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Listening to the Female Heart

A woman’s signs of cardiovascular troubles are more subtle & different than a man’s symptoms.

By Dr. Rob for MSN Health & Fitness

Q: Can you tell me the signs & symptoms of heart problems in a woman? I know they're different than for men. Sometimes I feel pain that runs for several minutes from my back, upper shoulder & down my left arm.

This seems to happen during periods of stress or too much activity. I've also been having shortness of breath with these pains along with a chest “aching.” My blood pressure has been running high, around 150 over 100.

Are these symptoms of a heart problem?

I'm worried because I'm at risk for heart disease - my 41 year-old brother just had quadruple bypass surgery & I have high blood pressure (& am on 2 medications). I see the doctor regularly (just went for my regular check-up), but I’m worried that my symptoms could indicate something serious.

A: When it comes to women & heart disease, subtle signs may precede a heart attack by one week to many months (6 or more). Even though the following symptoms may be (& often are) caused by other medical conditions, they also could be pieces of a puzzle that say your heart is in trouble.

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These include but aren’t limited to:

  • Chest pain that occurs in a predictable pattern (stress, activity, others).

  • Unusual & unexplained fatigue.

  • Sleep disturbances.

  • Shortness of breath.

  • Indigestion that may or may not be related to food.

  • Pain in the left shoulder blade or upper back.

  • Anxiety or feeling of uneasiness or impending personal doom.

Given the information supplied in your question, personal risk factors include but aren’t limited to:

  • Stable angina. Although additional information is needed & further testing (EKG, pharmacologic stress test, electron beam computed tomography heart scan, others) may be required, the aching chest pain you're experiencing may be a condition known as stable angina. If present, this type of heart pain happens in a predictable pattern & puts the affected person at a higher risk for a future heart attack.

  • Shortness of breath. While there are many reasons for this symptom to occur (asthma, chronic bronchitis, emphysema, others), I'm concerned because your shortness of breath occurs along with left shoulder & arm pain.

  • Uncontrolled high blood pressure. No doubt about this one, as your pressure isn't controlled. High readings definitely are linked to an increased risk for heart attacks & strokes. I would encourage you to keep a blood pressure diary for 2 weeks. Check your readings at least 2 times per day with a portable machine that has been verified as similar to the measurements at your doctor’s office. If your blood pressure is indeed too high (greater than 120 as top systolic number &/or greater than 80 as bottom, or diastolic number), the dosing of your medications needs to be adjusted, or even changed. High blood pressure absolutely needs to be controlled & in a safer range.

  • Family history of cardiovascular disease. Your brother had significant heart disease, requiring a quadruple bypass at the young age of 41. This puts you in a higher risk category for heart disease.

While you did not mention your cholesterol, LDL, triglyceride or HDL levels, I am hoping you have had them checked and they are in a healthy range. If not, that would add to your risk for cardiovascular disease. Other cardiovascular risk factors that need to be considered include:

  • Age 55 and older.
  • Smoking.
  • Excess alcohol (more than one drink per day for women).
  • Diabetes.
  • Metabolic syndrome.
  • Physical inactivity.
  • Waist measurement greater than 35 inches.
  • Obesity (check body mass index to calculate your personal category).
  • Race (black women have a greater risk of heart disease and stroke than white women).
  • Overwhelming stress.

Many people think heart attacks happen in the familiar television fashion: A person clutches his chest from the pain and drops to the floor after passing out. Even though chest pain is the most common symptom, women are more likely than men to have a heart attack without this pain. In fact, many women have other or “atypical” symptoms that require prompt attention. These symptoms include but aren’t limited to:

  • Chest sensation described as an ache, tightness or pressure.
  • Unusual and unexplained fatigue.
  • Shortness of breath.
  • Indigestion, nausea or vomiting.
  • Pain in the neck, shoulder or back.
  • Sudden weakness, dizziness or lightheadedness.

As we have learned from the large, ongoing study known as the Women’s Health Initiative, along with other research on women’s cardiovascular disease, a woman’s heart has its own way of communicating in the face of illness. I highly encourage you to visit a family physician, general internist, cardiologist or other health care professional skilled in the diagnosis, prevention and treatment of women’s cardiovascular disease.

