Women Getting Serious About Heart Disease and Stroke
By Sarah Kellogg
Photos By Patrice Gilbert

Nearly every minute of every day a woman dies of heart disease or stroke in the United States. If that seems hard to believe, consider this: heart disease alone claims more women’s lives than all forms of cancer combined, including breast cancer. While about one in 30 women die from breast cancer every year, nearly one in two women die from heart disease or stroke.

Even more shocking than these statistics is the fact that many of those deaths are preventable. Long thought to be immune to heart disease and stroke until they are AARP-eligible, women in their forties and fifties are learning they’re just as vulnerable as men. Women have fallen victim to the same lifestyle traps—smoking, obesity, and stress. And a family history of cardiovascular disease is as much a factor of concern for women as for men, even more so with stroke.

Beyond the obvious health factors, what else is driving this U.S. epidemic of heart disease and stroke? A lethal combination of ignorance and apathy on the part of both women and their physicians, experts say. Women’s health advocates believe the evidence is clear—cardiovascular diseases just don’t get the respect they deserve.

“It is amazing that people were sort of surprised and shocked to find out that women can have heart disease,” says Dr. Susan Bennett, a Washington cardiologist and clinical director of the Women’s Heart Program at The George Washington University Hospital. “In the past, people thought of heart disease as a problem for men. It wasn’t until a woman was in her late seventies that she was thought to be a candidate for heart disease. It’s hard to believe how long it’s taken for society to begin to get the message that women are just as predisposed as men.”

Culturally, heart disease and stroke were thought to be the price men paid for having high-stress jobs, working long hours, and taking all those two-martini lunches on the company’s dime. Not so anymore. More women than men in the United States die every year from heart disease and stroke.

For women, especially those in legal professions, the problem is exacerbated by a work life that focuses far more on production than prevention. In a world where an attorney’s value and salary are measured by how much she bills, a mandate from the doctor to slow down can be an invitation to failure.

“This is where many women attorneys are at in their lives,” says Kathy Kastan, a heart bypass survivor at the age of 42 and president of the board of directors of WomenHeart: the National Coalition for Women With Heart Disease, a national advocacy group devoted to reducing death and disability from heart disease. “They’re supposed to be these fantastic career women while managing their families and keeping their children’s lives moving forward. It’s the superwoman syndrome, and there’s no room for health problems and heart disease in that story.”

Yet the problem of women’s heart disease and stroke is everywhere—across the conference table, down the hall, and in the boardroom. The signs may be easy to miss or ignore, but at an exceptionally high price. Only through a commitment to education, understanding, and acceptance can women ably combat two of the toughest adversaries they will likely ever fight.

E. Gail Anderson Holness: A Typical Case
E. Gail Anderson Holness is a busy person. An attorney and a minister with the Metropolitan AME Church in downtown Washington, Holness keeps a hectic pace. She always has, although she has learned to slow down a bit since March 2006.

Holness’s life changed that month. She was in church and felt a heaviness in her chest. The room started to twirl. She kept telling everyone she was going to go home, but they pleaded with her to go to Howard University Hospital. It was good they did.

The doctors found a blocked artery in her neck. Despite running four miles a day, keeping a vegetarian diet, and watching her weight, the 49-year-old Holness was diagnosed with diabetes and high cholesterol.

“I thought I was eating in a pretty healthy way,” she says. “I didn’t eat red meat. I didn’t smoke. I didn’t drink. I was a nonclassic case, but I had all the internal symptoms that I never paid attention to for diabetes and high cholesterol.”

Today at 50, Holness feels that women face an especially daunting challenge with heart disease because it requires them to step outside of their traditional roles as wife, mother, and employee. Women are viewed as society’s caregivers whether a woman is a stay-at-home mom or the managing partner of one of Washington’s largest law firms, she says.

“Sometimes we don’t know when to stop,” Holness says. “We are the caregivers. We take care of everyone else. When my husband got sick and my daughter got sick, I was the one who took care of them. Mommy’s a lawyer. Mom-my’s an administrator. Mommy’s a minister. There’s very little room for Mommy when you look at all we’re expected to do. We forget about ourselves.”

