Dr. Samantha Avery joined the cardiology staff of the Heart Institute of St. Petersburg in July, becoming the only female in a group of 17 cardiologists.

That mix, and Avery’s presence, reflects the past and the present of heart disease. Once thought of as a man’s disease, heart disease has become the No. 1 killer of women, who account for nearly 50% of all heart disease deaths nation-wide. In Florida, heart disease and stroke account for 29.2% of all female deaths.

Many women who die of heart disease are older, but heart disease is the third leading cause of death among women 25 to 44 and second leading cause of death among women 45 to 64.

Lifestyle factors have changed: Women are waiting longer to have children and often take hormones. They are balancing work and family and make less time for exercise. The percentage of women who don’t exercise at all climbed from 19% in 1988 to 52% in 2010, according to a study by Stanford University published in the American Journal of Medicine. Their diets are often high in sodium and saturated fat. 

Avery says women often ignore the warning signs of decreased blood flow to their hearts. “Stress has become part of their daily lives. They might experience fatigue or anxiety, but they put off what they are feeling and go through the day.” 

She and other Florida cardiologists say women may experience different symptoms of heart disease than men — women, for example, may have a burning sensation in their upper abdomen, intense back pain, lightheadedness, an upset stomach and sweating, rather than the typical pain or pressure in the chest that men experience.

As a result, women and their medical providers may ignore symptoms that they are having a heart attack, attributing them to less dangerous causes such as aging, stress or the flu.

Doctors say this is particularly worrisome because heart attacks are generally more severe in women than in men. In the first year after a heart attack, 42% of women die compared to 24% of men, according to the Women’s Heart Foundation. 

Other aspects of heart disease, including risk factors, play out differently in women. Dr. Pamela Rama, a cardiologist with Baptist Heart Specialists and medical director of Baptist HeartWise in Jacksonville, says diabetes is a more deadly risk factor in women compared to men. “It increases the risk of a heart attack by five-fold, while in men it’s only two-fold,” Rama says. And, where high levels of LDL, or “bad” cholesterol are a strong predictor in men, low levels of HDL or “good” cholesterol, are a strong predictor in women, she says.

Another big indicator of future heart disease is behavior during pregnancy. Women who develop gestational diabetes, hypertension or preeclampsia during pregnancy have a 30% higher chance of developing heart disease later in life, Rama says. Menopause also is a factor, with research showing an increase in heart attacks among women about 10 years after menopause, possibly because of the decline in estrogen.

“For women, it’s very important to be in tune with your body,” says Rama.

Throughout Florida, the dynamics of heart disease have prompted the state’s cardiologists, hospitals and health centers to step up efforts to get women to pay closer attention to warning signs, particularly for women with known risk factors.

The campaign ranges from making emergency room doctors and nurses more aware of overlooked symptoms to communicating to female patients that their stressful careers may subject them to as high a risk for heart disease as men. Several hospitals around the state now have women’s heart centers and programs. Others are publishing dedicated newsletters on women’s heart health, offering free risk assessments, hosting ongoing workshops and putting on “go red” events In February in an effort to bring attention in their communities to women’s heart health.

Cardiologists are urging women, particularly those over 55, to have their cholesterol and glucose levels checked, blood pressure monitored and body mass index measured. BMI should be less than 25. “It’s important to know your numbers because it can help to detect your risk factors for cardiovascular disease in the earliest stages,” says Dr. Claudia Martinez, a cardiologist in Miami who is affiliated with Jackson Health System and the University of Miami. She urges all adults do a minimum of 20 minutes of cardio exercise a day for good heart health.

“We’re doing the education to get women to do the same prevention that men are doing,” she says.

Dr. Alvaro Gomez, an interventional cardiologist with the Miami Cardiac & Vascular Institute at Baptist Hospital in Miami, teaches about the additional risk in the Latina population. There are clusters of bad gene pools in the Latin population with intrinsically high levels of cholesterol despite what the women eat, he says. In addition, Latin American diets are often rich in starch and complex carbohydrates, which can create blockage of the coronary arteries.

“We’ve got to get these women To go get checked,” Gomez says. To educate them, he often speaks at community events and at free support groups for women who meet at Baptist Hospital in Miami.

Rama says risk factors like race, age and a family history of heart disease can’t be changed. But women can change or eliminate factors like weight, inactivity and smoking.

When a women’s numbers aren’t what they should be, doctors like Rashmi Schramm, a family physician for Baptist Primary Care in Ponte Vedra, urge patients to immediately make lifestyle changes such as cutting sodium and eating more fruits and vegetables as well as nonfat dairy products.

When women are diagnosed with heart disease, treatment ranges from medications such as statins, which reduce LDL cholesterol, to medical procedures that include angioplasty and bypass surgery. The type of treatment typically depends on how far along the Heart disease has progressed.

Medication may be part of the treatment, too. Schramm says advances in cholesterol-lowering medication are in trial stages, and injectable heart drugs may soon become a viable alternative to statins.

