Heart disease is the leading killer of women over the age of 50 and heart attacks are twice as deadly for women as they are for men. Statistics (which need not apply to you) show that one in two women will eventually die of some kind of heart disease—either coronary artery disease causing a heart attack or a stroke (a stroke is just a "heart attack" of the brain)! In contrast, one woman in twenty-five will die of breast cancer.

Disorders that are characterized by arteriosclerosis include diabetes, insulin resistance, high cholesterol, hypertension, decreased thyroid hormone, and a genetic tendency toward producing too much homocysteine.

No matter where cardiovascular disease first shows up, it is present throughout the entire body. Though most of us wait until mid-life to take steps to prevent or treat it, heart disease actually begins in childhood—the minute we learn to start shutting down our hearts to avoid feeling disappointment and loss.

Because the heart is so directly associated with and affected by emotions, midlife is the perfect time to prevent heart disease by learning to listen to your heart, nourish your cardiovascular system with the right foods and supplements, and find the courage to change the aspects of your life that no longer serve you.

Behind every behavior—whether health-enhancing or health-destroying—there are emotions that are processed by the heart and the entire cardiovascular system. And behind every emotion, there is a belief—a perception about reality. Thoughts and beliefs that support self-love and self-worth enhance health and well-being, (and the lifestyle behaviors that support them). This is true because positive emotions open the blood vessels, optimizing blood flow and nourishing your tissues.

But when we don’t feel our emotions fully, don’t deal with them directly and don’t let them flow through us, they have a constricting biochemical effect on the cardiovascular system. Indeed, some women experience heart symptoms related to emotions such as panic, fear, and depression. Thus, the more women truly care for themselves, the better their health is—pure and simple.

At midlife our hearts ask us to wake up and live our personal truth so that a seamless connection exists between what we say we believe and how we actually live our day-to-day lives. If we don’t follow our body’s lead and fuel our hearts and lives with the energy of full emotional expression, full partnership, and heeding our desire for more pleasure in our lives, then heart attack, hypertension, stroke, and dementia are more likely to result.

When we have the courage to open our hearts at midlife, however, we are opening ourselves up to the possibility of living more fully and joyfully than we have since we were young children—only now we have the skills and power of an adult with which to direct our openhearted energy.

Although our intellect-driven society leads us to believe the opposite, the intellect exists to serve the wisdom of the heart—not visa versa. All the drugs and technology in the world can’t mend a broken heart or heal someone whose heart is no longer in the game of life. The EKG signal coming from the heart is 60 times stronger than the EEG signal from brain waves. So when there’s a conflict between the intellect and the heart, the heart always wins. And the only way to heal the true discomforts of the heart is to feel them fully, have faith in a power greater than yourself, and then live your life robustly.

Men who are having a heart attack typically present with chest pain that begins under the breastbone and spreads to the jaw and the left arm. Women with heart attacks may not have chest pain at all. Instead, they may experience primarily jaw pain and indigestion. Or the first sign of a heart attack in women may be congestive heart failure, with no evidence of the heart attack preceding it except for telltale changes on an electrocardiogram. They may die from this "silent" heart attack. Women who do have chest pain often experience more functional limitation than men, but fewer women are referred to cardiologists for a complete workup.

Women’s blood vessels are also smaller and have a different organization from men’s. This is one of the reasons why coronary bypass surgeries and angioplasties don’t work as well in women as they do in men and also why more women die after these procedures. More women than men with so-called normal coronary arteries also have heart attacks, angina, and myocardial ischemia. As a result, a normal angiogram (blood vessel study) in a woman with symptoms doesn’t necessarily mean that she doesn’t have heart disease.

Most physicians until very recently have not appreciated this difference. Because of this, serious heart problems can and do go underdiagnosed and undertreated in women. In fact, women are only half as likely as men to undergo acute catheterization, angioplasty, thrombolysis, or coronary bypass surgery. The risk of dying of heart disease in a hospital is two times as great for a woman as it is for a man.

Most of the time, arteriosclerosis is not diagnosed until an individual has a heart attack or stroke. Individuals with chest pain or difficulty walking because of vascular insufficiency often have an angiogram (an X-ray test which looks at blood vessels injected with dye). Sometimes physicians use an ultrasound technology known as a Doppler device to diagnose vessels that are blocked. If you have diabetes or high blood pressure, are significantly overweight, never exercise, follow a poor diet, or are a smoker, I can virtually guarantee that you already have arteriosclerosis.