They're not just men with breasts

By DrRich

In this special section of the Heart Disease and Cardiology website, we'll deal specifically with the issue of heart disease in women. A special section is warranted because of two common misapprehensions held by both women and their doctors. These are that women don't really get much heart disease, and when they do, it behaves pretty much like the heart disease that men get. The real facts are that: a) heart disease is the number one killer of women, and b) when women get heart disease it often presents quite differently than it does in men. Failing to understand these two fundamental facts leads to a lot of preventable deaths and disability in women with heart disease.

In a recent survey conducted by the American Heart Association, 6 in 10 women said that the major threat to their health was breast cancer; only 1 in 10 said it was heart disease.

But in 1999, while cancer was killing 264,000 American women (41,000 of whom died of breast cancer,) cardiovascular disease killed 513,000 - and it's the same story every year. In fact, each year since 1984 even more women than men have died of heart disease. Many doctors don't get it either. Less than half the doctors in one recent survey considered heart disease to be a major threat to their female patients. Worse, less than half of all women receiving regular medical care say that their doctors have ever talked to them about reducing their risk of heart disease.

Worst of all, the symptoms of heart disease - and even the heart disease itself - can be quite different in women than in men. And since medical textbooks almost exclusively describe "typical" heart disease (that is, the kind men get,) doctors often fail to recognize heart disease when they see it in their female patients. The fact that heart disease is so common in women, and at the same time is underestimated and misunderstood by both women and their doctors, contributes in no small way to the high death rate.

The purpose of this special section is to tell women what they need to know about heart disease. There is a lot of information on this website about heart disease in general, but here, we'll emphasize the characteristics of the heart disease women get, trying to point out how heart disease in women is different from heart disease in men. We'll examine the differences in risk factors, in the symptoms of heart disease, in the diagnosis of heart disease, and in the heart diseases themselves. It is very important for women to understand this information - especially because there's a good chance their doctors don't.


There are some important differences in women's risk factors

By DrRich

Updated January, 2006

The risk factors for cardiac disease are similar between men and women, but there are some important differences.

While many women (and unfortunately, many doctors) apparently still do not know it, heart disease is the number one killer of women. About a half million women die of heart disease each year in the U.S. - indeed, more women than men die from cardiovascular disease. So it is as important for women as for men to control the risk factors that lead to heart disease. Aggressively managing risk factors can prevent or delay the onset of heart disease, even in women with strong family histories. In those who already have heart disease, control of risk factors can delay or even halt the progression of the disease, and strongly improve outcomes.

Non-controllable risk factors:

  • Family history of coronary artery disease or stroke

  • Age 55 or older

  • Being post-menopausal, or having your ovaries removed

A family history of premature cardiac disease (less than 60 years,) especially in a sister or brother, may be a particularly important risk factor in women.

Women with such a family history should be aggressive in controlling cardiac risk factors.

Controllable risk factors:

  • Obesity

  • Sedentary lifestyle

  • Smoking

  • Hypertension

  • High total cholesterol, and/or reduced HDL cholesterol

  • Diabetes

  • Metabolic syndrome

  • Increased C-reactive protein (CRP)

  • Use of birth control pills, especially if also a smoker

  • Complicated pregancy (hypertension, diabetes, low birth weight)

Obesity and sedentary lifestyle: These two risk factors are more common in post-menopausal women than in men the same age. Women tend to be caregivers, and (research suggests) out of a sense of duty have a hard time justifying behaviors that are "just for me," such as regular exercise. As a result older women may be prone to inactivity and obesity, strong risk factors for heart disease and stroke.

Smoking is a particular problem for women, as it accounts for the vast majority of heart attacks in women under the age of 45, and is a phenomenal multiplier of risk in women with family histories of heart disease. And birth control pills make things even worse - the combination of smoking and birth control pills increases the risk of early heart disease by 20-fold.

Hypertension is a major risk factor for heart disease and stroke. It is very common in women over 55, and is heartbreakingly undertreated. But good treatment is well worth the effort - ask anyone who has had a stroke.

Cholesterol abnormalities greatly increase the risk of heart attack and stroke. Low HDL levels are a more important risk factor in women than in men. Evidence is mounting that achieving very low LDL levels, and/or substantially raising HDL levels, can actually halt or reverse coronary artery disease. In many women cholesterol can be controlled with diet and exercise, but often drug therapy with statins or other medicine is also needed.

