February 13, 2018
by Sheri B. Doniger, DDS
We are all familiar with the signs and symptoms of gripping chest pain, radiating to the jaw and arm for males, but do we know the difference for women’s heart attacks?
Recently, many articles and television programs have been highlighting the very different signs for women in the throes of a heart attack. As dental professionals, we need to be aware of these signs, as well as alert the patient of risks of ignoring them.
Coronary heart disease (also referred to as stable angina, coronary artery disease or ischemic heart disease) is the most prevalent cause of death in the United States, accounting for one in every five deaths. In Canada, heart disease is also the second leading cause of death, causing more than 48,000 lives in 2012. With an incidence of over one million cases a year, approximately forty two percent of afflicted patients die within a year. The statistics for women under the age of fifty are more staggering. Women are twice as likely to die as men if they experience a heart attack.
According to the American Heart Association, “Coronary heart disease is the leading cause of death in American women”. One in five women have some form of cardiovascular disease. This includes: coronary heart disease, angina pectoris, stroke, high blood pressure, congestive heart failure and congenital cardiovascular defects. With one in every five women having some form of heart disease, the likelihood of one being in your care at any given time is high.
One of the more pertinent statistics from the AHA states: “In 63% of women who died suddenly of coronary heart disease, there were no previous symptoms of this disease”. Angina pectoris is more common in women than men. Over 6.4 million women suffer from angina and/or coronary artery disease. Many women have heart attacks that go unnoticed. Over 400,000 women have stable angina (pain or discomfort in the chest or adjacent areas due to insufficient blood flow though the coronary arteries), many with no pain. Furthermore, within six years of the first heart attack episode (a recognized myocardial infarction), 35% of women will have another heart attack, 14% will develop angina, 11% will have a stroke and 6% will experience sudden cardiac death. These are alarming statistics.
Thirty eight percent of women with recognized myocardial infarctions die within a year. Myocardial infarction occurs when there is a blockage to one or more of the coronary arteries. This blockage usually occurs due to atherosclerotic plaques that build up on the arterial walls, constricting the blood flow through the lumens. These plaques can also cause blockage and subsequent rupture of the arterial walls due to arterial pressure and weakness. Blood clots or thrombosis will also occlude the less than patent arteries. If this blockage occurs, there is usually a pain incident associated with the event.
Women tend to have their initial heart attacks at an older age than men. They are protected by estrogen through menopause. Estrogen keeps cholesterol in check: the good HDL cholesterol up and the bad LDL cholesterol and triglycerides down. After menopause, estrogen that was produced by the ovaries ceases, although some is produced from fat cells. This is not enough to afford cardiac protection. This dramatic drop may lead to the susceptibility of heart disease.
Risk factors for both sexes include: heredity (family member having a heart attack under the age of 55), acquired or inherited high cholesterol, acquired, inherited or untreated hypertension, obesity, diabetes, and an inactive, unhealthy lifestyle (smoking, eating high fat foods). For females, the individual risk factors can be increased, sometimes seven-fold. An additional risk factor for women is aging, especially the post-menopause years. Ninety percent of women have more than one risk factor for stroke or heart disease.
Triggers for heart attacks for both sexes include: arterial blockage, stress, exercise, and heavy meals. Where male triggers appear to be physical, female’s triggers appear to be emotional. Some studies have shown that men have physical exertion (as snow shoveling) prior to heart attacks while women experience emotional stress.
As stated, many women do not experience the crushing chest pain normally associated with a myocardial infarction or heart attack. Women’s symptoms can include the expected symptoms of angina, diaphoresis and shortness of breath. As with their male counterparts, the chest pain or pressure may be centrally located and can last a few minutes.
Non-chest pains occur more frequently in women. Women were more likely to present with neck, jaw or back pain. The pain could also radiate down both arms, starting from the back, with a deep throbbing or aching in the arms. The discomfort may only be mild. Nausea or flu-like symptoms are common. Non-chest pain symptoms such as musculoskeletal or neurologic pain can also occur. Many women who are familiar with the traditionally recognized symptoms of angina tend to dismiss these symptoms. Some women may have no pain at all. (See Table 1)
Additional signs of clammy sweating, dizziness, lower extremity edema, anxiety, general malaise, heartburn, vomiting and nausea not relieved by antacids may also present themselves. Chronic breathlessness or waking up short of breath at night can be another symptom. Women will experience extreme fatigue, with or without activity. The mere act of moving from one area of the house to the other or putting on clothes may be too strenuous.
