Cardiologist Dr. Friederike Keating and the Hearts of Women

By Amy Lilly

Photo: Margaret Michniewicz

Dr. Friederike Keating (r): “The major problem is women’s own lack of awareness: they just don’t recognize their symptoms in time.”

Anne, let's call her, woke up on a Sunday morning feeling sore and tight on one side of her ribcage. Soon her left arm went completely numb. A 59-year-old, she joked with her husband that she felt like she was having a heart attack, but thought that it was probably just fatigue and maybe the flu. In any case, her thinking went, women and especially mothers just tough it out, as she always had. And there was the inconvenience of a trip to the emergency room; who would pick up the house and make dinner for the guests that evening?

When she could no longer talk or breathe without difficulty, her husband drove her to the ER. If they had waited a day or even a few hours longer, she was told, the blood clot partially blocking a coronary artery might have caused irreversible damage to her heart.

According to Fletcher Allen Health Care cardiologist Friederike Keating, M.D., Vermont's first and only specialist in cardiac care for women, Anne's experience is typical, and her thinking epitomizes a common lack of awareness about cardiovascular disease in women.

In fact, says Dr. Keating, more women die of heart disease each year than men. It is the leading cause of death among women; the rates at which we die from breast cancer are miniscule in comparison. We may be older on average when it appears (60 and up, while men develop disease around 50 and up), but we are less likely to recognize symptoms early and therefore delay seeking medical attention up to an hour later than men in a situation where every minute counts. We are at higher risk for dying after a heart attack even with timely ER appearances, and twice as likely to die after bypass surgery (though, to be sure, the overall rate of death after bypass is low). "Why? We don't know yet," says Dr. Keating. Nor is it understood why women who develop heart disease have higher rates of secondary disease, like diabetes.

These are the questions that drive Keating, who stepped into the brand-new position in Women's Cardiovascular Medicine in July 2005. Sublimely unpretentious, she meets up with me somewhere in the maze of Fletcher Allen hallways on a search for new batteries for her pager. Along the way she explains my presence to a colleague, telling him that one day if he becomes a famous men's cardiologist he might get a visit from a GQ reporter. Eventually we reach a small, windowless office dominated by bookshelves and startlingly bright overhead lighting – provided by a patient who was a particularly tenacious light bulb salesman, she tells me, amused. Decor is limited to two photographs of her children, one of them her laptop screensaver. When I ask, she says that Katerina is seven and Lucas is six.

"I didn't really start becoming interested in women's cardiac health until I had children and started hanging out with other women with children," Keating explains. "Women in medicine are the last to think of going into women's health because we've been in such a boy's world." And, she says, as a trainee in the male-dominated specialty of cardiology, "the last thing I wanted was to be put into a gender-based niche. I wanted to be 'one of the guys.'"

Merging of the Twain: A Career and a Field

Keating, who is from Goettingen, Germany, has even more training than the usual cardiologist. She went abroad to Reed College in Oregon where she met her American husband, David, now a radiologist at Fletcher Allen. She returned to Germany to attend six years of medical school and five years of a combined residency-fellowship in cardiology, according to the German system. David joined her there after finishing medical school in New York. Then they made the decision to move back to the United States where job opportunities were greater. For Keating, this meant repeating the last five years of her training, none of which counted here. Five turned into eight: she did her three-year residency in internal medicine at a teaching hospital affiliated with the State University of New York at Stony Brook, another year as a chief resident, then moved to Burlington to pursue a four-year fellowship in cardiology.

David has worked part-time since her fellowship began, to help take care of the children. "If you see women in this position," she says, "there will always be something unusual about the set-up at home. Either they don't have kids, or the man is willing to be the one cutting back for a few years," refusing, like David, to "get caught in gender stereotypes."

During all this time, the field she would go into was gaining momentum. Women's cardiovascular medicine is only about ten years old, says Keating, showing me a program guide to the American Heart Association's Second International Conference on Women, Heart Disease and Stroke, dated 2005. "We all fit into a single resort," she says of the conference attendees, "and that was everyone in the field from around the world." Leading women's cardiologists, like Dr. Nanette Wenger at Emory University, had begun cardiology studies during the 1960s and started publishing on women's cardiovascular health in the mid-1980s, but recognition of the separate field did not come until the late 1990s.

Keating grows animated as she tells the story: in the sixties, it was thought that the reason women got heart disease later and less often than men might have to do with their hormones. It seemed a solid theory because the age at which women's heart disease generally sets in corresponds to menopause, when estrogen levels drop. Yet, when men were given experimental doses of estrogen, it had no effect.

