The Big Ticker: Heart Disease

Clench your fist—that’s about the size of your heart. Located in the center of your chest, the heart beats about one hundred thousand times a day, pumping five to six quarts of blood per minute.

Once the blood receives oxygen from the lungs, the heart sends the blood from the aorta through the arteries and into the capillaries, which are smaller, thinner blood vessels. Then, once the capillaries have brought oxygen and nutrients to every cell in the body, the blood is redeposited into the veins, and from there it goes back to the heart for the cycle to begin again.

So what we have here is a plumbing system essentially, a smart pump with different connecting parts that circulates blood throughout the body. The heart itself is made up of four chambers—the two up top are called the atria, the two on the bottom are called the ventricles—connected by a set of valves. And the whole system is set in motion, or beats, thanks to the electrical impulses sent out by a small bundle of specialized cells in the right atrium that act as the heart’s natural pacemaker, causing the muscles of this organ to contract and relax.

Any malfunction of this blood pump is known as heart disease, of which one of the most common types is coronary artery disease. It is the number-one killer of both men and women in the United States. Half a million people die of it each year, and more than 12 million people have the disease.

Coronary artery disease, also known as coronary heart disease, is a narrowing and obstruction of the coronary arteries, which are responsible for bringing oxygen and nutrients to the heart itself. As early as your teen years, fat deposits begin to develop in some of these arteries, and as time goes by, the fat deposits build up, ultimately creating an obstruction that begins to decrease the amount of blood to the heart and cause an inflammation as the artery tries to heal itself.

Over time the fat deposits in the arteries begin to harden, and you begin to get deposits of small platelets that compound the obstruction. All of this can lead not only to a significant narrowing of the arteries, but to blood clots that may either obstruct the artery or get dislodged and create further obstructions elsewhere in the plumbing system.

One of the consequences of this narrowing or total obstruction of the coronary artery is ischemia, which occurs when there is an insufficient supply of oxygenated blood for the heart muscle. Any activity—eating, excitement, or changes in temperature—can make the problem worse.

One of the most common symptoms of ischemia is angina, which is a discomfort, heaviness, pressure, numbness, or squeezing feeling in the chest. Sometimes it is mistaken for indigestion or heartburn. It is usually felt in the chest, but it can also migrate to the arms, especially the left shoulder. Other symptoms include shortness of breath, irregular heartbeats or palpitation, a very fast heartbeat, nausea, and sweating. If this ischemia is not corrected, if it lasts more than 30 minutes and does not get better, a heart attack may result.

In a heart attack, the heart muscle begins to fail, either through a very erratic electrical stimulation called an arrhythmia or by stopping altogether. It is important to recognize these symptoms because early intervention could save your life.

A doctor can tell you if you have coronary artery disease by discussing your symptoms, especially shortness of breath, taking your medical history, and looking at your risk factors, in particular, smoking, cholesterol, blood pressure, and sugar control. There are a host of diagnostic tests your doctor can do, such as an electrocardiogram (ECG or EKG); an exercise stress test; an ultrafast CAT scan, which looks for calcium deposits in your coronary artery; and cardiocatheterization, which can help determine the degree of obstruction of the artery.

If you are diagnosed with coronary artery disease, treatment is threefold. The first has to do with lifestyle changes, like quitting smoking, starting to exercise, and keeping to a low-fat, low-sodium, low-cholesterol diet.

The second aspect of treatment is medication, which may be needed to get your heart working more effectively. Other medication will be prescribed to reduce the cholesterol.

The third aspect of treatment has to do with procedures to help improve the blood flow through the coronaries. One possibility is a balloon angioplasty, in which a small balloon-tipped catheter is inserted into the coronary arteries and then inflated to open up the clogged artery. Another possibility is placing a small, metal stent inside the artery to keep it open and improve blood flow.

A heart bypass operation takes place when total replacement of the piece of the coronary that is obstructed becomes necessary.

Plumbing Vs. Electrical Problems

Other types of cardiac disease have nothing to do with obstruction of the coronaries but with the way the electrical system of the heart works. Sometimes the specialized cells that electrically stimulate the heart become dysfunctional, and you can develop an arrhythmia, where the heart beats either too slowly, too quickly, or out of sync. These conditions can be diagnosed with an electrocardiogram, and sometimes medications alone can help to regulate the rhythm.

