Heart disease is the biggest killer in the UAE, accounting for 28 percent of all deaths. In less than 30 years, deaths from cardiovascular disease have shot up alarmingly, from 1.02 million deaths in 1990 to 7.35 million in 2017. And contrary to popular belief, women are just at much at risk as men — and not just when they get older.
Unhealthy lifestyle choices have led to a rise in heart disease in younger women, says Dr Dima Quraini, a cardiologist at the Heart and Vascular Institute at Cleveland Clinic Abu Dhabi.
“Premenopausal women are now at a higher risk of developing heart disease because there is a higher incidence of diabetes, high cholesterol, obesity and complicated pregnancies among this group,” she tells The Livehealthy Podcast.
However, lack of awareness of the risk factors means it takes longer to diagnose heart disease in women than in men, she adds.
Women who suffer a heart attack are more likely than men to die of it. In a heart health survey of 1,000 residents commissioned by Cleveland Clinic Abu Dhabi, 64 percent of the women who took part said they did not suffer from the common risk factors for heart disease. But around 59 percent of those women also said they had not discussed their heart health with a doctor in the past year.
Where is women’s heart health at?
“In our women’s heart clinic we see a variety of different diseases, but there are two main categories. The first is women with a lot of risk factors coming in to get assessed. They have not developed heart disease yet, but they have diabetes or high blood pressure or they may have had pregnancies complicated by high blood pressure. We do a lot of work with them on prevention and they form a big proportion of our patients.
The second category is patients who have already developed heart disease. They are a varied group in themselves, from women who have had a heart attack, but also women with specific diseases that we see only in women or predominantly in women.
With a traditional heart attack, cholesterol plaques develop in the arteries which lead to a sudden blockage of the arteries. Eighty percent of women over the age of 40 carry at least one risk for the type of heart disease, whether it’s diabetes, high cholesterol or obesity.
One of my patients was a woman in her 30s whose arteries were so severely blocked that she had to have a coronary bypass. We initially thought it was because she had recently given birth but further investigation found that she was genetically predisposed to high cholesterol and her levels were extremely high, causing severe blockages in her arteries. Yet she was completely unaware of her condition.”
How much of a role does lifestyle play in preventing cardiovascular disease?
“Heart disease can be partly genetic and we can’t change that. But most risk factors can be altered through lifestyle changes and we focus a lot on that. It can be confusing for people. Fat used to get a lot of the blame, for example. But in the 1950s, people started to notice that those from the southern Mediterranean regions tended to have less heart disease than those living elsewhere, which led to studies on what we now call the Mediterranean diet.
This is the food people ate in the 1950s and 1960s in small villages and was predominantly plant-based with a lot of whole grains, vegetables and a lot less processed food. If they ate animal products, it was predominantly fish followed by chicken. They ate very little meat — perhaps only once a week or on certain occasions.
Then the studies looked at nuts and olive oil. A study in Spain showed that supplementing a Mediterranean diet with olive oil helped prevent strokes, heart attacks and high blood pressure. So that’s usually the diet we recommend.
We stay away from fad diets because this isn’t about losing weight, it’s about adopting a lifestyle. Fad diets do more harm than good because they are not sustainable and can restrict key nutrients which can cause a severe energy deficit, muscle loss and other deficiencies. Yo-yo dieting can lead to poor cardiovascular outcomes. So we don’t eliminate sugar entirely but focus on adding more fresh fruit and limiting the animal component. As for processed food, the more processed it is, the less you know about what’s in it. Fresh, real food is always better.
The best thing you can do for your heart is to have a healthy lifestyle. That means eating fresh, real food, not smoking, watching your weight and taking at least 150 minutes a week of exercise. And by exercise, I mean moderate exercise, like going for a walk or a swim. You don’t have to go to the gym and lift weights — just be active. Also, manage your stress and sleep. All of that will prevent heart disease.”
High cholesterol is usually treated with statins, but do they work?
“There are different types of cholesterol. There’s good cholesterol, or HDL. The more you have of that, the more you’re protected from heart disease. Unfortunately, we don’t have good medication that raises levels of good cholesterol. But eating a healthy, plant-based diet helps.
Then there’s bad cholesterol, or LDL, and the lower your level, the better. People sometimes think that since our body makes cholesterol we must need it for something, but that’s not the case.
Statins have had some negative media attention but I really believe that they benefit patients, not only by bringing down levels of bad cholesterol but also by preventing heart attacks and strokes, because they have an anti-inflammatory effect. These drugs reduce the risk of having a heart attack by 20 to 25 percent. That is a significant reduction. If I have a patient who is hesitant about taking statins, I say, ‘If I can give you something that brings down the risk of a heart attack or stroke by 20 to 25 percent, why wouldn’t you take it?'”
What concerns do people have about statins?
“Studies have looked at whether statins raise the risk of dementia, but the studies didn’t bear that out. There was also concern about statins increasing the risk of cancer, but that’s not proven either.
Statins can have some side effects, the most common being cramps, but we can look at alternatives.”
What are the warning signs of heart attacks in women?
