Women’s Cardiovascular Health

written for NDNR (www.ndnr.com) and published Feb 2008

Heart disease is the leading cause of the death in the U.S. The World Health Organization estimates that 17.5 million people died of CVD in 2005, representing 30% of all global deaths. Of these, 7.6 million were due to coronary heart disease and 5.7 million were due to stroke. It is also a major cause of disability. The risk of heart disease increases as the population ages. A man over age 45 of a woman over age 55 has a greater risk of heart disease than younger folk. Another known risk factor is having a close family member who had heart disease at an early age.

Heart disease kills six times more women than breast cancer (Heart Disease and Stroke Statistics 2006 Update. Dallas, Texas: American Heart Association; 2005) but only 30% of women (from a 1997 national survey) recognized CVD as a leading cause of death.  The Red Dress Campaign, kicked off in 2005, raised this awareness to 55% although disproportionately more of this increased awareness was in white or well educated folks.  Help spread the word.  Focus on cardiac health.

Until Bernadette Healy, M.D., became medical director of the National Institutes of Health (NIH) in 1990, most clinical trials studying heart disease did not include women subjects.  Thanks to her, we are now approaching nearly 20 years of clinical trials with women.  Patterns are emerging, such as:

1) Women tend to develop cardiovascular disease 10-15 years later than men; possibly estrogen is protective, although this is controversial.  By age 60, a woman’s risk for CVD equals a man’s risk.  Certainly ingesting hormones increases clotting risk for some women.  On the other hand, smoking lowers estrogen levels and this is thought by some to play a role in why women smokers are more at risk for CVD than comparable male smoking cohorts.

2) In general women are more vulnerable to toxins. Our lungs, livers, and hearts are smaller.

3) Women’s smaller hearts beat faster, even when asleep.  Women have different cardiovascular disease risk factors and manifestation patterns than men.  For example, women are more likely to have MIs not preceded by angina.  (Canto JG, Shlipak MG, Rogers JF, et al. “Prevalence, Clinical Infarction Presenting Without Chest Pain.” JAMA. 2000;283:3223-3229) Women are more likely than men to die from their first heart attack.  Prevention is therefore particularly urgent for women.

4) Women are less likely to develop atherosclerosis, and are likely to have lower blood pressure.  Thus the cholesterol issue is less pertinent for women and the number 200 probably should not be applied to women.  Over half of women presenting with their first heart attack have so-called normal cholesterol levels.  (Burke AP, Farb A, Malcom GT, et al. “Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women.” Circulation. 1998;97:2110-2116) A younger woman with high cholesterol may be more at risk for CVD.  However, after age 65, low cholesterol confers increased mortality risk for all diseases, including cardiovascular disease.

5) Daily aspirin has been definitively proven to not prevent the first MI in women, which it may it men, though it can also kill men from provoking bleeding gastric ulcers.  So, ladies, unless you’ve already had a stroke, clot or MI, aspirin is unlikely to help prevent these killer diseases. Watch for women patients unnecessarily taking a baby aspirin a day because some docs are still not up to speed with this concept. (Ridker PM, Cook NR, Lee IM, et al. “A Randomized Trial of Low-Dose Aspirin in the Primary Care Prevention of Cardiovascular Disease in Women.” N Engl J Med. 2005:352:1293-1304)

6) Conventional risk factors affect men and women differently.  For example, high total cholesterol to HDL ratio is more likely to mean atherosclerosis in men.  Women are less likely to build up plaque; they are more likely to have peripheral artery, as opposed to coronary artery, disease.

7) Also, the impact of alcohol consumption worse in women: Alcohol is metabolized more quickly by women, making the immediate impact on heart, brain and liver more severe.  Men have a higher water to fat ratio in their body composition, and this extra water helps men to dilute the effect of alcohol.  Further, women are more likely than men to binge drink, which is the most dangerous way to consume this pickling poison.

From a whole body, naturopathic perspective, we can think of cardiovascular wellness as having both the plumbing and the electricity working well.  In women, the vasculature is less likely to get jammed up with plaque in the coronary vessels, although certainly this happens to women too.  More often, women suffer from peripheral artery disease due to vasospasm and low mineral status.  Not infrequently, patients are chronically dehydrated, and this contributes to preferential distribution of available fluids to the major vessels, at the expense of the periphery.  Plaque (comprised of cholesterol, calcium and bacteria) only adheres to damaged intima, which is why bioflavonoids and avoiding lipid peroxidation are keys to maintaining healthy arterial walls.  We have all seen patients with marginally elevated cholesterol on a statin drug.  Suspect statin side effects with any complaints of muscle fatigue, muscle weakness or muscle cramping.  Statins may also adversely affect the electrical system of the heart.

Women are more likely to have mitral valve prolapse than their male counterparts.  Sometimes this problem is readily fixed with adequate magnesium intake; rarely surgical repair or replacement of the valve is required.  Magnesium and caffeine elimination will also help mild arrythmias, although I recommend electrocautery of ectopic electrical tissue for pronounced tacchycardias such as PSVT and some Atrial fibrillation syndromes.  A pacemaker is generally implanted for chronic and profound bradycardic episodes, and not infrequently directly after the first episode, especially in an elderly patient where the concern is syncope.  You may be able to help your patient avoid a pacemaker by evaluating B vitamin absorption (homocysteine level) and providing nerve nutrients such as lecithin, omega 3 oils, Hypericum, Convallaria and Cactus.