Diabetes is growing in frequency, right along with one of its root causes - obesity. Diabetes should be thought of as a disease of blood vessels as much as a disease of sugar metabolism, as it greatly increases cardiovascular risk. The risk of heart disease in women with diabetes is increased as much as 6-fold.

Metabolic syndrome, particularly common in post-menopausal women, greatly increases the risk of heart disease and stroke. It is diagnosed by the presence of at least 3 of these 5 features:

  • Central obesity (for women, a waist size greater than 35 inches)

  • Triglyceride levels greater than 150 mg/dl

  • HDL cholesterol ("good" cholesterol) less than 50 mg/dl

  • Fasting blood glucose greater than or equal to 110 mg/dl

  • Blood pressure greater than or equal to 130/85

Metabolic syndrome is probably an early stage of type II diabetes. While drugs can be used to help control various aspects of metabolic syndrome, the ideal treatment is exercise, diet control and weight loss.

C-Reactive Protein (CRP) is a relatively "new" risk factor that appears to be more important in women than in men. Increased CRP levels indicate active inflammation, and a high CRP level usually can be assumed to mean that blood vessel inflammation is present. Especially in women, inflammation is thought to be a major factor in the erosion or rupture of coronary artery plaques. Recent evidence suggests that reducing CRP levels (with statins) lowers the risk of heart attack in some patients with coronary artery disease. Here is a discussion of when you ought to have your CRP measured.

Finally, it now appears that women who develop certain complications during pregnancy - specifically preecclampsia (significant hypertension), gestational diabetes, or delivering low-birth-weight babies - have a signficantly higher risk of early cardiovascular disease and death. Women who develop these complications should begin to aggressively manage all their cardiovascular risk factors, and for the rest of their lives.

Updated: January 22, 2007

Women need to worry about cardiovascular disease, Dr. Rob for MSN Health & Fitness

Most people think heart disease is a man's problem, but when it comes to affairs of the heart, women don’t escape unscathed. In fact, 1 in 4 men as well as 1 in 4 women has some form of cardiovascular disease (CVD).

The statistics are depressing. Coronary heart disease takes the lives of more than 500,000 women each year & is the No. 1 killer of women over the age of 25. Yet in spite of these facts, most women don't consider heart disease to be their greatest health risk.

Why the disconnect?

Many women think cancer, especially breast cancer, is their top health worry. But the facts don’t bear this out.

1 in 2.5 women die from the effects of heart disease or stroke, compared to 1 in 30 from breast cancer.

Unfortunately, many women don't get that message. Women’s hearts, as men’s, need to be sheltered from the effects of high blood pressure, high cholesterol, obesity, diabetes & inactivity. Women also need to take precautions if they have a family history of early heart disease.

The medical community is perhaps also to blame for this lack of healthy heart urgency on the part of many women. In the past, many medical studies were only done on males & the model for diagnosing & treating heart disease was based upon this information. Thankfully, that’s changed. Now, we have up-to-date information regarding how heart disease manifests in women.

But, even so, when it comes down to diagnosing & treating CVD, a gender gap remains. Sadly, women who suffer heart attacks are more likely to die than men ... & that's not just older women.

Women of all ages are more likely to die.

It’s estimated that the cardiac death risk for women is 1.7 times that of men. But again there’s good news on the horizon. Women & their health care providers are beginning to team up to be more proactive in the prevention, recognition & treatment of heart disease.

As this approach becomes the norm, a woman's heart will be better protected.

Where to begin

As a woman, you need to know your risk factors for heart disease, change behaviors that contribute to the problem & finally listen to your heart.

Risk factors you can't control:

  • Family history

  • Age (55 & over)

Risk factors you can control:

  • Smoking

  • High blood pressure

  • Physical inactivity

  • Diabetes

  • Elevated blood cholesterol levels

  • Overweight

  • Metabolic syndrome (a group of health problems including abdominal obesity, elevated blood glucose levels & high amounts of cholesterol & triglycerides)

  • Waist measurement of 35 inches or more

  • Hormone replacement therapy

  • Overwhelming stress

  • Excess alcohol

After reviewing your cardiac risks, your physician will encourage you to begin lifestyle modifications (exercise, dietary changes, etc.) in an effort to reverse the risk factors you can control.

