SINGAPORE - Madam Kirti Harnal had just cooked a meal at home one Saturday in November 2018 when she suddenly felt fatigued.
The 60-year-old lecturer at the Singapore Institute of Management also had some pain in her shoulders, but thought it was due to her long hours using the computer.
But her family felt she should seek medical help, so they took her to the National University Hospital, where she found out she was actually having a heart attack.
One of her arteries was 95 per cent blocked while another two were 60 and 40 per cent blocked.
Two days later, she underwent a stent surgery, which involved inserting a tiny tube into a clogged artery to allow blood to flow freely.
Madam Harnal, who has two sons aged 35 and 32, said: "I was shocked because I maintained a healthy diet. I most definitely didn't think that I'd get a heart attack."
Like her, many women do not think they are at risk of a heart attack. But cardiovascular disease, associated with a build-up of fatty deposits in the arteries and an increased risk of blood clots, was the leading cause of death for women here last year, according to a check of the Registry of Births and Deaths.
Only 9 per cent of the 1,002 women aged 21 to 64 surveyed by the Singapore Heart Foundation (SHF) between January and March this year knew this fact.
In conjunction with World Heart Day on Sept 29 and Restart A Heart Day on Oct 16, SHF, a social service agency, organised talks on women's heart health along with other topics over the weekend.
Common cardiovascular diseases include coronary heart disease, which causes heart attack and heart failure; and carotid artery disease, where blood supply to the brain is disrupted, resulting in stroke, brain damage and death.
The SHF survey, titled Go Red For Women, also found that 34 per cent of respondents believe that breast cancer is their biggest health threat. But actually, cardiovascular disease claimed the lives of 2,689 women here last year, while breast cancer caused 445 deaths.
Dr Goh Ping Ping, a cardiologist at Mount Elizabeth Hospital, noted that women, especially those who are younger, tend to overlook the danger of heart disease.
Cancer diagnoses are "more commonly heard of and appear more sinister", she said.
"But the fact is, heart disease kills six times as many women every year and can lead to debilitating conditions such as heart failure."
Dr Rohit Khurana, a senior consultant cardiologist with Harley Street Heart and Vascular Centre at Gleneagles Hospital, said there is "an unfortunate lack of awareness" of cardiovascular disease in women not only among female patients, but also among healthcare professionals.
This may be due to an underrepresentation of women in heart disease research, he said, with women making up only 30 per cent of participants in most studies and trials.
"Gender differences in the symptom presentation result in women having longer delays in recognition, investigation and, ultimately, treatment for their heart condition.
"This combination of inadequate research and lack of examination widens the gap in knowledge about cardiovascular disease in women, increasing the risk of delayed treatment and a poorer overall prognosis among female patients."
The main risk factors for cardiovascular disease include high blood pressure, high blood cholesterol, diabetes, smoking, physical inactivity, obesity or being overweight and a family history of the disease.
Apart from chest pain, which can hit both men and women, the symptoms of a heart attack more common in women are neck, jaw or shoulder pain, shortness of breath, nausea, feelings of indigestion and fatigue.
These symptoms may not be as noticeable as the crushing chest pain associated with heart attacks. This might be because women are more likely to have blockages in the tiny vessels within the heart rather than the large arteries - a condition called small vessel heart disease.
Madam Harnal, for example, did not think her sudden fatigue could mean a heart attack as she did not have severe pain in her chest, unlike her father, who experienced that as well as strong pain in his left arm when he had a heart attack in his 30s. He survived the attack.
Dr Khurana said women also tend to have "silent" heart attacks which have no symptoms at all.
"This may be due to women having underlying conditions such as diabetes which may bring about numbness or a reduced ability to feel pain," he added.
Dr Goh said the risk of heart disease in women increases after menopause due to a drop in the female hormone oestrogen.
"Oestrogen is believed to have a good effect on the inner layer of artery wall, helping to keep blood vessels flexible to accommodate blood flow. Oestrogen also has a protective effect against hypertension and high cholesterol," she said.
After menopause, women experience lower levels of good cholesterol and higher levels of bad cholesterol, which increase their risk of cardiovascular disease and atherosclerosis - the build-up of fats, cholesterol and other substances in and on the artery walls, which can restrict blood flow.
