Cindi Lubeck had noticed that she tired out just a quarter-mile into her usual two-mile treadmill walks, but she thought it might have something to do with the 14 weeks of work she'd just completed in Louisiana. She had walked for miles every day through the ruin caused by three hurricanes, as a catastrophe insurance adjuster. And she was taking snowboarding lessons, which explained, she thought, the recurring pain in her right arm. Her shortness of breath, she thought, came from the dust she had inhaled while cleaning out her mother's attic.

A heart attack was not on her list of explanations, not even late one night when, trying to rest, she found she couldn't lie down without feeling anxious and nauseated. "I felt really weird," she said, "like everything was shutting down. There were 30 seconds when nothing functioned. The pain was in my right arm, not my left. I thought it had to be pulled muscles. Then I got really sick to my stomach." She called 911, and a couple of hours later, after a series of tests, doctors confirmed that she had had a heart attack.

She was only 49. She had been in great shape all her life, so much so that the California Department of Forestry had hired her as its first woman firefighter. Heart disease was definitely not part of her thinking, even though both her parents had developed heart problems later in life.

Two years later, Lubeck understands much more about her heart and about how to take care of herself. She is a patient at the Stanford Hospital & Clinics program, Women's Heart Health, one of only three dozen such centers in the U.S. dedicated to women's cardiovascular diagnosis, care and research. Her doctor is Clinic Director Jennifer Tremmel, MD, who offered Lubeck a comprehensive treatment plan that began with the discovery that Lubeck had a number of previously unseen problems with her heart. Treatment at the Women's Heart Health clinic is based on the most up-to-date research about sex differences in cardiovascular disease. It also includes an innovative care adjunct, the Heart-Mind Connection.

"It's our hope that, using this recent data, which clarifies the nature of those sex differences, we can help women do a better job of protecting their heart health and of recovering from heart disease," Tremmel said. "We know that effective treatment is not as simple as opening a blocked artery or improving diet and exercise."

Understanding the risks

Women's health has only recently become a field of study driving significant research to detect and analyze the differences in women's response to disease and illness. The startling statistics on women's heart health demand an immediate and proactive awareness in women and in the medical community. Heart disease kills more American women than any other illness or accident. Most women think of breast cancer as their biggest health threat. But six times as many women die from heart disease, about 500,000 each year. An estimated 8 million American women have heart disease—10 percent of all women age 45 to 65, and one in four of women over age 65.

For reasons not yet understood, women are more likely to die within one year of a heart attack than are men. Women who survive that first heart attack are twice as likely as men are to have a second attack. Researchers are also finding treatment differentials. And, studies show, women are more likely to suffer depression and stress which increases their chance of developing heart disease or having recurrent heart disease. 

Yet little is being done, Tremmel said, to address that particular influence on women's heart health. That lack spurred the Clinic, in collaboration with Stanford's Center for Neurosciences in Women's Health, to assemble the Heart-Mind Connection, a creative new program aimed at the side of heart disease not isolated to the heart itself. "A person who has a heart attack has an incredible emotional experience to deal with," said Marcia Stefanick, PhD, a member of the program's coordinating group. "We are eager to provide a clinical setting that really does take care of women who are at the intersection of heart disease and depression."

Soon after Lubeck arrived at Stanford, she learned that she was facing not just one blocked artery in her heart, but also that parts of her arteries were constricting when they should have been dilating, especially during times of physical exertion and emotional stress. Tremmel inserted a stent, a tube-shaped stainless steel mesh, to hold open one of Lubeck's narrowed arteries, selected medications to regulate her artery's function and explained that a heart healthy diet must be low in cholesterol, not just fats and sugars. When Lubeck complained of waking at night gasping for breath, Tremmel sent her to Stanford's Sleep Medicine Clinic for an evaluation. She had sleep apnea, but responded well to treatment.

Apart from the heart

Helped to a more restful sleep, Lubeck felt much better, but still experienced anxiety when she was short of breath or felt chest pain. Tremmel noticed, and asked her a question Lubeck says was a turning point in her recovery: "How are you, apart from your heart?"

Tremmel is an interventional cardiologist, trained in invasive repairs to open blocked heart arteries, but, with an undergraduate degree in psychology, she understands that psychosocial factors can affect physical ailments, and vice versa. "I can treat people with medications," she said, "open their arteries, tell them all the right things to do, but there's always this elephant in the room. It's difficult to address, but there's no doubt that anxiety, depression and stress must be considered if we're going to treat the whole woman who has heart disease."

Providing treatment for those psychosocial factors is an important part of the healing process, Tremmel said. One of the Clinic's primary goals is analysis of its treatments' effectiveness, within the frame of interdisciplinary research. The Clinic team includes not only cardiovascular experts, but also behavioral science clinicians who understand medicine.

Women's Heart Health at Stanford screens every woman who comes in to gauge her emotional state. "We want to see her as a whole," said Clinic psychologist Meg Marnell. "If you were suddenly told you had some kind of heart disease, it's very frightening. And that fear increases the general stress of life. We know a lot about the impact of stress on diseases."

As one way to help women handle stress, Tremmel and her behavioral science colleagues created a mindfulness seminar. Tremmel asked Lubeck if she'd be interested. "I was like, 'Yes, the more information, the better!' And I wanted to meet other women with heart disease," she said, "to find out where they were with it and to see how we could help each other."

New avenues to recovery

She learned techniques that allowed her to talk herself through those moments when she felt chest pressure. "It showed me I had more control over this than I previously thought," Lubeck said. She found that the more she used that approach, the less emotional and afraid she felt. Having others to talk to about her feelings and experiences, and having the chance to be a help to others, changed her attitude about her illness in a profound way.

"You've got to be patient and not beat yourself up about doing well and then having a horrible week," she said. "You have to do what you need to do for that day and think about being better."

The mindfulness seminar, said the Clinic's nurse-practitioner Mary Nejedly, gives women skills to deal with stress. "But they also realize they are not alone, that there are others like them, especially if they are younger women." For years, the stereotypical heart disease patient was an overweight, sedentary middle-aged man. That's changing, Nejedly said. "Women are smart and once they have the information, they do pay attention to their risk factors and to symptoms. They might say, 'I have a family history. Maybe I should get checked out.' It's just taking the time to do that. Women have to put their health higher on their to-do list."

Nejedly often recalls the 61year-old mother of a friend who had always worried about her husband's health more than her own. Two weeks after a doctor told her he thought her chest discomfort was probably heartburn, she died of a massive heart attack.

The program's goal, Marnell said, "is to normalize the idea that everyone's going to have some kind of a stress reaction to getting a new diagnosis. We can help them move through that more quickly. We want to teach them how to be a part of their treatment and to keep a positive attitude."

Confident and practiced in her ability to work through her tense moments, Lubeck is back on the treadmill and recently flew to Florida on her own, for the first time since her heart attack, and was able to keep up with her toddler grandson for a week. She's also volunteering at American Heart Association health education fairs. "I am me again," she said, "and, as always, I love life!"