Had it not been for her toe, Connie Burt's heart problem might not have been discovered until it was too late.

Burt, of Queens, N.Y., was bothered by heartburn—she couldn't walk more than a few steps without a burning sensation in her chest. Her internist had diagnosed her pain as a hiatal hernia, a common digestive tract problem. Burt, then 56, gobbled antacids but got little relief. Still, it wasn't chest pain but bunion surgery that took her to the hospital.

A routine pre-op electrocardiogram looked suspicious. More tests followed, revealing a deadly 90 percent blockage in a main coronary artery, the one doctors used to call "the widow-maker." Instead of getting her toe fixed, Burt had emergency surgery to expand her artery and improve blood flow. Her "indigestion" was in fact heart disease.

The notion that women are less susceptible to heart problems than men is widespread and persistent, even among women and sometimes among their physicians, too. But it's wrong. In fact, heart disease kills more American women than men every year and accounts for more deaths among women than the next seven causes combined.

Long neglected by researchers, heart disease in women is finally getting attention, and the discoveries are offering women and their doctors new tools to fight it. One of the most significant findings is that women often have different risk factors and different symptoms from men and are treated differently by doctors.

Until the mid-nineties, when the National Institutes of Health required that women be included in all clinical trials, women were virtually excluded from heart disease studies. "A lot of how we treat women has had to be extrapolated from what we know about men," says Sharonne Hayes, M.D., director of the Women's Heart Center at the Mayo Clinic in Rochester, Minn. "But that's changing."

Some findings are startling. New studies, published in the journal Circulation in February, show that:

• Doctors are much less likely to identify high-risk women than they are men with similar risk profiles. As a result, women are less likely to get the lifesaving preventive care they need.
• Among women at the greatest risk for heart attack because of dangerously high cholesterol levels, only one-third are getting drugs to lower cholesterol.
• Women at risk for coronary artery disease are referred less often for imaging tests even though such tests are known to be useful in women.
• Women are much less likely than men to get balloon angioplasty or stents, procedures that open blocked arteries.

Why are women treated differently? "I'm looking for answers," says Andra L. Blomkalns, M.D., of the University of Cincinnati College of Medicine and author of a study in the Journal of the American College of Cardiology showing that women get standard treatment less often than men for heart strain, a condition less severe than heart attack. "Therapies are getting better, but the benefit doesn't seem to translate to women," Blomkalns says.

One reason may be that women are less likely to demand treatment than men. "Women, especially older women," she says, "don't want to complain." Heart doctors across the country report that women don't want to cause a stir, don't want "fancy" treatment and may even minimize their symptoms.

"I have women coming in clutching their chests and telling me they're having indigestion," says Nanette Wenger, M.D., of the Emory University School of Medicine. "A man would be more likely to say, 'I'm having a heart attack.' "

A patient of Hayes', a 56-year-old woman with an uncomfortable and worsening but not necessarily life-threatening heart condition, has refused simple surgery that would cure her condition. "Most men would say, 'Let's deal with it,' " Hayes says. "She doesn't want to make a fuss."

On average, women are 10 years older than men when they're diagnosed with heart disease. One theory is that the hormone estrogen protects them until menopause. But sometimes women are misdiagnosed simply because men's experience is considered the norm. Exercise treadmill tests, for example, have long been used to detect clogged arteries. But researchers at the George Washington University Medical Center in Washington found the test to be less accurate in women with chest pain than in men, according to the American Heart Journal in March.

By the time heart disease is diagnosed in women, it's often at a more advanced stage. Even if they're having a heart attack, women wait longer than men to seek care.

The danger signs of cardiovascular disease often differ in men and women. Although pain is the first symptom in both, men tend to have a heart attack, with its classic crushing, heavy chest pain that lasts 20 minutes or longer. Women are apt to have the transient discomfort of angina, which can happen with exercise and disappears after a few minutes. Sometimes their heart disease masquerades as indigestion, as it did in Connie Burt. Symptoms are more diffuse—women complain of fatigue, nausea or sleeplessness.

"We have to be on the lookout for these women who don't show up with classic symptoms," says Jennifer H. Mieres, M.D., director of nuclear cardiology at North Shore University Hospital in Manhasset, N.Y.

Men and women share some major risk factors for heart disease, such as high cholesterol, high blood pressure and obesity, says Lori Mosca, M.D., director of preventive cardiology at New York-Presbyterian Hospital in Manhattan, but other factors are more significant in women. Data show that diabetes is much more dangerous for women and raises heart disease risk twice as much as it does for men.

Cigarette smoking is also more dangerous. A woman who smokes a pack a day has a much higher risk than a man who smokes a similar amount.

While the jury is still out on whether stress is a risk factor for women, some recent studies indicate that so-called psychosocial factors—anger, depression, poor relationships, money worries—can play a part in heart disease, mainly by exacerbating risk factors such as hypertension. "Life is stress," says Emory's Wenger. "It's not the stress itself that's bad, it's how you handle it."

One recent study of women with suspected coronary artery disease, sponsored by the National Heart, Lung, and Blood Institute, found that those with few ties to family, friends, co-workers or community organizations had elevated risk factors. There were more deaths among them than among women with larger social circles. Researchers found that the lack of relationships rivaled or exceeded biomedical risk factors such as smoking, diabetes and hypertension.

Researcher Elaine Eaker of Eaker Epidemiology Enterprises in Wisconsin found in her study of marital conflict that women who clammed up instead of expressing themselves during disputes with their husbands had four times the risk of dying during her 10-year follow-up. And a study led by the Johns Hopkins University showed that sudden stress, such as a death in the family or a car accident, can cause nonfatal heart failure, particularly in women. All the women recovered, but some could have died without treatment.

Given what experts are learning, what can women do to protect themselves?

First, recognize that you too can have heart disease. Women have historically been more afraid of breast cancer than of heart disease, the Mayo Clinic's Hayes says, but now almost half of American women recognize heart disease as their number one killer.

Learn about signs of heart disease. Know the optimal levels for blood pressure, cholesterol and glucose. If your readings are high, take action to lower them, even if your doctor isn't concerned. (You might also consider changing doctors.) Learn about the body mass index and your ideal weight.

Listen to your body. Then speak up. Doctors across the country report that women, even those with heart disease, downplay the seriousness of their condition. "Women think they don't have time to be sick," Hayes says. "They're so busy taking care of everybody else."

Take care of yourself. Exercise, eat healthy meals, quit smoking and get the medical screenings and care you need.

Be happy. "I'm concerned about social isolation in women after 50," Mosca says. "Some women that age feel like they don't have a purpose anymore." Her prescription? "Women should be a little bit more focused on their own needs. Let guilt go. Have fun and friends," she says. "The key thing is not just increasing life span but increasing health span. Happiness is really important."

Linda Greider is a journalist living in Washington.