The failure to recognize women’s heart attack symptoms could be the cause of higher death rates and pursuant disability due to heart attacks. Women tend to have their first
myocardial infarction at an older age (usually over 60). They may have concurrent conditions such as diabetes, arthritis and osteoporosis. Aches and pains are common and these crucial symptoms may be overlooked or dismissed. Many of these symptoms can be misdiagnosed: nausea for indigestion or gastritis, fatigue from activity for chronic fatigue syndrome.
Women do tend to downplay many of the symptoms, as well. Women tend to wait longer to call for emergency assistance. Women are also usually ten years older than men when their first coronary attack occurs. The sudden onset of weakness, body aches, a feeling of general “un-well being”, coupled with back or neck discomfort and nausea are usually attributed to the flu. Women also tend to wait longer to seek treatment, but when they do, historically, they receive less prompt treatment (the average waiting time in the emergency room is longer than men).
Certain patients, be it female or male, do tend to “forget” they were told they have a problem or on a new medication. Even though the front desk may have questioned the patient on their health history, it is incumbent for all team members to ask if there have been any changes. Additionally, they do not feel some of these symptoms are issues a dentist needs to know. We need to stress to our patients, even though they don’t think it is related, after all, the teeth are connected to the rest of the body.
We have much to offer in the dental office for our patients. Monitoring of blood pressure and questioning our patients concerning their diet and exercise can assist them in the long and short run. The oral-systemic link is highly important here. Proper oral hygiene will reduce oral bacteria and inflammatory sites. Stressing the need for routine preventive maintenance to monitor any gingivitis or periodontal concerns should be part of the treatment plan. Possibly discussing adjunct therapies, such as mouth rinses to decrease plaque and inflammation, may be beneficial to her gingival health.
We can discuss the risk factors that are reversible and offer alternatives. Recommending smoking cessation will not only help their cardiac health but their oral health as well. Evaluating diet diaries to assess both cariogenicity and “heart-smart” content of the food consumed will also be a dual assist in the patient’s overall health. Increasing fruits and vegetables, consuming lean meats, poultry and fish high in omega-3 fatty acids, checking food labels for hidden sodium and fat content are all nutritional suggestions that could be made. Recommending a consultation with the physician if the blood pressure is consistently elevated over 140 systolic or 90 diastolic (stage 1 hypertension classification). Discussing exercise of any form as a means to “work off” stress and “work out” the body is a dual contribution for decreasing stress and weight. Walking is an excellent example of exercise that can be performed at any age and ability level.
One very important thing is to remind patients to take their prescribed medications in the dosage dispensed. Many times, patients take it upon themselves to stop or alter prescription drugs. We need to discuss with them to do as their physician requested until a change is required. Furthermore, a large number of the medications given to cardiac patients do cause xerostomia. Discussing the side effects of dry mouth will lead to a conversation about proper hydration, the importance of keeping up personal oral hygiene and preventive visits.
Coronary artery disease is no longer a male dominated arena. Women have overtaken the mortality statistic. Lifestyle alterations (low fat and low sodium diet, smoking cessation, increase aerobic exercise), in addition to proper and timely health care will increase the chances of a long and healthy life. With proper counseling, and education, women will be more aware of the signs and symptoms to alert of a cardiac event. For ourselves and for our patients, we all need to be aware of the distinctively different signs and symptoms of women’s coronary disease.
Dedicated to my mom, Bernice R. Doniger, who died of heart failure, July 31, 2001.
About the Author
Sheri B. Doniger, DDS is a leading dental clinician, author, international educator, and consultant who currently practices dentistry in Lincolnwood, IL. Dr. Doniger is an avid researcher, frequently contributing to an array of dental publications on a variety of topics. She is a member of the IZUN Oral Healthcare Scientific Advisory Team. Please free to contact Dr. Doniger at www.donigerdental.com.