Nationally, heart health is getting attention: Clinical trials are under way for new medications, including a triglyceride-lowering drug. Statins with fewer side effects are rolling onto the market, new devices such as biodegradable stents are in development stages, and more surgeons are being trained in new procedures. In addition, there’s research under way around the country specific to women and heart disease.

“Right now we’re in a transition,” Gomez says. “The medical community has finally figured out they need to pay more attention to this. With all the advances, I still think the No. 1 thing that will make a difference for women is education.” 

Age 

Women usually develop heart disease about 10 to 15 years later than men because until menopause, the ovaries produce estrogen, which protects women against plaque buildup. But at menopause the ovaries stop making estrogen, and the risk goes up for women, who by age 70 have about the same risk for heart disease as sameaged men.

Family History

Women with a father or brother who developed heart disease before age 55 are at higher risk. Women with a mother or sister who developed heart disease before age 65 are also at higher risk. However, young women with a family history may not be aware of this risk and often are less careful about living a hearthealthy lifestyle than men with a family history.

Women’s Heart Health Facts

• 8 million women in the U.S. are living with heart disease; 35,000 are under age 65.
• For women under 50, heart attacks are twice as likely to be fatal than with men.
• 71% of women experience early warning signs of heart attack with sudden onset of extreme weakness that feels like the flu. 
• Women who smoke risk having a heart attack 19 years earlier than non-smoking women.
• After a heart attack, women are less likely than men to receive beta blockers, ACE inhibitors and aspirin — therapies known to improve survival. This contributes to a higher rate of complications after heart attacks in women, even after adjusting for age.
• While one in 31 deaths among American women each year is a result of breast cancer, one in three deaths is attributed to heart disease.
• Heart disease claims more women’s lives each year than the next seven causes of death combined, and nearly twice as many as all forms of cancer combined.
• Cardiovascular disease is the leading cause of death for African- American women.
• Only one in five American women believes that heart disease is her greatest health threat.
• Risk factors for women include physical inactivity, family history of heart disease, diabetes, irregular periods before age 45, specific complications in pregnancy, poor diet and high blood pressure.
• Heart attack symptoms include stomach pain or nausea, shortness of breath, discomfort in areas of the upper body, such as shoulders, arms, back, neck, jaw or teeth, unexplained fatigue and sweating.
• Symptoms in women may appear up to a month before a heart attack.

Source: Women’s Heart Foundation, American Heart Association, BaptistHeartWise.com 

Direct Injection

In Tampa, Dr. Charles Lambert is leading the way for the first FDAapproved clinical trial in the United States using regenerative cells, derived from fatty tissue, in chronic heart failure patients.

In the ATHENA clinical trial, doctors first collect fat from the patient’s body by liposuction. They then flter the fat sample through a machine that extracts the stem cells. Finally, the stem cells are injected into the damaged part of the patient’s heart in 15 places. The trial is a controlled study, and participants either have their own cells or a placebo injected back into their damaged heart tissue.

“There are people that definitely respond, and some that don’t,” says Lambert, director of Florida Hospital Pepin Heart Institute and the Dr. Kiran C. Patel Research Institute. “There is still a lot we don’t know, and it’s certainly not one size fits all.” 

Lambert says research shows many variables make a difference, including the type of stem cells administered, the stage of heart disease and when and how the stem cells are given.

Doctors at Florida Hospital also have tested the use of stem cells on heart attack patients by administering stem cells from the patient’s own bone marrow into the heart within five days after a heart attack. Studies done in Europe had varying results. 

“Our trials are high caliber in the level of evidence provided, and they are placebo controlled,” Lambert explained. Some of the patients at Florida Hospital’s research center who participated in the trials saw improvement. A big variable, he says, was how long after a heart attack someone was treated with stem cells. “It seems as if you do it too early or too late it won’t work.” 

Gene-Based Therapies

In one Tampa trial using genebased therapies, doctors directly injected plasmid DNA into the heart. The therapy attempted to promote regeneration of heart tissue by encouraging the body to deploy more stem cells to the injury site in patients who had suffered heart failure. “This trial is unique in that it uses gene therapy to turn on a process leading to cell regeneration rather than simply administering stem cells directly,” Dr. Charles Lambert says. The preliminary results were positive. A second trial is under way in which doctors will administer the plasmids through a catheter. “If it works, it’s an easier mode of therapy for different trials,” Lambert says

Stem Cells in Space

At the University of Miami’s Miller School of Medicine, Dr. Joshua Hare has been a pioneer in research that has shown stem cell therapies can repair damaged hearts and restore their function. In October, Hare, founding director of the Interdisciplinary Stem Cell Institute and the Louis Lemberg Professor of Medicine, was among seven stem cell researchers across the nation who were awarded up to $300,000 each to use the space station’s unique environment to explore “the impact of microgravity on fundamental stem cell properties.” Says Hare, “We believe that microgravity could play an important role in generating new heart muscle.”