Cardiovascular disease results, in part, from arteriosclerosis—an accumulation of oxidized fat in blood vessels that calcifies and eventually causes blood vessel and heart damage. This condition underlies all coronary artery disease and is responsible for the majority of deaths in the Western world. (Strokes, which kill ninety thousand women per year, can be likened to a heart attack in the head. Both heart attacks and strokes are caused by clogged vessels; the only difference is where the clogged vessels are located.) It’s accepted now that hardening of the arteries is caused by damage to the endothelial lining of blood vessels from free radicals. This, in turn, is caused by glycemic stress, trans fats, emotional stress, and micronutrient deficiencies.

The part emotional stress plays in this equation cannot be overemphasized. Emotions such as depression, anxiety, panic, and grief have been shown to cause constriction in blood vessels, thereby impeding the free flow of blood. And anything that causes constriction in your blood vessels makes your heart and your vessels work harder to do their job. I’ve seen happy, joyful women with high cholesterol counts live healthy lives into their eighties and even nineties, while much younger women whose lives were characterized by depression, anxiety, or hostility might have their first heart disease symptoms in their early fifties despite normal cholesterol levels.

In women over fifty-five, estrogen deficiency has been commonly thought to be a significant cause of heart disease. But that thinking changed when researchers stopped the original WHI study upon finding that Prempro (Premarin plus Provera) actually increased the risk of blood clots, heart attack, and stroke in healthy women. In addition, the Heart and Estrogen/Progestin Replacement Study (HERS), the Estrogen Replacement and Atherosclerosis (ERA) study, and the WHI study all showed that estrogen replacement did not decrease the incidence of heart attack in women who already have heart disease. In fact, research showed that risk was even increased for a while.

When in your life you take HRT can also have a big effect on risk. In 2006, an analysis of the data from the Nurses’ Health Study found that nurses who began taking HRT near menopause did indeed have about a 30 percent lower risk for heart disease than women who didn’t use hormones. In comparison, nurses who started HRT ten years or more after menopause showed no benefit. There was no difference between those who took estrogen alone and those who took it combined with synthetic progestin. The study also reanalyzed data from the WHI study and confirmed that the risk of heart problems increased in women who began taking HRT ten years or more after menopause. (There was a 22 percent increase in those who started HRT from ten to nineteen years after menopause.) But those who started it within a couple years after their last menstrual period experienced an 11 percent lower risk of heart disease. Even more striking, in the estrogen-only branch of the WHI, published in 2006, women who started HRT between ages fifty and fifty-nine had a 44 percent lower risk of heart disease.

This makes sense considering the large body of research that shows estrogen has a beneficial effect on the heart and blood vessels (at least in younger women). Even so, I still wouldn’t prescribe HRT to everyone just to prevent heart disease because too many other factors come into play, including breast cancer and stroke risk.

Among the many other characteristics that create a risk of heart disease, chief is increased insulin resistance, which is present to some degree in 50 to 75 percent of women in the United States. An enormous amount of data exists on the link between nutrition and heart disease, particularly with regard to the ill effects of excess insulin and the benefits of antioxidants. A 1997 study demonstrated that a diet too high in carbohydrates and too low in fat was likely to increase the risk of heart disease because of its adverse effects on lipids and insulin. The authors concluded that given their results, "it seems reasonable to question the wisdom of recommending that postmenopausal women consume low-fat, high-carbohydrate diets."¹

The high rate of heart disease in our society is related to a lifestyle that includes high consumption of trans-fatty acids (including hydrogenated oils) and refined carbohydrates, combined with inadequate exercise and protein, all of which sets the stage for cellular inflammation, creating a predisposition to hypertension, diabetes, and heart disease.²

Depression is consistently related to a high risk for heart disease in both men and women. Because at least 25 percent of women suffer from depressive episodes at some point in their lives, and because women are more apt to suffer from depression than men, depression emerges as a very important and modifiable risk factor for women. Though it is well documented that both men and women often suffer from depression after a heart attack, newer data conclude that depression is an important independent risk factor for heart disease. Depressed women were also shown to be twice as likely to develop coronary artery disease as were normal, non-depressed women.

Arteriosclerosis can be largely prevented or reversed by diet and lifestyle factors. In fact, the famous Nurses’ Health Study, which followed more than eighty-four thousand women for more than fourteen years, showed that the risk of arteriosclerosis is very low in women who get regular exercise, don’t smoke and eat a low-glycemic diet that minimizes simple carbohydrates (sugar and starch) and trans fats and contains plenty of the right kind of fats (such as omega-3 fats).