Holness spends a lot of time these days encouraging women to look out for number one. She’s an evangelist for good heart health for women who may think they’re too busy to take the time to listen to their bodies or to regularly see a doctor.

“My advice is if you have any symptoms, go to the doctor,” says Holness. “When our cars sputter, we immediately take them in, especially if they’re under warranty. Our bodies are under warranty if we have health insurance, and yet we don’t take them in to the doctor the way we take our cars in to the mechanic.”

Holness isn’t shy about admitting to heart disease even though there may be a stigma attached to it for some women, especially those in positions of power where even the slightest hint of weakness can mean the difference between success and failure.

“As an attorney, you’re not supposed to show weakness,” she says. “But I think you need to turn that around. The weakness comes from failing to acknowledge the truth, not from embracing it.”

Cardiovascular Disease 101
The first step to understanding cardiovascular disease is defining just exactly what it is. As far back as grade school, children were taught about the cardiovascular or circulatory system. And cardiovascular diseases are those diseases or conditions of the heart (cardio) and blood vessels (vascular), and they encompass a wide category of illnesses, from high blood pressure to strokes to varicose veins.

While individuals can be born with some kinds of cardiovascular disease, such as congenital heart valve defects, others are acquired through a lifetime of bad habits, and still others may be caused by other cardiovascular diseases, such as a hardening of the arteries triggering a heart attack.

Diseases of the heart include coronary artery disease, or CAD, where the blood flow through the coronary arteries is restricted, and coronary heart disease, which includes CAD but also the subsequent complications such as heart attacks. Cardiomyopathy encompasses all the diseases of the heart muscle, an enlarged heart or the loss of heart muscle are the best known. Then there are the diseases of the heart valves, which can result in the narrowing, leaking, and improper closure of valves.

The second half of the cardiovascular equation is the network of blood vessels that run through the human body. Blood vessels include the arteries, which carry blood away from the heart; the veins, which take blood back to the heart; and the capillaries, which are the small vessels that connect arteries and veins.

Blood vessel disorders range from the chronic, which includes high blood pressure and arterioschlerosis (thickening or hardening of the arteries), to the acute, which includes stroke and a rupturing aneurysm. An ischemic stroke occurs when blood flow to the brain is interrupted, while a hemorrhagic stroke happens when blood vessels in the brain burst. So-called ministrokes, or TIAs (transient ischemic attacks), have the same cause and symptoms as regular strokes, but they don’t last as long.

Finally, an aneurysm is a weakness in the wall of an artery or vein anywhere in the body, which can turn from a bulge into a rupture. The most common sites for these weaknesses are the abdominal aorta and the base of the brain.

Bette Walters: A Family History of Disease
Bette Walters knew something was wrong. She’d gone to the doctor for a physical, explaining she just didn’t feel right despite her high-energy, athletic life. Ignoring her concerns, the physician didn’t schedule any heart exams because stress tests weren’t a regular part of the female physical. It was 1999.

“The doctor I met with thought it was probably menopause,” says Walters, who was 52 at the time. “If I had believed him and accepted his diagnosis of menopause, I would be dead.”

Not satisfied with the puzzling menopause diagnosis, Walters went back to the doctor and complained. She told him about her family’s heart history. Three of her four grandparents died of heart problems, and her mother and father died of heart disease at 65 and 68, respectively.

“My mother was the only one of my relatives who didn’t have bypass surgery,” says Walters. “She had low blood pressure. She was a tremendous athlete even into her 60s. She just had bad genes.”

Eventually, the doctor set up a stress test for her. After finishing her stress test, Walters was sitting in the hospital at the nurses’ station with her computer on her lap and a cell phone in her hand. As the vice president, secretary, and general counsel for a Philadelphia middle-market, diversified management company, she couldn’t afford to lose a minute of time.

After reviewing the results of her stress test, the doctor came out and told her she needed to be admitted to the hospital. He also gave her nitroglycerin. But she was too busy to contemplate a hospital stay since she had a major presentation scheduled for the next day and a European trip in the wings. She negotiated with them to let her leave the hospital in exchange for returning later for a cardiac catheterization—a procedure designed to measure blood pressure within the heart, the pumping ability of the heart muscle, and how much oxygen is in the blood.