“The number one priority is: know your risk. I’m left baffled when patients can’t tell me anything about their family history, like whether their parents had high blood pressure. It’s very important to get an evaluation, to check your blood sugar, your weight, your BMI. Family history is a key part of getting the overall assessment.
What happens in pregnancy can predict what happens to a woman in later life with her heart health, so as cardiologists we go into detail about that, too. Pregnancy is like a stress test for a woman, so if you had high blood pressure when you were pregnant or there were any complications, you need to be monitored more closely.
Not all heart attacks are caused by a blockage. During pregnancy, young women can develop tears in the arteries of the heart, which can cause a heart attack. It’s rare and we’re still learning about it, but it can happen.
As for women presenting with different symptoms, a study of young women showed that women were coming in with chest pains, just like men. The difference was that they had to come in to the emergency department more often before a doctor would do further testing, so doctors need more education, too. If a woman comes in complaining of chest pain, we need to take her just as seriously as we would a 50-year-old man clutching his chest.
The most important message that I try to communicate is that women are just as susceptible to heart disease and heart attacks as men. Most heart diseases can be prevented by knowing your risk and addressing them early.”
What are the symptoms for women?
“Typically, people complain of a heaviness in the chest, as if someone was sitting on them. It can radiate to the left shoulder or arm or even up to the neck. If it goes down to the leg, then the problem is not the heart. Shortness of breath, fatigue when doing normal everyday activities, like not being able to finish off a walk, bad nausea, sweatiness — these are unusual symptoms which require attention.”
What about just thinking you’re having a heart attack?
“Chest pain doesn’t have to mean a heart attack, but I always take it seriously. We start with the basics: if the patient is in their 40s or 50s and diabetic, it needs further investigation. If the patient is a 20-year-old, the likelihood of her disease is low but I would never diagnose anxiety without doing testing, so we look at the electricity of the heart with an ECG and put them on a treadmill for a stress test. If you have chest pain but the tests come back negative, at least you’ll feel reassured. Anxiety is a diagnosis of exclusion. Half of our patients with chest pain turn out to have some form of reflux. That even happened to me when I was in my 20s and training in cardiology.
Chest pain can be due to a variety of reasons. If it happens at random and you can exercise with it or go about your activities without discomfort, you can rest assured.
Actually, we love seeing patients who come before they have a problem — it’s called preventative cardiology and we have a clinic for it at Cleveland Clinic Abu Dhabi. We can take a good history, do an ECG, check blood sugar and cholesterol and there’s even a risk calculator that can specifically estimate your risk of getting heart disease in the next 10 years, so you know just how aggressive you should be in your prevention. Sometimes we put people on statins even though their cholesterol numbers are not high yet but their blood pressure is a bit on the high side.”
What about strenuous exercise?
“There are certain extremes, of course, like marathon running, but generally, the more exercise you do, the more benefit you will reap. What I would recommend, though, is doing more aerobics rather than weights. Lifting weights is better than nothing but you get more cardiovascular benefit from aerobic exercise – plus lifting heavy weights can actually raise blood pressure.”
What are the links between cardiovascular health and perimenopause or menopause?
“It’s true that women go through a lot of changes around menopause. That’s the time we see blood pressure and cholesterol go up, weight gain and changes in fat distribution, with more fat around the belly.
As women, we may not like the fat on our hips for aesthetic reasons but it’s not linked to higher mortality, whereas we know that visceral fat — that’s the fat around the belly — is more dangerous and it’s linked to an increase in heat disease and thickening of plaque in the carotid artery. We can measure that thickness to get an idea of the risk.
Blood pressure normally goes up with age. We start seeing a rise in the mid-to-late 30s and after 50, there is more increase probably due to hormonal changes. Chest pain happens for a variety of reasons, but I would certainly take chest pains seriously in a perimenopausal woman
What can you do about it? It’s the same advice as usual: keep to a healthy weight, eat a good diet and exercise. Intermittent fasting is a good idea and it can improve overall health.”
What is the role of the hormone therapy?
“This was a big topic of discussion in cardiac health years ago. The thinking was that before menopause, women are protected from heart disease but we see an increase in it after menopause, so let’s kick the hormones back in and all will be well.
But a large study showed that HRT actually increased the risk. We don’t prescribe it as a preventative. The role of HRT is to alleviate symptoms that limit lifestyle, not to prevent heart attacks.”
What about taking supplements?
“We see people who are skeptical about taking statins, which are really beneficial, taking 10 different supplements without even knowing what’s in them.
Studies have looked at omega 3 (fish oil) and vitamin E and found that while they’re not harmful, they don’t give you any benefit either. It’s OK to keep taking them but I try to minimize the medication a patient takes. Just eat a varied diet of fresh food, try and get 80 percent of your food from plants and limit the animal fat and you’ll get all the nutrients.
Unless you have a specific problem, such as malabsorption, you shouldn’t need supplements.”
Dr Dima Quraini was a guest on the Livehealthy podcast on June 16, 2021.
Anna Pukas has reported from all over the world as a foreign correspondent for British media. She is now an editor based in Abu Dhabi.