We know a great deal about breast cancer and there is the mammogram screening for it, which more than 75% of American women ages 50-74 get. There’s been an enormous amount of research on this mostly women’s disease.
On the opposite end of the research spectrum there’s heart disease, which kills more women than breast cancer does, and is far less studied. Even the symptoms women and their doctors should be aware of, which are different from men’s, are less well known. Heart disease, called the “silent killer,” is still mysterious.
I spent many years worrying about ovarian cancer since my mother died of it when she was 45. I never worried about having heart disease. I thought it was a man’s disease. I am a physically fit 72-year-old violin teacher. My blood pressure and cholesterol have always been super low. I walk 3-5 miles daily.
In the spring of 2023, I started coughing non-stop. It was a dry, unproductive cough. Sometimes I’d be doubled over coughing. The strangest thing about the cough was that it didn’t follow a cold or any illness. It just popped up. I kept apologizing to anyone around me for the racket, assuring them that I wasn’t sick.
After a few weeks of ignoring it, I went to see my internist. She listened to my lungs and then had me get a chest x-ray. Everything looked good and my internist chalked it up to asthmatic bronchitis. She put me on prednisone and albuterol – the cough simmered down briefly but then came back with a vengeance. I went back to ignoring it.
Doctor visit after doctor visit
A year after the cough began I happened to see a different doctor. Naturally, I coughed throughout my first visit and said that I’d like to get rid of the cough. She put me on Flonase, an anti-allergy nasal spray. She also noted that “sometimes older people get a cough.”
A few months later, since the cough showed no sign of letting up, I went to the doctor again. She suggested I see a pulmonologist and an ear, nose and throat (ENT) doctor.
I coughed my way through my appointment with the pulmonologist and explained that I had been hacking away for more than a year now. He was determined to help me get rid of it. He promised to throw everything “including the kitchen sink” at it. Finally, we were getting to the root of the problem. The pulmonologist suspected it was asthma and put me again on albuterol, a medication used to control wheezing (a symptom I did not have) and told me to continue the Flonase.
Needless to say, many of the parents of my violin students were concerned with my cough. One mother commented, “You’ve had that cough for a long time.” “They’re trying to figure it out,” I replied. And another parent, himself a doctor, told me, “You’re going to give me a heart attack hearing that cough.”
The pulmonologist had the wisdom to have me get a CT scan of my lungs, which turned out to be abnormal. It seemed as if we were really getting somewhere. At the bottom of the image of my right lung was a cloudy area which is referred to as “ground glass.”
I went off to the ENT who numbed my throat and looked at my airways. She agreed with the pulmonologist that it was most likely asthma, but she thought it was also acid reflux and put me on two medications to fix that, as well as having me go on the gastroesophageal reflux disease (GERD) diet. No more spicy food, tomatoes, bubbly water, multivitamins, or citrus. As a pescatarian with an already limited diet, this change was not welcome, but if it was going to rid me of my cough, I agreed to do it. I am a very compliant patient. I even bought the enormous wedge pillow the ENT wanted me to use to elevate my head at night.
Since the Albuterol and Flonase didn’t seem to be helping, the pulmonologist added two more inhalers to the mix. So, now I was also taking Atrovent and Breo, a steroid, and gabapentin, just in case the cough was caused by a faulty nerve response. My voice, which is usually rather high-pitched, became hoarse. Apparently, this can happen when on a steroid inhaler. I was assured that this was not something to worry about.
Both the ENT and the pulmonologist wanted me to do a methacholine challenge test, which sees how reactive and responsive the lungs are. This exam is only offered by one place where I live so it is very hard to get an appointment quickly. The appointment was weeks away but both doctors felt it would be helpful in diagnosing and, therefore, treating my cough. Unfortunately, the week before the designated date I came down with COVID, so the test had to be postponed and rescheduled for several weeks later. Curiously, COVID did not seem to affect my cough.
A cardiologist gets involved
This past summer our extended family went on vacation and again my cough was terrible, but this time everyone seemed to notice and became alarmed. By this point I had become nonchalant about it, but I promised to go back to a doctor when I got home.
Having returned home I went to see the doctor who had sent me to the pulmonologist and ENT. I was having a ganglion cyst removed from my wrist a couple of weeks later and needed to have a pre-op checkup. My cough was as constant as ever.
