A woman's heart and its silent symptoms: Coronary disease is usually linked to men, but it is also the major killer of women, says Victoria McKee

SHERREE CUMMINGS can confirm, from the heart, an experience at which statistics only hint. Mrs Cummings, now 36, was a slim, fit, active non-smoker aged 34 when she had a heart attack in her local swimming pool. She drove herself home, doubled up with pain. Neither she nor her husband - nor her GP - thought of a heart attack, although eventually an ambulance was called.

'I'd been visiting my GP for months with pains in my stomach which I now know were angina,' says Mrs Cummings, an estate agent's wife with two teenage children, who lives near Worthing, Sussex. 'I kept saying I had this very sore stomach, because that's how I felt it. No one ever thought of heart disease, as there was no history of it in my family, although I now know you can feel angina in your stomach. I had had a particularly bad bout of pain a few weeks before my attack. If it had been my husband having the pain, not me, I'm sure someone might have thought of a possible heart attack.'

Mrs Cummings is right. New British findings echo growing concern in the United States that women face sex discrimination in the detection, prevention and treatment of heart disease.

It is often forgotten that coronary heart disease is the major killer of women. Although men under 65 have 3.5 times the risk, just over one in four men and one in four women in the UK die from CHD: 80,000 men and 70,000 women in England and Wales over the past year.

'In 1990, only 52 per cent of women picked out heart disease as a possible danger to their health,' says Imogen Sharp, director of the Forum for Coronary Heart Disease Prevention, an umbrella organisation of statutory and voluntary heart disease agencies. 'As many women under the age of 65 die from CHD as from breast cancer and cervical cancer combined.'

By the time Mrs Cummings was admitted to hospital her hands and feet were white, and she was sent to the resuscitation unit. She was treated with a clot-busting drug and another to relieve her pain, and later transferred to intensive therapy. That night she needed cardiac massage after a black-out, when her heart went into abnormal rhythms. She was eventually transferred to a ward for observation and discharged a week later.

'About three months later I had an angina attack which I recognised, so I was sent back to hospital where I was put on the bottom of the waiting list - probably because I was a 34-year- old woman,' she says. 'I was only pushed up by a young woman doctor who was concerned about my case.' It was found that Mrs Cummings had two badly narrowed arteries, and she was swiftly given surgery to correct them.

The forum is due to release a major report on women and heart disease next month and a women's health group in America is also focusing on the issue, so the topic should at last get the attention that those who have experienced such discrimination feel it deserves.

Ms Sharp welcomes the recent findings of a study by the health services research unit of the London School of Hygiene and Tropical Medicine, which concluded that female patients were being discriminated against by doctors and were offered fewer operations than men.

The unit analysed 23,707 patients in English hospitals for the study, which she says is 'the first UK data which confirms what our report, based on American research, will say.' She warns that 'the heart disease prevention campaign has been targeted at men, so there needs to be a dramatic shift of emphasis.'

Mrs Cummings says that occasional crash dieting was her only coronary risk factor. Her cholesterol level was 'slightly high - around 6.5'. She has started a local support group, which now has several other women members, mostly in their 50s and 60s.

Five years ago Millicent Higgins, a British doctor at the US National Heart, Lung and Blood Institute working on the Framingham Heart Disease Epidemiology Study, began a vocal campaign against sex discrimination in heart disease.

Dr Higgins, from Newcastle upon Tyne, an epidemiologist who has been involved with the Framingham study since 1959, said at the time: 'Our study is one of the few to have included women at all, and as heart attacks occur less frequently in women, and usually when they are older, it has taken much longer to build up any evidence. But at last, and for the first time, we have enough women in the heart-disease age range to make some meaningful observations.'

She had discovered the frightening 'silent symptoms' or 'atypical symptoms' that can be a woman's only warning of an imminent heart attack - and that it is much more likely that women with these symptoms will be overlooked until it is too late. This factor could account for the fact that when women have heart attacks they are twice as likely as men to die within 60 days. Dr Higgins had found that women often experience pain, a sensation of pressure in the chest or something like indigestion on and off for a long time before having a heart attack. 'With men, pain is usually a sign that an attack is starting.'

She says that women at risk of heart disease may have a high level of triglycerides in their blood. These are fats associated with clogging of the arteries. 'But these women do not have dangerously high cholesterol levels. By contrast, in men, triglycerides without a correspondingly high cholesterol count, are not significant.'

Dr Higgins gives a number of reasons that might help to explain why women are different - or disadvantaged. She suggests that the apparently lower risk of early heart attacks in mothers may be because they tend to have wider coronary arteries. But, she says, the fact that women have smaller hearts that are more difficult to operate on than men's, may be a reason why women do half as well as men in bypass surgery. Another may be that women are referred later when disease is more advanced. This may also explain why most cardiac rehabilitation programmes are geared towards men.

A study of between 30,000 and 40,000 Marks & Spencer employees - nearly 90 per cent of them women - is being carried out by AMI Healthcare in conjunction with the National Heart and Lung Institute, but it will be five years at least before it brings in better data on women and heart disease. It will be even longer before the women's health initiative (begun by the US National Institute of Health under its first woman director Dr Bernadine Healy) evaluates the effects of a low-fat diet and hormone- replacement therapy on the prevention of CHD in 100,000 women.

Dr Healy, a cardiologist, has fought 'the stereotype that says women don't get heart disease - that their symptoms are hysterical, emotional'. She has also insisted that women are included from now on in every NIH- funded study. 'In the past, women's raging hormones have been cited as an excuse for not using them in research programmes. But I say if we have these raging hormones, we should find out how they affect things.

'In the Seventies a big trial looked at oestrogen and heart disease, but gave it exclusively to men, where it showed undesirable side-effects such as pulmonary embolisms. No one thought to give it to women,' Dr Healy says.

In the meantime, Dr Higgins warns: 'Women cannot assume that the advice given to male cardiac patients is the correct advice for them.'

Ms Sharp urges women to make sure their GPs consider the possibility of heart disease, even if they do not fit the stereotypical profile of the cardiac case - which may need to be radically revised in the light of new research.

(Photograph omitted)