Last month, Toni Braxton competed in ABC's “Dancing with the Stars.” The accomplished singer performed against fellow celebrities in a highly rigorous dancing competition. The amazing aspect is that Braxton is living with heart disease. Like many Americans, she is battling the number one killer of all women - heart disease.

In fact, heart disease is not only the number one killer of women in America, but heart disease claims the lives of more women than the other top five causes combined.

In 2007, more than 450,000 American women died of heart related diseases, which equates to roughly one death per minute in the United States. The risk gets increasingly high as one ages, such that women older than 65 years have a one in three risk of developing cardiovascular disease.

What is alarming is that heart disease is often miss diagnosed in women, when compared to their male counterparts. Therefore a significant portion of the population is not getting the appropriate diagnosis and timely therapy for this life threatening disease.

The complexity of the situation lies in the fact that women tend to present with somewhat “atypical” symptoms of heart disease. The Framingham Heart Study group found that women have symptoms of progressive angina (dull chest pain) as opposed to men who more often present with a myocardial infarction (heart attack).

Women also tend to have different quality chest pain than men, usually describing the pain as more intense and sharp/burning. Men tend to have more classic symptoms of angina; usually dull, heavy and squeezing in quality.

Women also have a higher frequency of throat and neck pain and chest pain that radiates to their jaw and neck. The most common symptoms for women are new onset of fatigue, difficulty breathing or an upset sleeping pattern. The triggers for angina in women also tend to be different. Women have a higher incidence of angina at rest or while sleeping, while men tend to present more frequently with exercise or stress induced angina.

As only your health-care provider can make this diagnosis, it is critical that all women be mindful for the sometimes subtle signs of heart disease.

This diagnostic dilemma can possibly result in worse outcomes for women presenting with angina. A study in the American Journal of Cardiology in 1996 compared men to women who present to emergency departments with new onset chest pain. Women were less frequently diagnosed with heart disease than men and were less likely to receive an EKG, a heart monitor, lab work to evaluate for heart damage, consultation by a cardiologist, and admission to a cardiology service.

The same holds true for women who present with a heart attack. More women than men seem to present with “silent” heart attacks, which are unrecognized myocardial infarctions. In one study of nearly 2800 elderly females, of the 10 percent of women who developed a heart attack over a four year time period, almost half developed clinically silent or unrecognized myocardial infarctions.

These result in significant differences in both short- and long-term outcomes for women. Women have higher rates of acute mortality (death within 30 days of their heart attack) and worse long-term outcomes than men, with African American women having the highest death rates. Worse yet, women who survive their heart attack have a higher rate of developing symptomatic heart failure in the long term.

Next week, I'll continue with the essentials to detecting heart disease in women.

Dr. David M. Donaldson is an Auburn native and currently a

cardiologist at Massachusetts

General Hospital in Boston