Last May, Bonnie Beach, 64, of Madison, Wisconsin, woke with mild pain in her arms and burning in her throat. She "wondered" about heart attack but dismissed the idea. Her pain was gone the next day.
During previous checkups, she'd complained of reduced energy. She didn't think her blood pressure medication was working anymore, but doubling the dose didn't help. The doctor would listen with his stethoscope, Beach says, and tell her nothing was wrong.
Five days after waking up with pain, Beach went into cardiac arrest and a stranger performed CPR. Soon she was having emergency open heart surgery -- coronary artery bypass grafting, or CABG.
Choice of CABG
In severe coronary heart disease, one or more of the major arteries to the heart is partially or fully blocked. With CABG, surgeons graft a healthy blood vessel to the diseased artery, creating a bypass around the blocked portion. The breastbone is cracked for surgical access, and in most cases, the patient is put on a heart-lung machine.
Cardiologist Sharonne Hayes, founder of the Women's Heart Clinic at the Mayo Clinic in Rochester, Minnesota, says the volume of CABGs has dropped in the past decade. One reason is that percutaneous interventions -- less-invasive procedures to place tiny stents along the arteries -- are often done instead.
Many of Hayes' patients have already tried several treatments, from medications to stents. But for some patients with conditions such as diabetes or kidney disease, or with multiple blockages, she says "bypass surgery is the best thing we can for them, because it gives them a better long-term outcome."
Women Patients and Risk
Women tend to develop heart disease at a later age, and often have coexisting conditions that put them at higher risk during bypass surgery, says cardiologist John Erwin, governor-elect for the Texas chapter of the American College of Cardiology.
A review published last January in Surgery Research and Practice found stroke was more common in patients who'd undergone CABG than stent placement, and being a woman was a stroke risk factor. But for both genders, repeat heart procedures were more often needed for stent patients.
A 2012 review in Coronary Care found that while death rates have historically been higher for women with either procedure, the rates are similar when accounting for age and coexisting health conditions. And the gender gap is narrowing.
"The good news is that the risk for bypass surgeries has been steadily going down over the past two decades, even though the patients we're operating on are at higher risk," Hayes says. "We have better anesthesia techniques; we have better surgical techniques."
Diabetes is a factor in slowed healing, says Erwin, who is a senior staff cardiologist at Texas-based Baylor, Scott & White Health. And, he says, "Women who've previously had breast cancer with radiation heal very slowly."
Beach was in a coma for five days after her emergency CABG. It took months as she recovered -- and combing through her own medical records -- for her to comprehend the magnitude of her heart disease and surgery.
Younger Women and CABG
Angela Baird, 32, of Kansas City, Missouri, was 24 when she had open-heart surgery -- two years after a suffering a severe heart attack as a missionary in Africa.
After a hellish month recovering, Baird returned to the United States. But even though she described classic heart attack symptoms -- tightness around her chest and neck, difficulty breathing and severe nausea -- the medical focus was on ruling out travel-related infection.
Two years and an emergency hospitalization later, Baird was found to have severe arterial blockages and sharply reduced heart function, and she underwent CABG. The culprit turned out to be Kawasaki disease, which most often shows up in childhood.
In terms of age, Hayes says, the most common scenario for CABG in women is a patient in her 60s or 70s with hardening of the arteries. But she also sees patients have bypass surgery in their 30s and 40s.
Hayes is currently researching a condition called spontaneous coronary artery dissection. "SCAD is when the body of the artery tears, and it creates a plaque or blood clot. That happens more commonly in women -- the average age is 42," she says. "A lot of these women are very active and have no risk factors."
What to Ask Before CABG
When women in non-emergency situations have the option to sit with their doctors and weigh treatment options, here are some questions to ask:
-- Why are you recommending CABG?
-- What are my alternatives? Is a stent as good, or possible?
-- Is intensive medical therapy an option? That means "taking statins, exercising, having a good diet and limiting alcohol," Hayes says.
-- What are the risks of having this operation, for me? Do I have an additional risk because perhaps I'm diabetic, or because of my age or my kidney function?
-- If we do this, what are you expecting will be different for me? Am I going to live longer? Am I going to feel better? Am I going to have more endurance? In short, ask about the true benefits for any cardiac procedure, Erwin says.
Because it's difficult to focus when you've just learned you have life-changing heart disease, bring a family member or friend along to listen, too.
Carolyn Thomas, a heart attack survivor and blogger at Heart Sisters, says she had an image "about the kind of person who would have a cardiac event, and that person was not me."
Thomas, who had her heart attack at 58, did have an unsuspected risk factor. During her first pregnancy, some 30 years ago, she'd experienced preeclampsia (high blood pressure while pregnant), which has since been tied to future heart disease risk.
Thomas describes being misdiagnosed and sent home: "Central chest pain, nausea, sweating and pain radiating down my left arm," she says. "I wish that emergency doctor would have googled my symptoms, because only one thing would have come up."
WomenHeart: the National Coalition for Women with Heart Disease trains heart attack survivors, including Thomas, as "champions" who spread the message about women and heart disease.
Rehab and Recovery
On average, Hayes says, patients stay in the hospital five to seven days after surgery. "Usually by six to eight weeks, if they've got a sedentary job, they're back to work," she says. "People who have physically demanding jobs; they take a little bit longer."
Cardiac rehabilitation programs, usually outpatient, are crucial for physical recovery and emotional support. "Patients who undergo formal cardiac rehabilitation programs clearly recovery faster than those who don't," Erwin says. Cardiac rehab is covered by insurance, and if your doctor doesn't refer you to a program, ask.
Wearing Your Scar
Scars do matter to most women after CABG, and Hayes says many patients tell her they're more careful about their bathing suit and blouse choices after surgery.
Surgeons at Mayo Clinic are sensitive to the issue, and with bypass, "particularly with women, they try to make the incision not as high," she says, so the "zipper" no longer starts at the top of the sternum.
Baird says that as a younger patient, her scar really bothered her at first: "I wore high-necked shirts to hide it." She continued her work to help others, and was scheduled to speak at a women's prison in Kentucky about two months after her heart surgery.
"I woke up that morning and heard an internal voice telling me to wear my scar that day," she recalls. "And there was something about not hiding it -- my weakness or my struggles or my trial -- that felt like it would help me relate to other women, or other people." Now, she says, "I really view it as something beautiful, because it saved my life."