Though it was in my medical records, I inexplicably mentioned to the doctor that I had severe heart disease on both sides of my family. “Let’s get you checked out by a cardiologist,” she said. I made an appointment with a cardiologist for the next available appointment, a few weeks later.
The mother of a student of mine, , is a UCLA Health cardiologist and I mentioned that I would be in her department to see a colleague of hers in a couple of weeks.
“Would you mind if I got you in sooner?” asked the cardiologist mother.
“No, of course not. Why the rush?”
“I’ve been wondering if your cough is connected to a heart issue.”
“Is there any literature on it?”
“Sure. I’ll send it to you.”
My newly appointed cardiologist decided to get some baseline information. I had a CT scan of my heart which turned out to be abnormal. The cardiologist put me on a statin immediately.
According to a 2019 study, 78% of men are on a statin, only 67% of women. I then had a stress test which I was told would last about an hour. “Do you have any chest pain?” I was asked a few times. “None,” I replied. The test was stopped abruptly, which I sensed was not a good sign.
Two hours later, I was teaching when my cardiologist called to say that the scan revealed a serious blockage. She scheduled a diagnostic catheterization for two weeks later, the earliest she could get.
Even though I was still coughing my head off, the cough now took a back seat to my heart situation. With the intervention of another doctor parent of a student I got in for the procedure a few days later. I found myself in an operating theater having a diagnostic catheterization, where they put a tiny camera through a blood vessel in my wrist, and then placed a stent in the blocked artery.
Despite my anxiety preceding the surgery, it was easy. I went in at 11 am and came out that evening. I experienced no pain or complications. I suddenly realized that my cough was gone. Not diminished, but completely GONE.
Need for greater awareness
Symptoms of coronary artery disease in women can be very different than in men. You must really search the literature to find “dry cough” as a symptom of heart disease. But it’s there. Also, after listing lung cancer and COVID the next symptom associated with “ground glass” on a lung CT scan is congestive heart failure.
I don’t know why I brought up my family history of coronary artery disease but had I not, it is unlikely anyone would have suggested I see a cardiologist, and no one would have seen that I had what appeared to be a 90%-99% blockage in one artery.
When faced with a cough, doctors go down a list of the most likely causes. Asthma and acid reflux are at the top of that list. But when none of the medications or special diet had any effect on my cough, no one seemed to contemplate that there was a possible “other” explanation and one that was potentially life threatening. None of my doctors seemed to know that the terrible dry cough was actually a symptom of heart disease in a woman.
There have been several articles in the London daily newspaper The Guardian about the lack of parity in research on men and women vis-a-vis heart health. One of the articles is headlined: “Women dying ‘unnecessarily’ of heart disease.”
I am fortunate that I didn’t have a heart attack. I’m spectacularly lucky to have a clientele that includes some doctors. I’m especially fortunate to have a cardiologist mother of one student, who once had a patient with a terrible dry cough who turned out to have a heart problem. I am very lucky that another doctor parent was able to get me in for surgery right away.
But not every woman with heart symptoms is so lucky.
This is verging on medicine by rumor. The medical industry ought to study women more and bring attention to this situation. Medical students must be taught the differences in men’s and women’s presentations of heart illness.
Obviously, had I been a younger woman, not a 72-year-old white privileged woman with Medicare, this whole process trying to get to the bottom of a bad cough would have cost a fortune.
Even though there is significant heart disease on both sides of my family, I had never thought of it affecting me, even after it killed both my grandfathers, one at age 61. My father’s first coronary occurred when he was 58, and then he had two more. It looked like a man’s disease. I recently discovered that my maternal aunt also had serious heart disease.
We got the vote 100 years after men and we’re still working on wage equity. Women have been treated like second-class citizens when it comes to diseases of the heart as well. Most of the research has been done on men. It’s about time our physical health was deemed as important as men’s.
To this day, if you look up dry cough and heart disease in women, there are only a few references, while most articles on heart disease and coughs pertain to a wet, phlegmy cough.
I hope that one day there will be a test for women who are at high risk for heart disease. But it can be a slow evolution: The pap smear, a test for cervical cancer, was invented in 1928 but didn’t become widely used until 1960.
I am very grateful to be alive and outfitted with an improved heart. I am indebted to everyone who helped me through this, particularly to the mother of my student. I just hope that other women have an easier time getting heart healthy than I did.