The high-carbohydrate, low-fat diet usually prescribed for preventing and treating heart disease seems to have exactly the opposite effect. When compared to a higher-protein, higher-fat diet with exactly the same number of calories, the high-carbohydrate diet has been shown to increase risk factors for heart disease (including high triglycerides and insulin and lower HDL cholesterol) in healthy postmenopausal women. High-carbohydrate meals also trigger angina sooner and reduce exercise tolerance in patients with known heart disease because high insulin levels can cause constriction of arteriosclerotic coronary arteries.

On the other hand, eating five to six servings of fruits and vegetables per day has been shown to lower the risk of stroke by 31 percent. The strongest effect comes from the cruciferous vegetables, such as broccoli, cauliflower, Brussels sprouts, and cabbage, followed by green leafy vegetables and citrus fruit and juice. One study showed that women who ate just five large carrots per week lowered their risk of stroke by 68 percent compared to those who ate only one carrot per week.

Having elevated blood levels of the amino acid homocysteine (found in high amounts in animal protein) constitutes a strong risk factor for cardiovascular disease. At least 10 percent of the population has a genetic tendency for elevated levels. When high homocysteine levels are reduced, the incidence of heart attack is cut by 20 percent, the risk of blood-clot-related strokes decreases by 40 percent and the risk of venous blood clots elsewhere in the body plunges by an impressive 60 percent.

Studies have shown that dietary intake of vitamins B12, B6, and folate can help combat an elevated homocysteine level, as can cutting back on the amount of animalbased protein in your diet. Ask your health care provider to determine your homocysteine level. (It should be below 7.) If it’s too high, you need to add activated folic acid (L-methyl folate), vitamin B12, and vitamin B6 to your diet. L-methyl folate is the most biologically active and usable form of folic acid. It has been shown that conversion of folic acid is frequently disrupted by genetic factors, agerelated factors, and metabolic problems. Taking activated folate bypasses these problems.³ You may also need folate supplements of 1,000–2,000 mcg for three months or so, after which point you can decrease the supplements to a maintenance amount. (As one of those with a genetic tendency toward high homocysteine, I was able to lower my levels to normal by taking extra folic acid.)

A diet containing fish oil has been found to reduce the incidence of heart disease in a number of studies. Research shows that 3 g per day of fish oil containing both EPA and DHA (a specific type of highly beneficial omega–3 fat) protects the heart because it makes platelets more slippery and decreases cellular inflammation. Alternatively, you can eat three servings of cold-water fish per week, such as salmon, mackerel, swordfish, or sardines.⁴ (One 4-oz serving of salmon contains about 200 mg of DHA.) If you are a vegetarian or do not care for these fish, take high-quality flax seed or EPA and DHA supplements derived from algea. The usual dose of DHA is 100–200 mg per day; for other omega-3 fats it is 1,000–5,000 mg per day.

Some other supplements you might want to consider are:

