether any

organs have already been damaged. Your risk of

developing other diseases, especially heart disease,

will be another important factor your doctor will

consider. If you fall into the pre-hypertension range

(120-139/80-89 mm Hg), your doctor will likely

recommend lifestyle modifications, including losing

excess weight, exercising, limiting alcohol, cutting

back on salt, quitting smoking and following the

Dietary Approaches to Stop Hypertension (DASH)

diet – an eating plan that is a low-sodium, low-fat

and low-saturated fat diet that emphasizes eating

The more attempts you make

to quit smoking the greater

your chances are of succeeding.

Consider talking with your doctor

about the best option for you.

15

more fruits, vegetables, whole grains and low-fat

dairy foods.

Drug therapy is not recommended for pre-

hypertension patients with the exception of patients

with diabetes who have blood pressure readings over

130/80 mm Hg. Combination drug therapy in addition

to aggressive lifestyle changes is usually necessary for

those with hypertension.

How can I reduce high blood pressure?

You can reduce your blood pressure by making some

changes in your lifestyle and taking proper treatment.

Lose weight if you’re overweight. Eat a healthy diet

low in saturated fat, cholesterol and salt. Be more

physically active. Limit alcohol to no more than one

drink per day for women or two drinks a day for men.

Take medicine the way your doctor tells you and

know what your blood pressure should be and work

to keep it at that level.

I have diabetes and am on Metformin. What can

I do to prevent the complications of diabetes?

Diabetes is a disease that can be controlled. Careful

monitoring of diet, daily blood sugars and a blood

test called hemoglobin A1c will all help to reduce

complications. The hemoglobin A1c measures

average blood sugar over the course of three months

and your physician can order this test for you. An ideal

hemoglobin A1c result for people with diabetes is less

than 7 percent. Studies have demonstrated that tight

control over diabetes reduces the risk for subsequent

heart attack and stroke. You should aim to achieve

near-normal fasting plasma glucose (blood sugar)

of less than 110 mg/dL and near-normal hemoglobin

A1c of less than 7 percent. Other cardiac risk factors

associated with diabetes need to be treated more

aggressively. For example, change your blood

pressure goal to less than 130/80 mm Hg and your

LDL cholesterol goal to less than 70 mg/dL.

My doctor recommended that I start aspirin as

I am at high risk for coronary artery disease. I

thought aspirin is for people who have angina

or who have had a heart attack.

Aspirin is definitely recommended for patients who

have had a myocardial infarction (heart attack),

unstable angina, ischemic stroke (caused by blood

clot) or transient ischemic attacks (TIAs or “little

strokes”), in the absence of contraindications. This

recommendation is based on sound evidence from

clinical trials showing that aspirin helps prevent

the recurrence of such events as heart attack,

hospitalization for recurrent angina, second strokes,

etc., known as secondary prevention. Studies show

aspirin also helps prevent these events from occurring

in people at high risk, known as primary prevention.

The American Heart Association recommends low-

dose aspirin in high-risk people.

Secondary Prevention

What is secondary prevention?

Secondary prevention is aimed at identifying and

treating people with established disease and those at

very high risk of developing cardiovascular disease. It

also includes treating and rehabilitating patients who

have had a heart attack or stroke to prevent another

similar event.

16

I had a heart attack two months ago. I am on

aspirin, metoprolol, Pravachol and lisinopril. How

long will I need to be on these medications?

Aspirin, beta blocker (metoprolol), ACE inhibitors

(lisinopril, accupril or monopril) and statins such as

Lipitor, Zocore or Crestor have been shown to reduce

the risk of future heart attack in people with known

CAD. The American Heart Association recommends

to continue aspirin, beta blockers and ACE inhibitors

indefinitely for patients who have had a heart attack,

unless contraindicated.

I am overweight and I have diabetes, high

blood pressure and high cholesterol for which

I am taking medications. I also had a heart attack

and a mini-stroke one year ago. What can I do

to reduce my risk of having another heart attack

or stroke?

Aggressive lifestyle changes in addition to

medications will lower your risk for a future heart

attack or stroke. Complete cessation of smoking,

weight control, 30 minutes of physical activity on

most days, alcohol moderation, moderate sodium

restriction and emphasis on fruits, vegetables and

low-fat dairy products are some of the changes you

need to consider. Your blood pressure should be less

than 130/80, LDL cholesterol should be less than 100

(less than 70 being the optimal) and hemoglobin

A1c should be less than seven. You will benefit from

working with a dietitian or nutritionist to help you

achieve your dietary goals. Ask your doctor to help

you make a plan of care that includes a dietitian and

an exercise program, in addition to medications. You

may also want to discuss whether you are a candidate

for cardiac rehabilitation.

I am a 50-year-old woman who recently

underwent bypass surgery. Will a cardiac

rehabilitation program benefit me?

Cardiac rehabilitation is a medically supervised

program that includes exercise, lifestyle changes,

education and emotional support for people who

have had a heart attack, bypass surgery or have

other heart problems. It is individually designed

to enhance your quality of life by improving your

physical and emotional health. It can stabilize or

reverse CAD. Benefits include enhanced exercise

tolerance, less depression and anxiety, controlled

CAD symptoms and most importantly, lower risk

for future cardiac events. Attending a cardiac

rehabilitation in your community is strongly

recommended by the American Heart Association.

This booklet was developed by Suman Tandon, MD, Gail D’Onofrio, MD, MS, Lisa Freed, MD,

and Janet Parkosewich, RN, MSN.

S T E E R I N G C O M M I T T E E M E M B E R S

Mariane Carna, RN, MSNExecutive Director, Heart & Vascular Center, Yale-New Haven Hospital

Gail D’Onofrio, MD, MS, Medical DirectorChief, Section of Emergency Medicine, Yale-New Haven Hospital

Lisa Freed, MD, FACC, Co-DirectorAttending Cardiologist, Yale-New Haven Hospital

Clinical Assistant Professor, Yale University School of Medicine

Basmah Safdar, MDCo-Director, Chest Pain Center, Yale-New Haven Hospital

Assistant Professor, Yale University School of Medicine

Janet Parkosewich, RN, MSN, FAHA, Co-DirectorCardiac Clinical Nurse Specialist, Yale-New Haven Hospital

Charlotte Hickey, RN, MSClinical Coordinator, Yale-New Haven Hospital

Women’s Heart Program at

Yale-New Haven Hospital

Women’s Heart Program at Yale-New Haven Hospital

20 York Street

New Haven, CT 06510

203.688.4373

www.ynhh.org