“All of my vessels were blocked. Everything had something wrong with it,” she says.

Before her long health nightmare was over, Walters had had bypass surgery twice (during a single 24-hour period) along with additional surgeries to repair damage done to her esophagus while she was having her bypass. The surgeons also had collapsed a lung during her surgery, and they had trouble keeping it inflated as she recuperated in the hospital.

One of the events triggered by her health problems was the loss of her job. The stress of being “on” 24 hours a day was taking its toll on her body, and the doctors recommended a change. Today, Walters teaches at the Beasley School of Law at Temple University and practices law.

“My doctors told me that if I continued what I was doing then, I would die,” says Walters. “It was crushing to me, because so much of my identity was tied up in doing what I did. It was a very hard choice for me.”

Looking back, Walters believes one of the problems women face with heart disease is few people talk about it openly. She wishes there had been someone she could share her fears with, someone who could let her know what to expect.

Symptoms and Signs
Breaking it down by the numbers, it’s clear cardiovascular diseases are serious business. Heart disease remains the leading cause of death among American men and women. Nearly 700,000 of 2.4 million deaths in 2003—the latest year that comparison data is available—were the result of heart disease. Another 157,689 men and women died from a stroke in 2003. More women continue to die from diseases of the heart than men.

The Centers for Disease Control and Prevention reported that 348,994 women died of cardiovascular diseases in 2003, compared to 336,095 men. The differences were even more striking for stroke, which was the third-ranked killer of women and the fourth-ranked killer of men in 2003. Strokes caused the death of 61,426 or 5.1 percent of men, while they killed 96,263 or 7.7 percent of women.

Cardiovascular diseases tend to share symptoms. Look at the lineup for heart attack and stroke, and there will be overlap, ranging from dizziness to extreme fatigue. But the diseases have unique symptoms as well. Those suffering from heart failure could experience a shortness of breath, chest and limb pain, and swelling in the feet, legs, and ankles. Meanwhile, the signs of a stroke include numbness or weakness of the face, arm, or leg, sudden confusion speaking, trouble seeing in one or both eyes, and severe headaches with no cause.

For women, the uniqueness continues. Along with traditional symptoms, women may have trouble sleeping, problems breathing, an upset stomach, and a feeling of unease or worry.

And despite their increased incidence, women are no different than men when it comes to the basic factors that can contribute to cardiovascular diseases. Family history remains a central factor, alerting doctors to a predisposition to heart disease and stroke. If a father or brother has had a heart attack before the age of 55, or if a mother has had one before 65, then a woman is more likely to develop heart disease or stroke.

“A lot of the problem with women is perception,” says Bennett. “If a woman’s mother doesn’t have a disease, the daughter doesn’t think she’s at risk for it. They forget that they get half of their genes from their fathers. If their father has had a heart attack or stroke early in life, they have a better chance of having one.”

Lifestyle choices are a key element of the health care formula for men and women as well. As with men, women are susceptible to heart disease if they smoke, are obese, fail to exercise on a regular basis, have high blood pressure, and have high low-density lipoprotein, or LDL, cholesterol levels.

“Women walk around with risk factors their whole life, and they never get them checked or talk to their doctor about them,” says Kastan. “Then they end up being surprised and shocked when those risk factors are a factor in a heart attack. We’re our own best advocates if and when we decide to take responsibility for ourselves.”

Along with issues about size and differing sexual organs, women’s cardiovascular health is distinguished from men in two specific areas—birth control and menopause. Birth control pills can pose a heart-disease risk in certain women over the age of 35 who have diabetes or high blood pressure. And women in menopause lose their estrogen shield as the hormone is depleted, placing them more at risk of heart disease as they age.

Elaine Gregg: A Bad Diagnosis
Elaine Gregg saw all the signs, but she ignored them.

She started losing things at first. She was dizzy, even speaking in gibberish at certain points. And then one day, she lost her keys to the office, including her security pass. It wasn’t like her. After all, she was the human resources administrator for a large Washington law firm. She juggled the movements and lives of hundreds of people. She didn’t lose things.

