Health: Women and affairs of the heart: Heart disease is now the major cause of death in British women, yet until recently doctors saw it as as largely a male problem. Victoria McKee reports on new research

MANDY ALLEN was just 29 when her heart 'short-circuited' on the squash court. Unknown to her, she had a serious congenital defect, a condition known as Wolff-Parkinson- White Syndrome. Mandy, a teacher from Cardiff, was rushed to hospital and lived to tell the tale, but she believes the attack could have been prevented if her condition had been diagnosed earlier.

Now 32, and fit enough to work out five times a week, she explains that she repeatedly complained to her GP of tiredness and chest pains. These, she says, were attributed to the after-effects of an earlier attack of pneumonia and pleurisy. 'Since most doctors seem to think heart disease is for men,' she says, 'it's important for women to insist on getting themselves checked out.'

Why is it that heart disease, which is the leading cause of death among British women, is still considered a man's illness? Could heart attacks among women be prevented if the warning symptoms were picked up earlier in the way that a man's might well be?

These are two of the questions being asked as the subject of women and heart disease becomes a dominant health issue of the 1990s. 'What we are seeing is an increasing number of younger women with heart disease,' warns Dr Diana Holdright of the London Chest Hospital, co-author of a report in last month's British Medical Journal on the difficulties of identifying women in danger.

'A lot of the tests we apply to men simply aren't so useful in women,' she explains. 'The treadmill test is particularly unhelpful, as women show more false negatives on the electrocardiogram than men. So more research has to be done to devise reliable tests for women.'

Some women, Dr Holdright adds, can have abnormalities of the tone of the coronary artery even if there is no furring up. 'Hormones are vaso-active and can alter the size of the artery. Women are therefore more prone to heart attacks at certain times of the month, such as at ovulation or the onset of menstruation.'

Despite increasing awareness of the risks, the symptoms of women who complain of classic indicators of heart disease are sometimes misread. Maureen Parsons went into cardiac arrest nine times on the way to hospital at the age of 49. Since her early menopause, at 39, she had complained to her doctor of 'palpitations' and two years before her attack of pains in her chest and back. These were 'indigestion', she was told. 'I'm sure if I'd been a man they would have thought of my heart,' she says, 'and referred me for further tests instantly.' She feels that since she had had an early

menopause and was a smoker, the possibility of heart disease should have been investigated. Joan Richardson had a similar history of 'indigestion' when she had a heart attack at the age of 46. She has since been trying to raise awareness of the risks of women's symptoms being overlooked, campaigning for the British Heart Foundation and working as a community health officer in Worcestershire.

At 37, Sherree Cummings is only just beginning to get over the debilitating fear and insecurity caused by the heart attack she suffered in her local swimming pool at the age of 34. Slim, fit and active, she had been visiting her doctor for months with pains in her stomach. Sherree now knows that these were due to angina, but no one ever anticipated a problem with her heart. 'If it had been my husband having those pains,' she says, 'someone might have considered that possibility.'

She was taken to hospital by ambulance after her attack, but believes she was 'put on the bottom of a hospital waiting list - probably because I was a 34- year-old woman. I questioned this and was only pushed up by a young woman doctor who was concerned about my case. I was found to have two badly narrowed arteries and was rushed in for a double angioplasty.'

As the problem grows, initiatives have been launched on both sides of the Atlantic to 'feminise' the prevention, testing and treatment of heart disease, areas which have for so long been geared towards men. Dr Ian Baird, advisor to the British Heart Foundation, believes there is an urgent need to change the perception by the public and the profession that heart disease is not a woman's problem. His organisation is currently funding Professor Kay-Tee Khaw of Addenbrooke's Hospital, Cambridge, to help do just that.

Professor Khaw believes there are a number of questions that need to be answered. 'Women have been excluded from so many big trials that we need to study them more closely,' she says. 'Although men have three times the rate of heart disease, it is still the number one killer of women, far exceeding breast cancer, and is a leading cause of disability. Women in Britain have the highest rate of heart disease of women anywhere in the world.'

Studies conducted on men may not hold true for women, Professor Khaw points out. 'There is some thinking that perhaps women are less susceptible to a high-fat diet than men, since fat produces oestrogen, which is thought to offer some protection against heart disease. But Japanese statistics don't bear this out, as Japanese women have a low-fat diet, low oestrogen levels and the lowest rate of heart disease and breast cancer in the world.' The thyto-oestrogens they absorb from a diet rich in soya bean could be one explanation. It has been thought that oestrogen levels afford women protection against heart disease until the menopause, and that hormone replacement therapy (HRT) may decrease post-menopausal risk by as much as 50 per cent.