Retired data entry clerk Cheah Aek Hong, whose mother died of heart disease more than 50 years ago, did not pay much attention to her diet and hardly exercised. The 65-year-old often felt tired quickly and would feel breathless after climbing a short flight of stairs.
A check with the doctor showed that she had mitral stenosis - a condition where there is a narrowing of the mitral valve that blocks blood flow to the heart.
She underwent surgery in February last year at the Singapore General Hospital (SGH) to replace the entire valve with a mechanical one.
This was followed by therapy sessions at the hospital and rehabilitation under SHF's Heart Wellness Programme at the Heart Wellness Centre at Fortune Centre where she learnt to do simple exercises and got advice on nutrition.
Madam Cheah, who has two children, aged 32 and 29, says she watches her diet more closely now.
Likewise, Madam Harnal hardly exercised in the past but now takes walks in the park and does simple exercises at home with light weights.
She has also undergone rehabilitation at the SHF Heart Wellness Centre in Bukit Gombak.
Dr Goh said prevention against cardiovascular disease should start as early as possible, even though the risk of such diseases in women increases after menopause.
"Women should not wait till they are in their 40s before making heart health their priority. Early risk assessment and early detection of risk factors are important, as well as early adoption of a healthy diet and exercise," she said.
She advised those aged 18 years old and above to go for screening of cardiovascular disease risk factors such as diabetes and hypertension.
Depending on the results, a regular cardiovascular screening or further evaluation for heart disease may be suggested by the doctor.
Said Dr Khurana: "Women need to be educated about their risk of cardiovascular disease and taught to recognise the symptoms of coronary heart disease and stroke early so that they can speak to a doctor immediately when they experience them. Early detection and treatment improves long-term outcomes and quality of life."
7 tips to manage or prevent the disease
Dr Rohit Khurana, a senior consultant cardiologist with Harley Street Heart and Vascular Centre at Gleneagles Hospital, shares seven tips to manage or prevent cardiovascular disease.
1. Maintain a healthy diet
Try to avoid unhealthy food loaded with trans fats, salt and sugar as these increase risk factors such as bad cholesterol and triglycerides, high blood pressure, diabetes and obesity.
If unsure about what healthy food to eat, try sticking to a Mediterranean diet of vegetables, fruits, fish and whole grains.
2. Avoid smoking
The chemicals in cigarette smoke can narrow the blood vessels and cause cardiovascular disease, stroke, peripheral artery disease and aneurysm.
Exposure to second-hand smoke can also cause cardiovascular disease in non-smokers. If you do not smoke but are always around someone who does, encourage him or her to quit.
3. Be physically active
At least 150 minutes of moderate-intensity exercise a week can lower blood pressure and bad cholesterol to a healthy level.
If you are currently inactive, start slow as even a few minutes of exercise a day may offer some health benefits.
4. Maintain a healthy weight
Obesity puts you at greater risk of high cholesterol, high blood pressure and insulin resistance - the factors that increase the risk of cardiovascular disease.
If you are unsure whether your weight is in the normal or healthy range, use a Body Mass Index (BMI) calculator to measure your body fat. In general, a BMI of 25 or higher is considered overweight.
5. Reduce stress levels
Some people cope with stress in unhealthy ways - such as overeating, drinking and smoking - giving rise to cardiovascular disease.
Stress in women can also result in Takotsubo cardiomyopathy, which changes the shape of the heart muscle, resulting in heart rhythm problems, shock or even death.
6. Get good quality sleep
People who do not get enough sleep have a higher risk of obesity, high blood pressure, heart attack, diabetes and depression.
If you are clocking in the recommended seven to eight hours of sleep a night but are still tired throughout the day, ask your doctor if you need to be evaluated for obstructive sleep apnea.
Treatments for sleep apnea may include losing weight if you are overweight or using a continuous airway pressure device that keeps your airway open during sleep.
7. Go for screenings
High blood pressure, high levels of blood sugar and bad cholesterol increase your risk of cardiovascular disease.
These can be monitored through regular health screenings, which will enable you to know whether you need to make the appropriate lifestyle changes to reduce your risk.
In conjunction with World Heart Day on Sept 29 and Restart A Heart Day on Oct 16, the Singapore Heart Foundation held a series of virtual programmes over the weekend to encourage individuals to take charge of their heart health. The events, which included talks by health experts, workouts and cooking demonstrations, can be viewed at this website until Oct 31.