Distressed, she went to the office of one of her staff members. Sitting there trying to calm down, she noticed that her leg started to shake uncontrollably and then her arm. She asked her manager to call 911. When she tried to stand up, she fell on the floor. The ambulance came and took her to Georgetown University Hospital. She had had a stroke. She was 58.

“I’ve been an administrator for 25 years and worked in this business a long time,” says Gregg, who today works as the regional human resources manager handling attorney and staff recruiting for Squire, Sanders & Dempsey L.L.P. “We do think we’re invincible. We think we have to be strong, and all of a sudden here is this weakness, and you wonder ‘How will it affect me professionally?’ When I had a TIA or ministroke, it was hard to talk about. It wasn’t supposed to happen to me.”

Gregg was in the hospital for five days, and she’ll be on Coumadin for the rest of her life to combat a stroke recurrence. At Georgetown, doctors diagnosed her with paroxymal atrial fibrillation—a recurrent heart arrhythmia.

Gregg finds it hard not to be troubled about her now lifelong relationship with Coumadin since, though she didn’t know it, this was her second ministroke. Her first occurred a week earlier when she broke into gibberish on a telephone call in her car while en route to her Edgewater, Maryland, home.

By the time she reached a Maryland hospital, her symptoms, so obvious a few minutes before, had disappeared, and she was able to speak clearly. The attending neurologist spent little time with her, sending her home simply with a prescription to take a daily dose of an aspirin.

“I think I wasn’t thoroughly diagnosed,” she says. “I’ll pay the price for that for the rest of my life. The doctor didn’t examine me long enough and discounted my symptoms, I think, because I was a woman.”

Gregg says that if she had gotten the right diagnosis in the beginning, she wouldn’t be where she is today. She’s learned to be her own health advocate and not to believe everything a doctor tells her. “You have to do the research, and you have to insist on the tests. They were very cavalier about my care, and I think it’s taught me that you have to think for yourself,” she says.

Her stroke also taught her the importance of priorities. “The one thing I do differently is I don’t work until 10 at night anymore,” she says. “I try to have a life. There’s a lot of stress in this job, but I like to think I’m better about managing it and about setting priorities than I was in the past.”

Getting the Word Out
While women may be learning more about their risk for heart disease and stroke, the word hasn’t reached everyone yet. In fact, it’s shockingly clear that both women and their doctors don’t know enough about women’s risks or the importance of early checkups and tests to halt the march of cardiovascular disease.

“In 2005, the American Heart Association [AHA] surveyed primary care physicians and cardiologists to find out how many knew that heart disease kills more women than men,” says Phyllis Greenberger, president and chief executive officer of the Society for Women’s Health Research, an advocacy group based in Washington. “Only 8 percent of primary care doctors knew and only 17 percent of cardiologists knew. Apparently women know more about it than their physicians.”

A 2003 survey of women commissioned by the AHA showed that 46 percent of women in the United States knew that heart disease was the number one killer of women, an increase from 30 percent in 1997. Unfortunately, only 13 percent of women perceived heart disease as their greatest health problem, proving that the not-in-my-backyard theory of life applies to health problems as well.

To correct those attitudes, the National Heart, Lung, and Blood Institute of the National Institutes of Health and the U.S. Department of Health and Human Services, in partnership with the AHA and other groups, launched The Heart Truth campaign in 2002 to draw attention to heart disease and to encourage women to participate in free health screenings. First Lady Laura Bush joined Hollywood celebrities and fashion designers to alert women to their risk of heart disease and to persuade them to take symptoms seriously.

“The main purpose of The Heart Truth campaign is just to let women know that heart disease is not just a man’s disease, because women a lot of times don’t have the same symptoms if they’re getting ready to have a heart attack,” the first lady said during a May 2007 event, “and so they don’t go to the doctor, because they think they can just lie down. And in a little bit they’ll get up and keep doing whatever, and so they get to the doctor and the emergency room later, and quite often suffer more damage because of that.”