Reluctant to let go of the possibility of a hormonal connection, researchers in the mid-1980s seized on a national survey of female nurses' general health, isolating a correspondence in the data: those who were on estrogen therapy had half the rate of heart disease of those who were not. The FDA was on the verge of issuing a black box label, says Keating, advising women that estrogen replacement therapy reduced their risk of heart disease – when someone thought to question whether the Nurses' Health Study had adequately taken into account other factors indicated in the surveys. Subsequently, the large hormone trials of the nineties, the Women's Health Initiative and the Heart and Estrogen/Progestin Replacement Study, trumped their predecessor by demonstrating that women who were assigned to hormone therapy did no better, and possibly even worse, than those assigned to placebo. Perhaps, says Keating, what the older observational study showed was that women on hormone therapy were more attuned to their health in general and had been taking better care of themselves over the years. Keating reported on these studies to her colleagues during a routine "journal club" meeting two years ago – and the experience helped to propel her into her specialty.

Currently, women's cardiovascular medicine breaks down roughly into three areas of study. Coronary disease, or heart disease due to the arteries becoming blocked, addresses questions like the difference in death rates between men and women, including the social factors that lead to such statistics. Pregnancy-induced heart disease, a second area of study, is tricky not only because the symptoms so closely resemble those of pregnancy itself (shortness of breath, weight gain, fluid retention) but because medications have to take the baby into account. The third area studies heart failure, which happens when the body doesn't get enough blood because the heart itself is either too weak to pump (systolic) or too stiff to fully refill after pumping (diastolic). Women are at higher risk than men for diastolic heart failure, another little-understood statistic that requires more research.

Ambassador for Truth and Clarity

Through the research she has pursued since arriving at Fletcher Allen on the links between platelets and clotting, inflammation, and heart disease, Keating is addressing new questions, such as why there is a slight excess of heart attacks during the first stage of hormone therapy in women. At the same time, she has become a voice for public awareness of women's cardiovascular health in general. "The major problem is women's own lack of awareness: they just don't recognize their symptoms in time," she says. Keating is acutely aware that the sudden prominence of the field could generate a miasma of misinformation among the public, and she is on a mission to expose the "hype," as she calls it.

Pulling up a quote from a purportedly respected medical organization's web site, she picks it apart: the site begins by positing a theoretical woman who feels "stabbing" pain in her arm but fails to recognize her symptoms. In fact, says Keating emphatically, the most common symptom of coronary disease in women is chest tightness, or angina, just as it is for men. True, she adds, women experience those more unusual symptoms (neck, back, and arm pain) more often than men, but the scenario conveys two false messages: first, women should look for atypical rather than typical symptoms, and, second, that it is men's symptoms which are typical, while women deviate from the norm. Finally, the web site mentions that women get angina twice as often as men between the ages of 25 and 54. This is true, says Keating, but alarmist because they fail to mention that the cause of that angina is not necessarily women's hearts; women have a lower incidence of heart disease as the cause for chest pain than men.

"The organization isn't totally unjustified in what they're doing here," Keating concludes, "because the main concern is raising awareness. But it doesn't help to overshoot. It's just not factual."

It is not only the public who needs to be more aware, she goes on; it's the medical establishment as well. "Doctors are still not likely to diagnose heart disease when women present with chest pain," says Keating. Then she describes a truly alarming recent study: a number of professional actresses playing women patients with identical heart disease symptoms were asked to visit a number of real doctors, all fully aware of the situation. Nevertheless, the study revealed, the actresses who described their symptoms in an overly emotional manner were given inadequate test recommendations and follow-up advice, while those who maintained a calm, businesslike manner during their visit received the full gamut of tests and follow-up.

Keating merely laughs at this story; but then she is constantly negotiating a traditionally male milieu. She is still only one of three women cardiologists in the state. And, she says, male colleagues still feel the need to comment or joke when they open a door and find Keating in the company of some of the department's only female fellows, Eram Chaudhry and Letitia Anderson. "They call us Charlie's Angels," she says, remarking that none of the women, herself included, ever thinks to comment on coming upon a group of their male colleagues.

Instead, she remains focused on "the key": raising awareness. She will be giving a talk in Fletcher Allen's "Community Medical School" series on April 11, which is free and open to the public. It is sure to be crystal clear, factual, and heartfelt.

Dr. Keating’s April 11 presentation will be held in Carpenter Auditorium on the UVM College of Medicine Campus in Burlington. For the time and other information, call 847-2886 or 656-0728, or visit www.med.uvm.edu/cms.

Amy Lilly is a freelance writer from Burlington.