FRESNO, Calif. Vicki Westburg made excuses for being tired and short of breath. She blamed long, stressful days on her job as a special education administrator for a weariness she couldn't shake. And she thought her labored breathing was due to asthma.
When she woke gasping for breath on New Year's Eve a year ago and her husband rushed her to the hospital, Westburg, 48, of Fresno, suspected an asthma attack.
Instead, she was stunned: Tests showed congestive heart failure. "The left side of my heart was just not functioning," she said.
Westburg is among 8 million women nationwide and more than 85,000 in California's San Joaquin Valley diagnosed with heart disease and that doesn't include many others who don't even realize they have it.
Heart disease is the No. 1 killer of women in the United States, claiming the lives of more women each year than men. But in doctors' offices across the country, heart disease in women often goes undiagnosed. Their symptoms don't mirror those seen in men, and women tend not to recognize the warning signs, doctors say.
Like a lot of women, Westburg ignored her symptoms and kept working.
"I'll get better," she remembers thinking. "I'll get better."
We expect men to die of heart disease. But it has been killing more women nationwide than men each year since 1984, and the gender gap shows no signs of going away.
The number of women who die from breast cancer and all other forms of cancer combined doesn't equal the death toll from cardiovascular disease, including heart attacks and strokes, according to the American Heart Association.
This year, an estimated 490,000 women nationwide will die of heart disease.
Nearly half of women who have a heart attack had never been diagnosed with heart problems, according to a June 2006 program brief on women's cardiovascular health by the federal Agency for Healthcare Research and Quality.
The agency cited a review of medical records of 150 Minnesota women who suffered heart attacks between 1996 and 2001.
The women had made 8,732 visits to doctors and had 457 hospitalizations in the 10 years before their first heart attacks, the report said. Doctors diagnosed only 52 percent with heart disease before they had heart attacks.
Westburg knew something was wrong. Her 50- to 60-hour workweeks as manager of special education services and programs at the Fresno Unified School District had never bothered her, but she found herself leaving meetings early to lie down in her office.
She could barely walk a flight of stairs. She had to ask her secretary to drive her to meetings that were only two blocks away.
Westburg now recognizes her symptoms were those of heart disease. At the time, she said, "I kept thinking it was just overwork stress. All the things that women say to ourselves."
But even doctors were puzzled by her symptoms. There was little reason to suspect serious heart problems. She was overweight and had a rapid heartbeat, but other than that, she didn't have risk factors high blood pressure, high cholesterol or a family history of heart disease. She never smoked.
After her January 2007 trip to the emergency room, she had a triple bypass to clear arteries and surgery to repair a damaged heart valve.
Westburg took a medical retirement from the school district, where she worked for 23 years in various positions. Now she spends long hours in bed. When she ventures out of her northwest Fresno home for a walk, she uses a motorized scooter.
"I'll have to have a transplant at some point," she said.
If Westburg had complained of chest pains, her heart problems might have been caught earlier, family members said.
But the possibility of heart disease never came up, said Westburg's sister, Louanne Kruse, 50, of Fresno. "If she'd just said she couldn't breathe 'it feels like an elephant sitting on my chest' that might have triggered something," Kruse said.
Women's symptoms don't make it easy for doctors to detect heart disease.
In men, chest pain or pain in the arm or jaw are classic signs of coronary artery disease, which can lead to a heart attack when an artery is blocked. In women, those signs may not be present.
Even when women with coronary artery disease exercise, "they may not get the typical chest pain," said Dr. John Telles, a Fresno cardiologist.
Instead, women can have an array of subtle symptoms: unusual tiredness, anxiety, problems breathing, indigestion, trouble sleeping. These can be mistaken for other ailments. Doctors are still trying to understand why women have different symptoms.
But without chest pain to warn them, women may not seek treatment for heart disease until it's an emergency.
Emergency room doctors fail to diagnose about 2 percent of patients with heart attacks because they don't have typical symptoms, according to the Agency for Healthcare Research and Quality. The misdiagnosed patients tended to be women younger than 55 or minorities reporting shortness of breath instead of chest pain, the agency said.
Doctors are trying to understand why heart disease kills more women than men.
The American Heart Association says 77 percent of women age 40 and older compared to 82 percent of men survive a year after a first heart attack.
One reason doctors suspect for the difference: Women's heart disease often has progressed by the time they are treated for it. And the longer heart disease goes undetected and untreated, the greater the risk of complications from procedures or surgery.
But research also suggests women receive fewer standard drugs for their heart disease than are prescribed for men, and that they also have fewer procedures and operations to open clogged arteries.
An analysis of 327,040 men and women who had heart attacks found women were less likely to receive drugs aspirin, beta-blockers, intravenous heparin or nitrate therapy during the first 24 hours in a hospital.
The women also were less likely to get angiography to examine blood vessels and angioplasty, a balloon procedure to open them. They also were less likely to have coronary bypass surgery than men, according to the Agency on Healthcare Research and Quality. And the women were more likely to die while in the hospital, the agency said.
"Women tend to be underdiagnosed, undertreated and have higher complication rates in therapy than we see in men," said Dr. John A. Ambrose, chief of cardiology at the University of California at San Francisco-Fresno Medical Education Program.
Operating on women with advanced coronary artery disease can be technically challenging, said Dr. Richard Gregory, medical director of cardiothoracic services at Community Regional Medical Center and Fresno Heart & Surgical Hospital.
Women's hearts, valves and arteries are smaller than men's. And the chest area is smaller, giving doctors less room to work during open-heart surgery, he said.
Inserting stents in small arteries also can be difficult. Stents are tiny metal-mesh cylinders that are slipped inside arteries to keep them open.
Complicating things further, women with heart disease tend to have other chronic health conditions, such as diabetes, said Dr. Pervaiz Chaudhry, a UCSF-Fresno clinical associate professor and chairman of the cardiothoracic surgery division at Saint Agnes Medical Center.
Older and sicker patients benefit from coronary bypass surgery that is done on a beating heart instead of using a heart-lung machine, Chaudhry said.
Living with heart disease isn't easy. Ongoing struggles with fatigue and shortness of breath reduce the quality of life.
And younger women may be more affected emotionally and otherwise by congestive heart failure than older women and men, according to the federal health-care research agency.
Westburg said it's been difficult adjusting to life with a failing heart.
"I don't work. I'm still not able to unload the dishwasher. I don't drive very often," she said. "So I went from total independence to having to be very dependent."
Visits to the emergency room when her blood pressure plummets have become routine. So have trips to cardiac rehab, transplant specialists and doctors' offices.
Her days at home consist of naps, writing on the computer, watching television. When she has the strength, she fixes breakfast a microwave muffin for her husband, Dan, before he leaves for his job as a teacher.
Faith and family keep her from getting depressed, she said. Westburg belongs to NorthPointe Community Church.
But she knows heart disease may shorten her life.
"I wrote my family letters and put them in the safe. I said goodbye to them."