Another common problem is heart failure. This occurs when the heart can no longer effectively pump all the blood that it receives. Heart failure affects about five million Americans, and it’s the leading cause of hospitalization of people older than 65. Many times, heart failure is due to prior damage caused by coronary artery disease, or by arrhythmias that have weakened the function of the heart. Ultimately, heart failure creates a backlog of pressure into the lungs, and people with heart failure tend to have difficulty breathing. Depending on the cause of the heart failure, different medications are available for treating it.

The valves of the heart are another source of heart problems. The valves can be damaged at birth or through infection. Abnormal or infected valves can interfere with normal blood flow and heart function and can lead to major cardiac disease. Surgery may be needed to replace the valves.

Sometimes the lining of the heart may be infected, a condition called pericarditis. If this membrane is inflamed, the heart may not beat properly. Valve abnormalities, arrhythmias, and heart failure all have a common symptom—shortness of breath or difficulty catching your breath. If you have this problem, see a cardiologist to get the correct diagnosis and treatment.

The heart is a remarkable organ. It is the core of life, and its beat is central to your survival. Keeping it in prime working order is of paramount concern.

All for One and One for All

When we talk about heart attacks, we tend to describe them in a way that suggests there are different kinds of heart attacks. But those are just words to describe our experience of the same underlying disease.

Number one is the silent heart attack. Here you don’t have major chest pain, you don’t have shoulder pains, you may have a little palpitation, but you’re not tired, you’re not fatigued, and you’re not dizzy. However, when you go in for a physical, the doctor finds that you have had a silent heart attack.

Number two is typical angina. This is the chest pressure that doesn’t go away, and you have thirty minutes to get yourself to an emergency room.

Number three is the sudden heart attack. This occurs when you have a major, catastrophic obstruction in a main branch of the coronary artery, and a very large area of your heart is instantly void of any blood.

Even though the three heart attacks described here evolve differently, the underlying theme is the same—they all involve chronic coronary artery disease. In other words, you don’t go around with a normal coronary artery one day and the next day develop a major clot. That’s just not the way it works. The heart attack may present itself differently in different people, but the cause is the same no matter how we experience the critical moment.

A Heart Test for Venusians

What works for men, doesn’t always work for women. We all know that, but medicine is just catching up to the fact.

The standard test for heart disease is known as an angiogram. In this test a dye is injected into the coronary arteries, which are then X-rayed to look for blockages. The test is very effective in detecting heart disease in men, but a new study has discovered that this test often misses the symptoms of heart disease in women. When the tests turn up nothing, women are given a clean bill of health, even though as many as 3 million women could be at risk with a buildup of fatty deposits that could ultimately interfere with blood flow to the heart and cause a heart attack.

Hidden heart disease may be a significant problem in women. It appears that one cause may be due to a phenomenon called arterial remodeling. This means that the artery dilates as plaque is deposited in the blood vessel so that, in the early stages of atherosclerosis or coronary artery disease, very little overall narrowing is seen on an angiogram. But late in the disease, the deposits may overwhelm the body’s ability to compensate by remodeling, and severe narrowing or complete blockage can occur. If this happens, a sudden heart attack can result.

To diagnose heart disease in women, physicians will now have to use the new generation of CT scanners and magnetic resonance scanners, which can visualize the heart’s blood vessels with ever-greater detail. In many cases, these tests can detect problems before a stress test or a conventional angiogram. Physicians should test for the presence of coronary artery disease in women who have risk factors for heart disease such as diabetes, hypertension, high cholesterol, a family history of heart disease or stroke, or nicotine use.

The moral of this story is: paying closer attention to the vast differences between men and women could save lives—in this case, women’s lives.

Which Fruit Are You?

Researchers have long noted the importance of body shape in determining a person’s risk factors for heart disease. They talk about the apples versus the pears. The apples tend to store their access fat in their stomach and chest. The pears store it below the hips, in their thighs and buttocks. A recent study found that a person’s waist-to-hip ratio is an even better predictor of cardiovascular risk than their body mass index, or BMI, the commonly used ratio of weight to height. It appears that a large waist size, which generally indicates large amounts of abdominal fat, is more harmful than a larger hip size.

Determine your body shape and risk for cardiovascular disease by calculating your waist-to-hip ratio. First, measure your waist at its smallest circumference; then, measure your hips at their widest. Next, divide your waist measurement by your hip measurement. For example, a person with a thirty-six-inch waist and forty-inch hips would have a waist-to-hip ratio of 0.9. Waist-to-hip ratios over 0.85 in women and over 0.9 in men are strongly associated with an increased risk for heart disease.

Doing It, or Not?

One reason—if not the main reason—we diet and exercise is that we want to look good to the opposite sex (or maybe the same sex).