Professor Khaw and others involved in the sudden rush of research on the subject believe that women's lifestyles, once healthy in comparison with men's, may have protected them in the past. But as more men give up smoking, more women are taking it up, so this protection may be disappearing. Dr Holdright also points out that the thirtysomethings under her care are the first 'television generation', and have almost certainly had much more sedentary childhoods than their mothers.

Charon Coats, who is 38 and recuperating after angioplasty at the London Chest Hospital, is a good example. 'I'd never taken the risk seriously before,' she says, sitting up in bed sipping a cup of tea. 'Even though I knew my mother had had heart problems when she was older, I still thought it was a man's disease and that I was too young to worry about it.'

Charon experienced no warning signs, nothing to make her consider givng up smoking and trying to lose weight, until a crushing pain in her chest and arm when she was shopping heralded the attack. 'I didn't want to make a fuss in the street,' she recalls. 'So I went home and my husband called an ambulance.'

Dr Holdright's report in the British Medical Journal, based on 800 patients of whom 23 per cent were women, showed that there is some foundation for the medical profession's traditional response. Chest pain in women is less likely to be an indicator of coronary artery disease than it is in in men; 41 per cent of women with chest pain had normal coronary angiograms (examination of the arteries), compared with only 8 per cent of men with the same symptom.

Dr Holdright contends that GPs should be more aware of the unconventional symptoms which women may manifest. The statistics offer conclusive proof that 'we need urgently to find a more reliable way of deciding which women require further investigation'.

It is crucial for doctors to listen to patients closely, Dr Holdright advises. 'They should be questioned in detail about the kind of pain they're feeling, its duration and location and when it comes up. Anginal pain is likely to involve a crushing sensation in the chest which radiates out into the left arm and up to the throat, and becomes worse on exertion.' Patients should also be questioned about their family history, and assessed for other known risk factors such as early menopause.

Professor Khaw emphasises that finding out what protects some women from heart disease may help doctors learn how to protect men - a big selling point when seeking funding for research. She and her team started studying a representative population of 25,000 men and women three years ago, and have found cholesterol levels to be 'extremely high' among British women. They are not sure, however, at what level treatment is necessary, since for a given cholesterol level women have a lower mortality rate than men.

It has been suggested that women who take on 'men's jobs' are also taking on men's diseases. Professor Khaw disagrees. 'Men have just been more accessible in the past for screening through work sites, and now we have access to more women in that way,' she points out. Dr Laila Kapadia, an occupational health specialist in charge of a coronary risk-factor screening programme of 50,000 Marks & Spencer employees, 90 per cent of them women, believes unemployed women are more at risk. 'Working women are often healthier than non-working women. The unemployed are less well off, have a poorer diet, smoke more and don't take as much exercise.'

In addition to the coronary risk factors shared between the sexes - heredity, obesity, smoking, lack of exercise, high blood pressure and a diet high in saturated fats - women have additional ones to worry about. 'Anaemia, which is much more common in women due to menstruation, makes it more difficult for the blood to oxidise and causes the heart to work harder,' Professor Khaw says. Diabetes is also a much greater risk factor in women than in men (although no one really knows why), as the diabetic author Sue Townsend discovered when she had a heart attack in her thirties.

Other differences between the sexes have already been discovered by the Framingham Heart Disease Epidemiology Study in the US, started nearly 50 years ago. Dr Millicent Higgins, an English epidemiologist involved with the Framingham study since 1959, explains why. 'We have discovered that women are at risk from heart disease if they have a high level of triglycerides - fats which contribute to the carrying of cholesterol to blood vessels - in their blood, even if they don't have dangerously high cholesterol levels. In men, triglycerides without a correspondingly high cholesterol count are not significant.'

Dr Higgins found that 'silent' or 'atypical' symptoms can be a woman's only warning of imminent heart attack. 'It is common for women to experience something like indigestion on and off for a considerable time before having a heart attack. This is likely to be overlooked until it is too late.'

The US National Institute of Health - under its first woman director, Dr Bernadine Healy - began a major Woman's Health Initiative at the beginning of the Nineties. It was designed to evaluate the effect of both low fat diet and HRT on the prevention of coronary heart disease in 100,000 women.

'In the past,' she says, 'women's raging hormones have been cited as an excuse for not using them in medical studies. But I say if we have these raging hormones, we'd better find out how they affect things.' It was Dr Healy who coined the term 'The Yentl Syndrome' to describe the phenomenon of women having to display masculine symptoms to be given the treatment men get. In Britain, where coronary heart disease kills 75,000 women every year and causes illness and disability for thousands more, the same syndrome prevails.

Later this year, the National Forum for Coronary Heart Disease Prevention will publish a report called Coronary heart disease prevention: Are women special? It will round up the latest research on the subject worldwide and suggest that health professionals be made aware of the risks of coronary heart disease among women.

Affairs of the heart have always been considered women's domain, but now heart disease has become a feminist issue.-

(Photograph omitted)