Next, further medical information may need to be gathered via blood tests, EKG, an exercise stress test or even a CT scan using next-generation electron beam technology to look into your heart & its blood supply. Depending upon the results of these tests, a heart healthy plan will be put into place.

Listen to your heart

When we think of a heart attack, the most common thought is a sudden "crushing chest pain" that goes into the neck, jaw, left shoulder & arm.

But this isn't always the case, especially in women.

In fact, about 1/3 of women don't even have chest pain. What they may experience is an unusual & unexplained fatigue, in addition to 1 or more of the following symptoms, which may appear in a gradual, rather than sudden, manner:

  • Pressure, fullness, discomfort or squeezing in the center of the chest

  • Shortness of breath or difficulty breathing

  • Pounding or a feeling of extra heartbeats

  • Upper abdominal pain

  • Nausea, vomiting or severe indigestion

  • Sweating for no apparent reason

  • Dizziness with weakness

  • Panic with feeling of impending doom

Please know the above symptoms can be caused by many other conditions. However, if you exhibit them, it's best to play it safe & consult your nearest health care professional or emergency room.

Every beat counts

If you suspect you’re having a heart attack, here is a checklist of things to do:

  • Call 9-1-1 right away. An ambulance will take you to an emergency room with 24-hour cardiac care capability.

  • As long as you are not allergic or have any other reason why you cannot take aspirin, chew an aspirin immediately, as this can reduce damage to the heart muscle.

  • Even if you are not sure you are experiencing a heart attack, it is best to go to your local emergency room to find out.

  • Every minute counts. The quicker you get diagnosed and treated, the better the chance for your heart muscle to survive.

Hidden Hypothyroidism Raises Cardiac Risk

Heart failure and CAD increased with subclinical hypothyroidism

By DrRich

Two studies appearing in the November 28, 2005 issue of the Annals of Internal Medicine suggest that individuals with subclinical hypothyroidism have an increased risk of developing heart failure, and hospitalization or death from coronary artery disease (CAD).

Subclinical hypothyroidism is a condition where the thyroid gland is having difficulty producing enough thyroid hormone. Thyroid hormone helps to regulate the body's metabolism, as well as digestive function, muscle function, and the normal integrity of the skin. Because the thyroid gland is borderline insufficient in subclinical hypothyroidism, the patient's system has to "whip it" to produce enough thyroid hormone. Thus, blood levels of the hormone called thyroid stimulating hormone (TSH,) which stimulates the thyroid gland, are elevated in subclinical hypothyroidism.

Since the thyroid gland is indeed making enough thyroid hormone with the extra stimulation provided by high levels of TSH, the patient has no symptoms or signs of hypothyroidism. In fact, the only abnormality seen in this condition is an elevated TSH level. (Given enough time, in most of these individuals the thyroid gland would continue to weaken, and overt hypothyroidism would eventually develop.)

In the two new studies, thousands of patients in the U.S. and Australia agreed to be followed for a period of years, in an effort to evaluate the ability of various risk factors to predict subsequent disease. One of the lab tests measured at the beginning of these studies was the TSH level. Investigators in the U.S. study, the Health, Aging and Body Composition Study, found that patients with elevated TSH levels (at least 4.5 mIU/L) had a significantly higher risk of developing heart failure over the next 4 yeats than patients with normal TSH levels. In the Australian study, the Brusselton Health Study, patients with elevated TSH levels had an increased risk of hospitalization or death from coronary artery disease. In both studies, the higher the TSH level, the higher the risk. The highest risk was seen in patients with TSH levels of 10.0 mIU/L or greater.

DrRich Comments:

Since these are observational studies and not randomized, prospective, controlled trials, they don't actually prove that subclinical hypothyroidism produces heart disease. They just help to establish an association.

Whether subclinical hypothyroidism ought to be treated at all has been controversial, since patients with this condition, in fact, have "normal" levels of thyroid hormone. Still, for patients who have this condition these studies do identify a potentially increased risk for subsequent heart disease, and at the very least ought to stimulate both the doctor and the patient to take special pains to reduce all controllable risk factors for cardiac disease.


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