• Magnesium: Recent research shows the crucial role that magnesium plays in maintaining health, including heart function. Magnesium deficiency is relatively common because our food supply tends to be poor in this mineral. Using diuretics results in the loss of magnesium through the urine, too. Excessive use of the stomach acid inhibitors cimetidine (Tagamet) and ranitidine (Zantac) can result in magnesium deficiency as well. If you’re healthy, start with 200 mg twice a day. If you have cardiovascular challenges, boost it to 500 mg twice a day. (You’ll know you’ve reached your limit when you develop loose stools.) Be sure to take magnesium with meals.
• Calcium: Adequate calcium intake also helps keep blood pressure normal. This mineral works in tandem with magnesium, and therefore it’s important to make sure you get enough of both. In general you want to be sure that your calcium is balanced with magnesium in either a 1:1 or 2:1 ratio. Take 400–1,200 mg/day with meals, depending upon how much calcium is present in the diet.
• Coenzyme Q10: CoQ10 acts to increase the supply of energy for cellular processes in general and thereby contributes to the improvement of overall health. Some of the documented benefits include improved ability of the heart to pump effectively. It has also been shown to help reduce high blood pressure and congestive heart failure in those who already have heart disease. Statin drugs, including lovastatin (Mevacor), pravastatin (Pravachol), and atorvastatin (Lipitor) lower Coenzyme Q10 levels, as well. Studies have shown that almost half of patients with hypertension have coenzyme Q10 deficiencies. I recommend taking 50 mg twice a day for ten weeks. Studies have shown that for those already taking medication for high blood pressure, the need for antihypertensive medication declined gradually in about four and a half months in half of the patients who took coenzyme Q10 (225 mg per day); some were able to stop taking blood pressure medication altogether. The minimum dose of coenzyme Q10 I recommend is 30 mg/day. For anyone with any family history of heart disease, I’d recommend 60–90 mg/day. The dose can go up to 300–400 mg per day for those with advanced heart disease.
• Carotenoids: Dozens of studies show that individuals who consume high amounts of pigment-rich foods have less risk for heart disease. These foods are loaded with carotenoids such as beta-carotene, which has been shown to decrease risk of free-radical damage to the heart and blood vessels. Beta-carotene prevents the lipoprotein LDL ("bad" cholesterol) from becoming oxidized. The usual dose of beta-carotene is 25,000 IU per day in supplement form. However, a mix of the carotenoids is better than taking just one. For example, lutein is present in HDL ("good") cholesterol and may help prevent LDL cholesterol from oxidizing. The best way to get lutein is in fruits and vegetables, but it is also available in health food stores as a supplement; take 3–6 mg per day. Lycopene is another good antioxidant; eating tomatoes a couple of times a week will give you all the lycopene you need.
• Vitamin E: The Cambridge Heart Study, which looked at the effects of vitamin E on two thousand patients with documented heart disease, found that those who took between 400 and 800 IU of vitamin E per day had a 77 percent decrease in cardiovascular disease after one year. The dosage is 200–800 IU per day of d-alpha-tocopherol (natural vitamin E; check the label) or mixed tocopherols.
• Tocotrienols: These are part of the vitamin E family, but they are 40 to 60 times more powerful antioxidants than regular vitamin E. Tocotrienols improve total cholesterol levels, oxidation of low-density lipoprotein (LDL, or "bad" cholesterol), and the clumping of red blood cells. Free-radical damage (oxidative stress from poor diet, psychological stress, smoking, etc.) that accompanies LDL oxidation is particularly dangerous because it can cause serious injury to artery and vein walls. Fresh fruits, dark green leafy vegetables, almonds, peanuts, and wheat germ also contain tocotrienols and the other types of vitamin E. Most multivitamins don’t have significant amounts, so if you want to supplement your diet, you have to take these supplements separately. Take about 50 mg per day daily for a month, and then lower the dose to about 30 mg (two capsules per day) thereafter.
• Selenium: This antioxidant has been shown to decrease the risk of free-radical damage to blood vessel walls. Usual dose is 50–200 mcg per day.
• Oligomeric Proanthocyanidins (OPCs): Derived from grape seeds or pine bark, OPCs are in the class of foods known as the flavonoids. Cardiovascular disease risk is inversely proportional to flavonoid intake. The usual dose is 40–120 mg/day.
• Alpha-Lipoic Acid (ALA): This unique antioxidant is both water- and fat-soluble. That means that it can stand guard against free-radical damage in every part of the cell. It has also been shown to help preserve intracellular levels of vitamins C and E and to help regenerate another antioxidant known as glutathione. Alpha-lipoic acid is also helpful for the metabolism of insulin. The usual dose is 50–200 mg/day.
• Vitamin C: This powerful antioxidant helps protect the endothelial lining of your blood vessels and has also been found to aid the absorption of calcium and magnesium, two key minerals for heart health. A dose of 1,000 mg per day has been shown to significantly reduce systolic blood pressure. You can take it in the form of plain old ascorbic acid, although if you have a sensitive stomach, use the ascorbate form. I recommend at least 1,000–3,000 mg/day.
• Hawthorn: Herbalists have used Hawthorn berry extract for years as a tonic for heart-related conditions. Take this as a tea or a pill (look for a standardized extract that contains 10 percent proanthocyanidins or 1.8 percent vitexin-4"-rhamnoside). The usual dose is 100–250 mg three times per day.