That message also has come through in the AHA’s awareness campaign, known as Go Red For Women. The ever-present red, in dresses, T-shirts, and ribbons, is a reminder of heart disease’s status as the nation’s number one killer of women.

All of the cardiovascular awareness campaigns are pushing similar themes: encouraging women to talk to their doctors and be aggressive enough once they get into the examining room to demand tests even if doctors are reluctant. Additionally, they’re pressing women to keep lifestyle factors in check: lower blood pressure through diet or drugs; maintain a healthy weight; get tested for diabetes; stop smoking; watch cholesterol and triglyceride levels; and find healthy ways to cope with stress such as exercise, yoga, and meditation.

Meanwhile, the American Stroke Association has used its Power To End Stroke promotion to reach out to women and alert them to the risk factors for stroke. The awareness campaign is especially vigilant in trying to connect with women of color, since they are more at risk for stroke than white women. The organization has successfully used campaigns featuring African American celebrities to encourage testing for diabetes, and it has pitched “healthy” soul food cookbooks to get the message out on nutrition.

Still, advocates for women’s cardiovascular health say they stand in the shadow of breast cancer, which has become a favorite women’s health cause for celebrities, politicians, and corporations. The ubiquitous pink ribbon and the crowded calendar of walk-a-thons and 10K runs have elevated the issue of breast cancer awareness to the top of the female-health consciousness.

While those fighting the battle for women’s heart disease and stroke awareness acknowledge the important work being done by philanthropic groups to fund breast cancer research, there is a touch of envy for the fundraising ability of powerhouse organizations such as Susan G. Komen for the Cure and the Avon Walk for Breast Cancer. The Komen name has become synonymous with breast cancer through its many events, including runs, golf tournaments, and BMW test drives.

“Breast cancer is sort of sexier than heart disease,” says Greenberger. “Heart disease is most often seen in older women, although there are exceptions. There’s a certain ageism, consciously or unconsciously, playing in here.

“Breast cancer has become more of a chronic disease, and women with breast cancer are younger and vital and energetic.”

Despite the awareness gap, the publicity effort for cardiovascular diseases continues unabated, even here in Washington. Law firms have jumped on the healthy heart bandwagon, supporting the Go Red For Women campaign and the AHA’s Greater Washington Region in sponsoring the Lawyers Have Heart 10K run. A fixture on the calendar for the past 17 years, the race has raised nearly $4 million for heart disease outreach and research in the Washington area.

“I think the event is kind of unique in the law firm community,” says R. Bruce McLean, chair of race-sponsor Akin Gump Strauss Hauer & Feld LLP and chair of the 2007 and 2008 runs. “Many members of the law firm community unite in terms of supporting pro bono legal services in the Washington, D.C., area, … but this is philanthropy that is really not directly related to the law, although a great number of lawyers are affected by heart disease.”

Lois Lipton: A Ticking Time Bomb
Lois Lipton got lucky, very lucky. Like many professional women, she paid close attention to her health. She watched her weight. She exercised. She didn’t overindulge in food or drink. Her blood pressure and cholesterol were within acceptable ranges.

Like many professional women busy with the details of work and personal life, she also took for granted that she had done everything she could to guard against health problems. And she believed that her occasional trips to the doctor’s office were warding off more serious health problems.

“Looking back now, I think maybe I didn’t take myself seriously enough,” says Lipton, who worked as litigation counsel for AT&T Corporation in Chicago at the time. “My brother, who is a few years older than I am, was seeing a cardiologist all through his fifties because my father died at 58 of a heart attack. My brother, of course, was fine, but I wasn’t.”

In the fall of 2003, Lipton received a solicitation for an executive physical, and she signed up. She’d been on estrogen replacement for 15 years, and the doctor was reluctant to keep her on the hormone therapy unless she had a heart scan. As the technicians were finishing up the scan, they told her someone would get back to her within a week or two about the results.

Two hours later, she got a call from her doctor. The results from the scan were shocking: Lipton had an aneurysm. Her physician told her she had an appointment with a heart surgeon in 15 minutes. Lipton went to the appointment and found out her aneurysm was 4.5 centimeters wide and needed surgery. The surgeon reluctantly agreed to delay the surgery until after a trip Lipton had planned to Europe—one she was determined to take despite the news.

