“It’s a men’s condition,” or “It only occurs in older people.” That is the mistaken belief many have about heart disease, the country’s biggest killer.
However, the condition can affect men and women of any age and it is increasingly affecting younger and middle-aged people. The risk rises as you get older – one in six cardiovascular deaths occurs in the under 70s.
Heart disease develops quietly over many years. Everyday risk factors such as high cholesterol, high blood pressure, diabetes, and stress all contribute to a slow build-up of fatty deposits in the arteries.
This build-up can cause atherosclerotic cardiovascular disease (ASCVD ), a condition responsible for about 85 per cent of heart attacks and strokes. More than 300 million people worldwide are living with ASCVD with another two billion at risk. The good news is that 80 per of cardiovascular deaths can be prevented.
Dr Irene Gibson, the Head of Clinical Innovation at the National Institute for Prevention and Cardiovascular Health, and a former cardiovascular nurse specialist with Croí, said we can protect ourselves against a number of risk factors for ASCVD by taking preventive action. Tackling high cholesterol and high blood pressure, not smoking, taking sufficient exercise, and having a healthy diet are all ways to do this.
“Atherosclerotic cardiovascular disease is the build-up of fatty deposits and plaques within the walls of our arteries,” she explained. “The foundations for these plaques are laid down as early as in the womb. Certainly, from the age of two years upwards, you can see these fatty streaks depositing. We need to be thinking about this early in life. It’s a very gradual process, this build-up of plaque is over a lifetime and, for various different reasons, these plaques can be disturbed and become problematic.
“I often draw the analogy of it being a little like a volcano building up. It can lie dormant for a number of years and for whatever reason, maybe as a result of the ageing process, maybe because your blood pressure is particularly high, that volcano can become very unstable and can erupt. As a result of that, you’ve got lava that spills out and pours into your arteries and it can either form a clot on the way to the heart and result in a heart attack, or if it’s in an artery on the way to the brain, it can cause a stroke.”
Silent killer
Speaking at a podcast organised by Croí, the local heart and stroke charity, she outlined that high blood pressure, often known as the silent killer and the leading cause of stroke, is “extremely common” in Ireland. More than 60 per cent of people over 50 have it.
“High blood pressure is one of the keys things for us all to be aware of, to have it checked, to know our numbers, and to know what our blood pressure should be. Ideally, everybody in the population needs to be working towards a blood pressure [reading] of less than 120 over 70.”
The fact that the symptoms of high blood pressure tend to be “silent” and sufferers tend to feel well until it has caused significant damage to their bodies, means they are often unaware their levels are high.
The situation is similar with high cholesterol. It is also a “silent” enemy with people often not experiencing any symptoms until it causes a major health event like a heart attack or stroke. The build-up to those events develop slowly over the years, clogging blood vessels without causing pain or discomfort. A simple blood test will reveal your cholesterol levels. A major driver of ASCVD is the LDL or “bad” cholesterol in your blood which can lead to dangerous blockages in the arteries.
When referring to high blood pressure, health professionals often talk about the “rule of halves”, stated Dr Gibson. “Only half the people who have it, know they have it, and of those who know they have it, only half are on treatment. And of those, only half are on the treatment that controls their blood pressure to the recommended targets.”
She said there is a common misconception that cardiovascular disease solely affects older people and that we only need to worry about risk factors as we get older. But that is not the case.
“Really, we need to be thinking of these risk factors very early in life and making all the healthy lifestyle changes that are associated with reduced cardiovascular risk. These are important for reducing our risk for many chronic diseases, including cancer. For example, when we look at [untreated high] blood pressure, that is a major contributor to an increased risk of cognitive decline and dementia. Often, we don’t consider blood pressure in that way. Making these lifestyle changes are important for many organs in your body and will lead to positive gains. You will see these right away.”
Genetic disease
There are risk factors within and outside our control in terms of preventing cardiovascular disease. Some people have genetic high cholesterol which results in very high “bad” cholesterol levels from birth. They are much more likely to develop heart disease or stroke approximately 20 years earlier than those without the condition, say experts.
“There are things within our control and there are risk factors outside it,” said Irene Gibson, who has a PhD in Digital Health and Cardiovascular Disease. “There is a bigger picture at play as well, we know there are environmental stressors that increase our cardiovascular risk such as climate, air pollution, and noise exposure – all of these things increase our cardiovascular risk.