Hypertension (140/90 or more) is possibly the most dangerous of the CVD risk factors, and one of the most difficult to resolve.  It remains a problem of westernized societies; rarely found in rural, agricultural or less developed communities.  Smoking tobacco significantly increases the risk for high blood pressure.  Please quit.  If you have a patient that still smokes, yet continues to seek your services, they are asking for help quitting (even though they may deny that!)  If you have hypertension, enroll in a local meditation class, or learn some other relaxation techniques.  There’s a new tool to improve hypertension via self-awareness called RESPeRATE (www.respearte.com) which is a home biofeedback device, and basically helps you lower blood pressure through breathing exercises.  Daily contrast hydrotherapy (chase your shower or bath with at least one cooler rinse) will also help alleviate circulatory insufficiency.

Find some kind of movement you enjoy: belly dancing, Aikido, ball-room dancing, contact improv, roller-blading, yoga, hula hoops, getting to 10,000 daily steps on your pedometer.  As long as it gets your heart rate up, and you’re having a good time, this is successful exercise.

The American College of Sports Medicine last published exercise guidelines in 1995.  These updates are more exact about the types and duration of exercise. They are based on recent scientific findings about the relationship between physical activity and health. The authors point out that an increase above the recommended minimum amount of exercise may provide further health benefits.

A companion guide is also available for adults ages 65 and over and adults 50 to 64 with chronic medical conditions.  These guidelines are similar but add important detail about flexibility, balance and how to stick with a plan.

Currently only about 25% of the US population follows these guidelines, according to the CDC.  Haskell states this percentage could increase to 50% over the next decade with the active support of the community agencies, medical personnel and, especially, employers.

Classifications of CVD:
Coronary heart disease (CHD) and coronary artery disease (CAD): disease of the blood vessels supplying the heart that may lead to:

Myocardial infarction
Congestive heart failure

Cerebrovascular disease: disease of the blood vessels supplying the brain that may lead to:
Transient ischemic attacks (TIA) or mini strokes

Peripheral vascular disease: disease of blood vessels supplying the arms and legs that can lead to:
Claudication – obstructed blood flow in arteries, causing pain
Gangrene – death of tissues in legs due to poor circulation
Aneurysms – bulges or enlargements in the aorta

Naturopathic protocol considerations:
1) Nattokinase or Lumbrikinase for IMT over 1 mm, for high fibrinogen, for history of or current thrombus.  Proteolytic enzymes not with food are also useful.
2) Hawthorne solid extract to improve lipid digestion and maintain or restore smooth healthy vasculature.  Anecdotally I have not found niacin to be particularly helpful for lipid profile improvement.
3) Rauwolfia serpentina tincture, up to 30 drops twice daily, for hypertension.  Watch for depression.  Anecdotally I have not found arginine to work reliably for HTN.
4) CoQ10 (as much as affordable) and exercise to reduce hypertension.
5) Vit E (not synthetic, mixed tocopherols) for overall cardiovascular health.
6) Vit C & D to promote tissue repair and reduce inflammation (high CRP).
7) To reduce inflammation, avoid white sugar and white flour; increase use of fresh garlic and ginger in the diet; eat less red meat (ideally fresh game only) and avoid fried foods.
8) Take adequate amounts of B6, B12 and folate to optimize homocysteine and reduce stroke risk.
9) Pantothene (B5) to improve systolic (adrenal) hypertension and raise HDL.
10) Magnesium at bedtime to reduce vasospasms, mild arrythmias and diastolic hypertension.
11) If you have high blood pressure, you may need antihypertensive drugs short-term, until the diet and lifestyle changes kick in.  If you are diabetic, avoid beta-blockers which tend to raise blood sugars.  If you are on a calcium channel blocker, magnesium may work just as well. ACE inhibitors often cause a chronic cough.
12) Statin alternatives such as Vit D, red yeast rice or chitin, if warranted.
13) Sodium restriction if the you are salt sensitive.
14) Optimal hydration (avoid diuretics as the kidneys quickly become dependent).
15) Daily movement: know the options in your community.  (see Exercise sidebar)
16)  Avoid fried foods, but not high quality fats.  Fish oils, nuts, flax seed will reduce risk of premature cardiovascular disease.

In closing, evidence is emerging that the long-held “truth” linking saturated fats and high cholesterol levels to cardiovascular disease was based on inaccurate tabulation of data.  For a comprehensive and fascinating discussion of this issue see Volk, MG, “An Examination of the Evidence Supporting the Association of Dietary Cholesterol and Saturated Fats with Serum Cholesterol and Development of Coronary Heart Disease” Alt Med Review: Sept 2007, Vol 12:3; 228-245.  Despite widespread use of statin drugs, cardiovascular mortality in the US has not improved.  In fact, more cases of nerve damage, TIAs, rapid progression to Alzheimer’s, chronic fatigue and depression have been reported in the population taking statins (sample reference: Li G, Higdon R, Kukull WA, Peskind E, Van Valen Moore K, Tsuang D, van Belle G, McCormick W, Bowen JD, Teri L, Schellenberg GD, Larson EB. “Statin therapy and risk of dementia in the elderly: a community-based prospective cohort study.” Neurology. 2005 Apr 12;64(7):1319 .

It is by now well known that statins deplete CoQ10, and thus produce their array of muscle cramping/muscle wasting side effects.  What has yet to be fully appreciated is the additional devastation caused by artificially lowering cholesterol levels.  Statins may be contributing to the widespread disruption of hormone synthesis (including pandemic hypothyroidism), demyelination of nerves (more depression in the elderly, more dementia, more ALS) and weaker immune response (more colds and flus).  Instead of reflexively reducing cholesterol, clinicians would do well to focus on reducing inflammation instead, using natural therapeutics.  This will provide you with a safer and more effective approach to improved cardiovascular health.  Drink a green smoothie, put your face in the sun, and dance for joy today!