(The San Antonio Express-News) -- It wasn't so much pain as a feeling of weakness followed by anxiety and a wave of perspiration that didn't make sense given the wintry temperature.

Marilyn Montgomery Sepich asked her future husband and friends to stop and let her rest after they strolled the River Walk that Sunday night in January two years ago. She went home, took some aspirin and slept. But over the next few days, troubling symptoms returned, especially a streak of pain that shot up her neck and turned her jaw icy cold. Thursday night she took aspirin before bed, but the symptoms escalated.

"Have you ever had a heart attack?" asked the operator at her doctor's answering service after hearing her symptoms. Alarmed, Mike Sepich quickly drove her to the hospital emergency room.

"The next thing I knew all kinds of people were starting IVs, putting monitors on me and scaring me half to death," Sepich says. Soon a doctor she didn't know was delivering dire news. She could go home, have a massive heart attack and die, or she could have heart bypass surgery. A cardiac catheterization showed 80 percent to 90 percent blockages in several major arteries.

No choice really. A couple of days later, she had quadruple bypass surgery. A week later, she sat at home, a different person. At 48, she says, "my ability to care for myself was at a 3-year-old level, and my husband had a struggle taking care of me."

Sepich has the No. 1 killer of American women - heart disease, which takes the lives of almost 375,000 women a year, according to the National Heart, Lung and Blood Institute. About 3 million women have had a heart attack, and two-thirds of them don't make a full recovery. Of concern to many are studies showing women know little about their heart risk and don't receive as aggressive diagnosis and treatment as men.

In the months after that first attack, Sepich was not only stricken by another heart attack but by the illness experts say often accompanies and predicts cardiac problems -- depression.

The connection is profound, complex and multilayered, says Steven Roose, a research psychiatrist at Columbia University Health Sciences. "Depression is a risk factor for developing heart disease in the same way that smoking and high cholesterol are. If you have depression earlier in life - before any sign of heart disease - it's a predictor for coronary heart disease and stroke later."

What's more, depression can develop after a heart attack or heart-bypass surgery - Roose says in 20 percent of patients, some say in more. In a survey funded by WomenHeart, the National Coalition for Women with Heart Disease, and published in the January/February Women's Health Issues, 38 percent of women with heart disease reported clinical depression, 17 percent anxiety and 21 percent both.

Depression during recovery can be deadly. Studies show cardiac patients who suffer from major depression have a significantly higher mortality rate over a six-month period than those who have just as severe a heart event but no depression. Treating depression can reduce the risk.

Depression as a risk factor and companion illness affects both male and female heart patients. But Roose says the relationship is particularly relevant for women. Mortality rates for cardiovascular disease declined in men over the past decade but not in women.

Women don't always have the classic male symptoms of crushing chest pain and pain in the left arm. Instead, they may have indigestion, nausea, sweating and neck, jaw, back and arm pain. The Mayo Clinic cites one survey showing 90 percent of women didn't know about these symptoms.

Coronary heart disease can come on gradually. Some 63 percent of women who died of it suddenly had no previous symptoms.

The link between heart disease and depression is also critical for women because they experience twice as much depression as men. Depression during a woman's 20s and 30s is a risk factor for developing heart disease in her 50s and 60s.

Again, the symptoms may not ring alarm bells. Sepich, a trained social worker who is grants and contracts manager for Family Service Association, knows the signs of depression well, including persistent feelings of sadness and helplessness. But after bypass surgery, she says, "I didn't recognize them in me. A friend, a mental health professional, told me, `You have a clinical depression going on."'

Mary Rogers, a registered nurse experienced in caring for cardiac patients, has had seven cardiac catheterizations, angioplasty and heart-bypass surgery that failed, all in the last seven years. She says health-care providers "don't talk to you about depression."

"They don't say, `If you get depressed, you need to come talk to us.' I didn't recognize I was depressed. I recognized I was angry -- frustrated that I was in and out of the hospital, and after heart surgery, it wasn't fixed," Rogers says.

Although the disease link has been researched for 20 years and is well-recognized by heart specialists and psychiatrists, Roose says, few cardiologists adequately screen post-heart attack patients for depression.

Post-bypass surgery patients often complain of short-term cognitive impairment and memory loss, and some attribute that to having the heart stopped and being on the heart pump during the procedure. "The general impression is people on the older machines also get silent strokes," says Ranga Krishnan, chairman of the psychiatry department at Duke University and a researcher in cardiology and psychiatry. "If you get the strokes in the parts of the brain that regulate mood, that could lead to depression."

Newer heart machines have fewer ill effects. Roose also says difficulty concentrating and memory problems are signs of depression.

Krishnan explains that several biological mechanisms in depression raise the risk of heart disease. "One is that platelets actually form clots more easily with depression, probably due to altered serotonin function." Studies show people with depression have high levels of stress hormones. Psychological problems can cause rapid heartbeat, high blood pressure, high cholesterol and elevated insulin.

There are behavioral issues, too, Krishnan says. People with depression may neglect taking aspirin and other heart-related medications prescribed after a cardiac event.

Copyright 2003 The San Antonio Express-News. All rights reserved.