“There are other risk factors as well that people are less aware of. If you have an autoimmune condition such as arthritis, it puts you at increased risk of cardiovascular disease. Or if you have psoriasis [an autoimmune condition that causes red patches of dry, flaky, itchy skin] that increases your risk of cardiovascular disease, too. Or, if you suffer from migraines, that also increases your risk. [However] these [risks] are maybe not to the same level as some of the more established CVD risk factors. We are seeing new and emerging research all the time.”
For decades, heart disease has been regarded as a man’s disease leading to women’s symptoms being misunderstood or overlooked. Unlike the classic chest pain signs often reported by men experiencing heart attacks, women’s symptoms can be more subtle, resulting in delayed diagnoses, misdiagnoses, or poorer outcomes.
“There is a misconception heart disease is a man’s disease and that misconception is hugely problematic,” she said. “It means women are under diagnosed, under treated, and under studied. If we look at all the research studies in cardiology, only 25 per cent actually include women. We have a general understanding of the sex specific differences but we need to understand this much better because as women, anatomically we are very, very different.
“Our blood vessels are much smaller, the walls that separate the chambers of our hearts are thinner and also we carry less oxygen in your blood to the different parts of the body. Men and women are equally affected by heart disease but the difference is that men are impacted at a younger age. That risk is delayed about 10 years in women. This is because oestrogen protects us up to a certain point in life. But once we reach the menopause years, we very quickly catch up with our male counterparts.”
Unfortunately, not only do women catch up with men, they actually move ahead of them in this regard, she said. More women than men die of cardiovascular disease at an older age and women are seven times more likely to die from cardiovascular disease than from breast cancer.
Attending mammograms
“I think that’s pretty startling because as women, we hear so much about breast cancer, and checking our breasts and attending mammograms. The same emphasis and focus is not on cardiovascular disease and we’re more likely to die from it.”
Misconceptions and lack of awareness about how heart disease affects women have impacted negatively on how they are diagnosed and treated. “When it comes to the diagnosis, that’s complicated by the fact that our symptoms are different to men. We don’t present in the same way as men (their typical symptom is chest pain ), 40 per cent of women won’t have that typical symptom.
“Our symptoms tend to be a little more subtle, we might be feeling nauseous or have an ache radiating down one arm or to the back or to the neck or jaw. Women often talk about this overwhelming feeling of fatigue. We’re all tired all the time from life and doing activities but this is a different level of fatigue. It doesn’t feel right. Some women will have indigestion, if you heard about that in a man, you’d think straight away it’s got to be the heart whereas for women, less so. When women do attend the emergency department, or their GP, their symptoms can be put down to anxiety. It’s important we educate the public, but equally we need to educate health care professions and clinicians.”
Some conditions put women, especially younger women, more at risk of heart disease. “If you had pre-eclampsia [a high blood pressure disorder that typically develops after 20 weeks into a pregnancy] in your pregnancy or high blood pressure in your pregnancy that significantly increases your risk for heart disease. When we look at how much it increases your risk, a research study published recently said a pre-eclampsia diagnosis makes a woman 75 per cent more likely to die from cardiovascular disease in later life. That is pretty startling stuff.
“If you have diabetes in pregnancy, often referred to as gestational diabetes, not only does that increase your risk of diabetes later in life but, it also increases your risk for cardiovascular disease. There are other things as well. If you start the menopause before the age of 40 or if you suffer from endometriosis, [a condition where tissue similar to the lining of the womb starts to grow in other places] or if you suffer from polycystic ovary syndrome [a common hormonal disorder affecting about 10 per cent of women of reproductive age], all of these things increase your cardiovascular risk. I’m not sure women are aware of that.”
Not only do women frequently wait longer than men to seek medical help for their symptoms, they are less likely to receive guideline recommended treatments for cardiovascular disease in comparison to men, according to Dr Gibson. “They are also less likely to receive the same medication and are less likely to be referred to the ongoing supports and rehabilitation services that exist, as well. That’s a real barrier because these treatments are lifesaving.”
• Croí’s free nurse helpline, Croí Connects, is available Monday to Friday, 9am to 5.30pm. Telephone (091 ) 332999 or email [email protected] You can also register for weekly online health chats on croi.ie/croi-connects