Regeneration

Dr. Claudia Martinez-Bermudez led a team at UM that participated in an international clinical trial to assess whether gene therapy can reduce the frequency of hospitalizations for advanced heart failure patients. The therapy could increase the time a person experiencing heart failure would be able to wait for a transplant or possibly even eliminate the need for a transplant, Martinez- Bermudez says. The yearlong trial is over. Researchers are awaiting results. “We know based on small studies that this regenerative approach works,” she says. “Now we are trying to prove that on a large scale.”

Leg Pain

In Gainesville, Dr. Carl Pepine at the University of Florida College of Medicine also is conducting stem cell research, with one study focused on helping people with chronic leg pain from heart disease. The trial, the fourth using patients’ bone marrow stem cells, examines whether injecting a concentration of cells directly into the affected leg muscles will result in the formation of new blood vessels and improved blood fow. A better blood supply would reduce the pain caused by peripheral arterial disease and allow patients to walk longer distances.

Studying Heart Disease

Baptist Health has begun work on its Miami heart study, which will span several years and include 4,000 participants who are 40 to 60 years old (2,000 from the community and 2,000 Baptist Health employees). Doctors will assess risk factors using advanced blood tests and imaging studies and gathering extensive genetic information to understand how cardiovascular disease begins and progresses and how to prevent it.

Aspirin and Cardiovascular Disease

UF researchers have discovered that a daily low dose of aspirin can offer important protection against heart disease, but people who could receive the most benefit from the medication may not be taking it. The study found only 40% of people who were at high risk of cardiovascular disease said that doctors had recommended aspirin therapy, while one-quarter of people at low risk reported their doctors told them to take the drug. The results appear in July in the Journal of the American Heart Association.

Better Monitoring

Doctors at Florida Hospital Orlando are treating arrhythmia in patients with a new heart monitor called a loop recorder. The implantable recorder is designed to help doctors diagnose rhythm problems while people do their day-to-day activities. Traditionally, patients had to wear a cumbersome halter monitor made up of electrodes attached to the chest and a battery pack to record heartbeats so doctors could diagnose rhythmic heart issues. The patient had to bring the device back into the doctor’s office to analyze the data that was recorded. With the new implantable loop recorder, data can be transmitted via cell phone to the doctor’s office.

Blood Pressure Monitoring

Alejandro Arrieta, assistant professor in the Department of Health Policy and Management at Florida International University in Miami, has documented the usefulness of home blood pressuremonitoring kits in early detection of medical emergencies related to hypertension. Arrieta’s study, published in the American Heart Association’s journal Hypertension, found that insurance firms realized a return of 85 cents to $3.75 for each dollar invested in home monitoring kits within the first year. The return increases over 10 years to $7.50 to $19.34 for every dollar invested.

Holistic Approach

Mona Shah, a cardiologist with Baptist Heart Specialists in Jacksonville, has become board certified in holistic medicine through the American Board of Integrative Holistic Medicine. She is one of only two cardiologists in the state with the certification. Shah says she will do a traditional cardiac visit that will address all the patient’s cardiac concerns and order appropriate testing and medications, but she will also address stress management, diet, nutrition, exercise and lifestyle. “Many patients Don’t want to use traditional medications when being treated, and in those cases I suggest alternative methods, including herbs and supplements,” Shah says. “I also review vitamins and supplements and confirm there are no interactions with their medications.”

Women’s Care

Florida Hospital Orlando broke ground in February on a comprehensive women’s hospital. The complex, north of downtown Orlando, is scheduled for completion next year. The 12-story, 322-bed tower will offer comprehensive health care and includes cardiac care among other areas of specialty services.

Robotic Surgery

Da Vinci robots are now a well-established tool in surgical suites throughout Florida. Baptist Medical Center in Jacksonville has purchased its sixth da Vinci robotic system. Its latest one is dedicated for cardiac use. Dr. Robert Still, a cardiothoracic surgeon, heads a team that will use the robot for complex procedures like coronary bypass or repairs to valves or holes in the heart. Still says the da Vinci allows more mobility “to cut, sew, dissect, pull and push and do whatever you need to do and get where you want to go.” With robotic surgery, patients typically have less pain, fewer infections and faster recovery, he says. Still and his team, which has trained with a group in Alabama that has been using the machines for heart surgery for about eight years, plan to offer robotic surgery in Jacksonville for heart care by year’s end. The use of robotic surgery of all types has increased more than 400% in the U.S. between 2007 and 2011. 

Teaming Up

Baptist Cardiac & Vascular Institute and South Miami Heart Center have created the Miami Cardiac & Vascular Institute. The rebranding effort reflects Baptist’s combined resources of experienced physicians, treatments and technology to bring the most advanced heart and vascular care to south Florida. A $100-million expansion under way on the Baptist Hospital campus will transform the institute and include unique programs for aneurysms and structural heart disease.

Stem Cell Therapies

Can a patient’s heart disease be cured by injecting his own fat cells into damaged parts of his heart?

Across the state, doctors and medical researchers in Miami, Tampa and Gainesville are conducting leading-edge cardiovascular stem cell research to answer that question and explore other possible ways to use stem cells to treat coronary heart disease.