Up to six times more women die of heart disease than of breast cancer; in fact, heart disease is the number-one killer of women, and the number-three killer of women under 45. Surprised? Given a lack of awareness about gender-specific risks, even women who think they practice good heart health may be relying on outdated or mistargeted information. Here, experts answer common questions about women’s cardiovascular health.

Q. My cholesterol, blood pressure, and stress test results are normal. Am I still at risk?                                                                          A. You might be. A 2010 study found traditional risk factors like high cholesterol and blood pressure failed to identify two-thirds of women with the highest risk: those whose heart X rays showed “substantial” narrowing of the arteries. In the 6,800-person Multi-Ethnic Study of Atherosclerosis (MESA), researchers found a third of the “low risk” female subjects in fact had heart disease. Cholesterol numbers can be deceiving partly because when it comes to LDL (bad) cholesterol, size matters, says Patrick Fratellone, MD, an integrative cardiologist in New York. Small, dense LDL particles block arteries; large, fluffy ones float. “A woman could have normal cholesterol but the wrong particle size, and she could have a heart attack,” he says. Ask your doctor for a cholesterol fractionation test, also called a VAP or NMR test.

Stress tests also aren’t reliable. To fail a stress test you need at least a 70 percent blockage in at least one artery. But the vast majority of heart attacks (86 percent) occur in blood vessels with less than 70 percent blockage, says William Blanchet, MD, a prevention-focused physician in Boulder, Colorado. This phenomenon is slightly more common in women because they have less obstructive disease (when cholesterol blocks the whole artery) and more plaque lining vessel walls (where it can break off to form a blood clot and lead to heart attack). And because most women don’t become hypertensive until after menopause, blood-pressure readings tend not to raise red flags, either.

Q. What is the connection between hormones and heart disease?

A. “We do know heart disease risk increases after menopause,” says Lorna Vanderhaeghe, MS, nutritionist and author of A Smart Woman’s Guide to Heart Health (Fitzhenry & Whiteside, 2010). Within a year of a woman’s last period, bad LDL levels rise, good HDL levels drop, and some women develop more of the dangerous small LDL particles. Moreover, lipoprotein(a), a gluelike type of cholesterol, goes sky-high during menopause, says Fratellone. Scientists aren't entirely sure what causes these changes, but fluctuating levels of estrogen and other hormones are thought to play a role.

Low thyroid often causes higher total cholesterol, Vanderhaeghe says—and leads to hypertension, according to a 2009 study. Fluctuating estrogen (and cholesterol) levels may slightly raise heart attack risk at certain times of the month, but the time of day is a more significant risk factor, says Blanchet: “The most common time for a heart attack to occur is in the early hours of the morning, usually before awakening.” Researchers think this is due to normal blood-pressure variations during the sleep-wake cycle; undiagnosed sleep apnea may also contribute.

Q. Can taking calcium supplements harm heart health?  

A. A controversial research review published last summer in the British Medical Journal indicated taking calcium supplements alone (without important cofactors magnesium and vitamin D) may calcify women’s arteries, putting them at risk for heart disease, theoretically outweighing the mineral’s bone-health benefits. Although it’s true that calcifications are often first detected in small breast arteries on mammograms (and their presence doubles heart attack risk), evidence that calcium from food or supplements can cause or increase these deposits is weak to nonexistent, says Delicious Living’s medical editor, Bob Rountree, MD. In fact, studies show calcium supplements may improve cardiovascular risk factors such as blood pressure and cholesterol. And in a new Harvard study, women with the highest magnesium blood levels had a 37 percent reduced risk of sudden heart failure compared to those with the lowest levels.

 

To lower risk for both heart disease and osteoporosis, eat calcium- and magnesium-rich foods such as milk, yogurt, tofu, beans, nuts, seeds, and green leafy vegetables and supplement as needed. Take 500 mg calcium citrate, aspartate, or glycinate along with 250 mg magnesium and 2,000 IU vitamin D, says Vanderhaeghe.

Q. Do statin drugs work as well for women as for men?

A. Statins like Lipitor or Crestor effectively lower LDL and total cholesterol. But they’re not great at reducing heart attacks, cutting the rate by only 30 percent for men and 20 percent for women, Blanchet says. And because cholesterol is rarely a woman’s primary risk factor, statins alone usually are not adequate treatment for at-risk women. Fratellone prefers to treat high lipoprotein(a), which is strongly linked to heart attacks, with 1,500 mg each of the amino acids proline and lysine; plus 500 mg niacin, 200 mg CoQ10, and 2,000 mg vitamin C, adjusting the dose of the latter over time as needed if loose bowels result.

In addition, red yeast rice (RYR), which contains a family of statin-like compounds called monacolins, can also help women with high LDL and total cholesterol. A recent study found 3,600 mg daily of RYR was an effective, well-tolerated dose, says Rountree.

Laurie Budgar is a Longmont, Colo.-based freelance writer who takes the experts’ advice to heart.

Top 5 ways to reduce heart disease risk for women

Go with grass-fed.  Eat red meat sparingly and, when you do, choose grass-fed beef, says Lorna Vanderhaeghe, MS. People with high levels of conjugated linoleic acid, an unsaturated fat found in beef and dairy from grass-fed cows, reduce their heart attack risk by more than a third, according to one study.

 

Select extra-virgin.  Extra-virgin olive oil boasts monounsaturated fat that reduces LDL and total cholesterol, it’s loaded with antioxidants, and recent research suggests it may alter genes that influence heart health, says Vanderhaeghe.

 

Don’t ignore stress.  Women who report their job stress is “much too high” have nearly a 50 percent higher risk of developing heart disease, according to a recent study. Stress often plays a bigger role for women than for men, says Patrick Fratellone, MD. “They have to balance their roles as mother, wife, and worker.” He asks his female patients to meditate 15 minutes, twice weekly; exercise 30 minutes, three times weekly; and pursue a hobby 30 minutes, twice weekly.

 

Brush up.  Cleaning teeth and gums well twice a day lowers the risk for cardiac disease by as much as 70 percent. Researchers think it’s because periodontal disease might make it easier for bacteria to enter the bloodstream and attach to plaque in the arteries, causing blood clots; and the inflammation that goes along with gum disease could lead to plaque buildup in the arteries.

 

Cancel cable.  A large Australian study found people who watched TV for four hours or more a day were 80 percent more likely to die from heart disease than those who watched two hours or less. And a similar Canadian study found those who sat most of the day were 54 percent more likely to die of heart disease than those who stood or walked at least half the time.

Heart disease predictors: Which tests are best?

Beyond measuring cholesterol and blood pressure, it’s important to talk with your doctor about additional tests, especially if you have a genetic history of heart disease or risky lifestyle factors such as smoking, stress, or inactivity, says Patrick Fratellone, MD. Blood tests can measure important heart disease markers including lipoprotein(a), a genetically influenced type of cholesterol linked to heart attacks; C-reactive protein, an inflammation marker; fibrinogen, a protein that helps blood form clots; homocysteine, an amino acid that in excess may increase risk for blood clots and narrowing of arteries; vitamin D, deficiency of which is strongly correlated with heart disease; and even insulin resistance.The cholesterol fractionation test determines cholesterol particle size. And a coronary calcium scan, an ultrafast CAT scan can pinpoint calcium deposits in the coronary arteries, an early sign of heart disease.