And, of course, one reason—if not the main reason—we want to do that is to be attractive to our (real or imagined) sexual partner.

Now, what does any of this have to do with health, you wonder? The answer is, plenty. A healthy sex life improves your overall quality of life. It improves your immune system because it significantly relieves stress. Good physical exercise burns calories, and it improves your mood by pumping endorphins into your bloodstream that make you feel good. It also plays a key role in keeping couples together, so the benefits of sex are innumerable.

But once you get on into your forties, you might find your sex drive shifting into a lower gear. This diminished or lack of sex drive is more common in women than it is in men. Even men with erectile dysfunction usually have a normal sex drive. While libido problems can be either physical or psychological, the root causes tend to be the same in both sexes. Alcoholism is the main physical factor responsible for a decreased libido; another is drug abuse, of cocaine, for example.

Obesity and anemia are other potential physical problems. And there are certain tumors of the pituitary gland that increase the hormone prolactin, which lowers the libido. Some prescribed medications, especially antidepressants, lower the level of the hormone testosterone, which is needed by both sexes to maintain an adequate sex drive. Psychological factors influencing libido include depression, stress, and confusions about sexual orientation.

Anyone with a lack of sexual desire should first try to take these factors out of the equation. So if you’re drinking excessively, overweight, depressed, or taking medications, these issues need to be dealt with to resolve a flagging libido. Counseling can help with the psychological problems of sexual hang-ups, depression, or stress.

There is no magic remedy for the loss of sexual libido. Though testosterone has been identified as a key hormone that improves sexual appetite in women, doctors who have been giving women testosterone supplements for the past 30 years have found that it has little effect on their libido, while it sometimes causes facial hair growth, a deepened voice, and an enlargement of the clitoris.

I have no doubt that one day there will be a libido pill for women and men, as I’m sure the drug companies are hard at work on this potentially lucrative solution.

There are a number of other sexual problems that women may experience at any age. One is dyspareunia, or painful sexual intercourse. Any part of the genitals can cause pain during sex, including the skin around the vagina. Vaginal infections, like yeast infections or viral infections, are a common cause, and the pain can be felt when either a tampon or penis is inserted into the vagina. It can also occur from just sitting or wearing pants. To treat dyspareunia, physicians may recommend hormone creams, dilators to help stretch the vagina, Kegel exercises, or, in rare cases, antidepressants.

Another potential cause of dyspareunia is vaginismus, an involuntary contraction of the vaginal muscles that may prevent insertion of the penis during intercourse. The diagnosis of vaginismus is usually problematic because it’s often difficult to separate the physical pain with the emotional anxiety of experiencing that pain; in other words, just the fear of the pain can cause vaginismus.

Any woman complaining of these symptoms should be taken seriously. A doctor must conduct a physical examination to eliminate the possibility of such physical causes as infections, fibroids, or anatomical deformities of the uterus, ovaries, or vagina. Even vaginal dryness can cause painful sex. A decrease in estrogen at menopause can cause the vaginal walls to become dry, creating a discomfort or pain during intercourse.

If there are no treatable physical conditions, it’s important to discuss the woman’s feelings as well as the physical situations that lead to this type of discomfort. Some women have a very positive attitude toward sex; other women have had negative sexual experiences that play a significant role in their fears and negative feelings about sex.

Some women may have a history of sexual abuse, rape, or trauma, for instance; these things need to be identified in a very delicate way. Treatment of vaginismus usually involves practicing relaxation techniques and doing Kegel exercises to relax the vaginal muscles. At home, one exercise that may prove beneficial is to have your partner gradually insert a dilator into your vagina. This must be done at a pace with which you feel comfortable until the pain and discomfort are overcome. Partner, doctor, and patient all have to be in sync for this type of therapy to be successful.

Many women experience discomfort or pain at the time of their period. This pain is caused by contractions of the muscle of the uterus during menstruation that occur due to the release of the prostaglandins, which are hormones that are produced in the lining of the uterus. For most women these menstrual contractions are neither severe nor disabling. But some women experience significant menstrual pains called dysmenorrhea.

Women suffering from dysmenorrhea should exercise, get plenty of sleep, and avoid stress. Over-the-counter painkillers can minimize the amount of prostaglandins released, and they usually help reduce the pain. If the painkillers are not effective, your doctor will have to look for other things that are causing the pain. And ultrasound is sometimes used in such cases to make sure you don’t have any other medical conditions, like pelvic inflammatory disease, endometriosis, or fibroids.