That night, Lipton couldn’t sleep. She weighed whether she should go to France, telling her best friend, who had gone to the doctor with her and who would accompany her, “How do you feel about going to Paris with a woman who’s like a grenade with the pin pulled halfway out?

“The next morning I woke up and realized that I was out of my mind,” Lipton says, noting that she wouldn’t have a good time in Paris fearing that every step could be her last. “I cancelled my trip and began the process of a million tests.”

Over the course of those tests, she learned that along with the surgery for the aneurysm, she would have to undergo additional treatment for a congenital abnormality in her aortic valve, which had to be replaced. She was 57.

Lipton survived the nearly eight hours of surgery and several hours spent on a heart-lung machine, which kept her alive. While recuperation was painful and long, she did recover. She continued her work as litigation counsel.

Lipton feels today she was a willing accomplice in her own fate. There had been signs that something was wrong despite her apparent good health. She would pass out in her office occasionally for no apparent reason, and she fell asleep right after dinner almost every night. Looking back, she realizes that circumstances could have been very different for her and her family, and that providence somehow intervened and stopped the worst from happening.

“People who have aneurysms like I do just die,” recalls Lipton, who is 61 now and retired. “It was such an accident that it was found and in time. Typically what happens is you just die, because when it finally blows, you’re gone.”

Beyond the Status Quo
What impeded Lipton, Gregg, and so many other women seeking help wasn’t a lack of access to proper health care, but rather a lack of understanding about the differences between men and women when it comes to cardiovascular diseases—both in diagnosis and treatment.

Those differences stand in their sharpest contrast when examined through the lens of heart disease death rates. Since 1979, the death rate for heart disease in men has declined by 17 percent while the rate for women has increased slightly, according to the American Heart Association.

Despite the disparity, advocates, cardiologists, and nonprofit health groups are pushing for a more comprehensive approach to combating heart disease in women. In effect, they’re calling the public and Congress to pressure health care and scientific communities to get serious about women’s cardiovascular health.

The cornerstone of that effort is the Heart Disease Education, Analysis and Research, and Treatment (HEART) for Women Act. First introduced in February 2006, it looks to improve the prevention, diagnosis, and treatment of heart disease in women by raising awareness among women and their health care providers. In addition, it would mandate that scientists provide gender- and race-specific information in their research, while requiring clinicians to provide additional screenings for low-income, at-risk women.

“Heart disease and stroke are the top killers of American women, and yet we’re still not doing enough to address this problem,” says Sen. Debbie Stabenow (D-MI), who cosponsored the legislation in the Senate. “We have to stop thinking of heart disease and stroke as men’s diseases. They’re not, and the numbers prove it. We have to insist on the best kinds of prevention, diagnosis, and treatment for women to ensure that more of our mothers and daughters and sisters can survive these diseases.”

To address the disproportionate share of heart research focused on men instead of women, the legislation, pending in the United States House and Senate, would require that health care data for clinical trials, drug and device approvals, and hospital quality be categorized by gender, race, and ethnicity when it’s reported to the federal government—something that hasn’t been done consistently in the past.

If information is the key to devising a successful strategy to combat heart disease and stroke in women, then clinicians, government agencies, and policymakers are flying blind at this point, say women’s health research advocates. “There’s been a one-size-fits-all approach on heart disease,” says Greenberger. “That should not, and cannot, be the case anymore.”

The disparities extend to research dollars as well. The U.S. Health and Human Services Department spent $8.2 billion on women’s health in fiscal year 2005 and less than 6 percent of it, about $5 million, was earmarked for cardiovascular and pulmonary research, according to the Society for Women’s Health Research.

While no one argues this lack of fairness, it is clear women haven’t been included in traditional research studies for heart disease and stroke, because they were looked at as diseases that traditionally felled men. In effect, if they are men’s diseases, why include women in the research?

At the same time, there was an attitude that women were men—only smaller. They shared all the same organs, except sexual ones, and there was no need to see if a woman’s heart reacted differently to a medication than a man’s.