Consuming specific foods has been found to aid heart health, as well. Among them are:

• Garlic: Garlic has a long history of use in the treatment of hypertension. One pilot study showed that high doses of garlic (2,400 mg of deodorized garlic per day) significantly lowered both diastolic and systolic blood pressure. Like alpha-lipoic acid, garlic appears to increase the activity of the endothelial cells that produce nitric oxide, which is a blood vessel relaxant. Numerous studies have also shown that regular consumption of garlic reduces cholesterol by 10 percent or more and lowers triglyceride levels by up to 13 percent. It may also inhibit platelet aggregation and blood clot formation. Look for garlic suppliments with the active ingredient alliin. This substance is relatively odorless until it is converted into allicin in the body. These supplements supply all the benefits of fresh garlic but are more socially acceptable. A daily dose should be 10 mg of alliin, or a total allicin potential of 4,000 mcg.
• Tea: Both black and green tea consumption have been shown to have beneficial effects on the endothelial lining of blood vessels, which helps decrease the risk of stroke.⁵  The Zutphen Elderly Study in the Netherlands found that foods rich in an antioxidant known as quercetin (such as apples, tea, and onions) also decreased the risk of stroke. Black tea consumption (five or more cups per day) decreased the risk of stroke by 69 percent.⁶
• Soy: For years, studies have shown that soy lowers triglycerides and total cholesterol levels, including LDL ("bad") cholesterol, while raising HDL ("good") cholesterol. Soy has further been shown to reduce blood levels of such markers for cardiovascular problems as C-Reactive Protein (CRP) and homocysteine. Some studies even document improvements in the width of the arteries. This may be due to soy’s antioxidant properties, which could prevent LDL cholesterol from clogging the arteries. The data has been so overwhelming that on October 26, 1999, the FDA approved the health claim that consuming 25 gm of soy protein per day reduces the risk of coronary artery disease.

Baby aspirin has gotten a lot of attention for its potential to reduce stroke because it decreases cellular inflammation and subsequent platelet "stickiness." The Women’s Health Study (involving 40,000 female health workers over the age of forty-five) found that women who took the equivalent of a baby aspirin every other day reduced their risk of stroke by 17 percent—but there was no reduction in heart attack risk. Yet 127 women were hospitalized for gastrointestinal bleeding among the aspirin users compared to 97 among the non-aspirin users. I think there are far more effective and healthy ways to reduce risk without any possible side effects.

Weight-bearing exercise can be very helpful for heart health because it lowers insulin resistance dramatically. It increases lean muscle, and because lean muscle mass has a higher metabolic rate than fat, it helps to burn excess body fat and thus lower the risk of heart disease. Women who perform such exercise live an average of six years longer than those who do not. Your goal should be to exercise five or six days per week for at least thirty minutes. The best fitness regimen includes strength, flexibility, and endurance so chose activities that cover each of these.

If you smoke, quit. Smoking is responsible for 55 percent of the cardiovascular deaths in women less than sixty-five years old because smoking greatly increases oxidative stress in every cell of the body. In the Nurses’ Health Study, smokers had four times higher relative risk of total coronary artery disease than women who never smoked. But in women who stopped smoking, the relative risk immediately decreased to 1.5. Two years after stopping smoking, the risk dropped to that of a woman who has never smoked.

A number of compelling studies have shown that gum disease is a risk factor for coronary artery disease and stroke. This association may be due, in part, to the fact that inflammation plays a central role both in gum disease and in hardening of the arteries. It has also been shown that the inflammation seen in periodontal disease is associated with narrowing of the carotid arteries, a risk factor for stroke. Periodontal disease is easily preventable (and often treatable) through proper brushing, flossing, and regular visits to the dentist for professional evaluation and cleaning.

If you don’t already have a pet, consider getting one. It’s well documented that the presence of a pet lowers blood pressure and is relaxing. Studies on the health benefits of pets backs up the idea that our hearts are touched and healed, quite literally, by the unconditional love that animals can bring to our lives. The presence of a pet is associated with decreased cardiovascular reactivity—which means that the influence of a pet helps us stabilize our blood vessels and heart rhythm. People have been found to have lower heart rates and lower blood pressure when they are with their pets. If you can’t own a pet yourself, volunteer at an animal shelter or visit other people’s pets.

The number and diversity of your friends and associates also contributes to heart health or lack of it. Women with greater numbers of children and too many demands on their time combined with a lack of emotional support have been shown to be at greater risk for heart disease. But women who perceive that their families are supportive are at lower risk. In fact, studies show that if you perceive that you are valuable and powerful in the world and have choices, then your heart will be more apt to work optimally. But your risk for heart disease increases if you feel that you have no autonomy.

Remember that underneath it all, understanding the language of the heart is the most important way for you to prevent or recover from heart disease. A healthy and functioning cardiovascular system is inextricably related to the regular expression of joy and creativity, and in the final assessment, free expression of a full range of emotions may be the most effective prevention for heart disease.