The best example of this is the ubiquitous aspirin. Used as a preventive measure for heart attacks, research on the efficacy of the aspirin tended to focus on male reactions to the over-the-counter drug. They were positive, and an aspirin-a-day has proved a successful treatment for heart disease in men.

When it came to women with heart disease, it was assumed the same prescription would help women, but a comprehensive study of nearly 40,000 women found aspirin didn’t have the same effect in women, unless they were 65 years of age or older. The study did discover that younger women taking an aspirin did reduce the likelihood of stroke, a benefit not seen in men. Still, that study didn’t prove definitive. A new study released in April 2007 contradicted earlier research, showing that a daily dose of aspirin did avert heart attacks in some women.

“It’s unconscionable that this is happening,” says Bennett. “You cannot assume that what works for men will work for women. They are different in the way they respond to medications. No doubt a number of them will have the same effect, but it’s terrible to be in that situation as a physician, to go into an emergency room and have to give a patient something and you don’t know whether it will work or not.”

And the problems aren’t just with differences in medication. Studies show that women receive fewer referrals for diagnostic tests, such as the electrocardiograph and cardiac catheterization, than men. They also are less likely to be put forward for angioplasties and coronary artery bypass surgery.

Moreover, the results from extensive research studies into cardiovascular and other diseases often are not broken down by gender or race. For example, randomized clinical trials of acute coronary syndrome between 1966 and 1990 had only 20 percent participation from women; similar studies conducted between 1990 and 2000 had a 25 percent female participation rate.

“We need to be looking from the very beginning at what the sex differences are,” says Greenberger. “We’re still not doing that. Yes, we’ve made strides forward in research and care, but we still have so far to go.”

What They Aren’t Saying
Very few women want to volunteer stories about a debilitating heart attack or being sidelined by a TIA, even if it is a “ministroke.” Within the women’s health advocacy community, these women and their reluctance to speak is attributed to the continuing stigma associated with these cardiovascular diseases and women. While men who have come through bypass surgery may be asked to proudly display “their zipper,” women find it harder to accommodate their newest accessory—an obvious surgical scar.

In law firms across the Washington region, there are women who have had heart attacks or been felled by strokes, and they don’t discuss them. For some, it is a personal matter that doesn’t have a place in the law firm. For others, it’s a secret to be tightly held for fear it could ruin a promising career or sidetrack efforts at midcareer advancement.

“There’s a stigma that you’re no longer capable of being a full contributor, especially in a law firm which is still very much a man’s world,” says Gregg, noting that the public feedback on cardiovascular illnesses can be quite different than the reaction to something such as breast cancer. “If you have breast cancer, people feel sorry for you. You’re a victim. You didn’t deserve it. If you have heart disease, people question your lifestyle choices. Somehow you’re responsible, even if you aren’t.”

There are a growing number of health evangelists on the subject. One of the more prominent is Kastan of WomenHeart who told her story in a book, From the Heart: A Woman’s Guide to Living Well With Heart Disease. She describes her experience with heart disease, using the lecture circuit as her bully pulpit to encourage women to take their health seriously and be better advocates for their care.

The women telling their stories in this article, some of them speaking for the first time publicly, have had to deal with their share of insensitivity and judgment about their heart attacks, bypass surgeries, strokes, and aneurysms. None of them were dragged against their will to these pages, but they all understood telling their stories could have unforeseen consequences. They all felt it was worth the risk.

One of their brethren in heart disease—a male heart attack survivor—agrees with them about the risk. The act of speaking publicly about heart disease is part of an educational effort that starts in the home and ends in the public square.

“I was 57 when I had the heart attack,” says Rob Rubenstein, director of administration at Sidley Austin LLP. “I didn’t have to worry about my career. That made it easier to talk about. If I was in my 40s or a woman, I’m not sure what would happen to my career. I think that may be why so many women don’t talk about it, but I wish they would.

“The more women know about heart disease, the more we all can do to stop it,” Rubenstein says. “I don’t want my daughters to go through any of this if they don’t have to.”

It’s a hope shared by the many women who have walked that same path.

Freelance writer Sarah Kellogg wrote about the art and power of the apology in the June issue of Washington Lawyer.