Physician's Weekly Article - Preventing CVD in Women: A Focus on Lifetime Risk & Lifestyle

       Updated guidelines emphasize the lifetime risk for cardiovascular disease in women and offer a new direction for using aspirin, hormone therapy, and vitamin and mineral supplements in the prevention of heart disease and stroke.

      In 1999, the American Heart Association (AHA) published its first Guide to Preventive Cardiology in Women. The guide synthesized the most recent clinical research data and highlighted unique aspects of risk factor management in women. Subsequently, in 2003, a systematic review was conducted, and evidence-based guidelines for the prevention of cardiovascular disease (CVD) in women were released. Since that time, numerous clinical trials have been conducted to evaluate differences that exist between men and women in relation to CVD diagnosis and prevention.

      A 2007 guideline update provides the most current clinical recommendations for preventing CVD in women aged 20 and older. They are based on a systematic search of the highest quality science interpreted by experts in the fields of cardiology, epidemiology, family medicine, gynecology, internal medicine, neurology, nursing, public health, statistics, and surgery. The 2007 Guidelines for Preventing Cardiovascular Disease in Women were published in a special women’s health issue of Circulation on March 20, 2007.

      The new guidelines offer several important changes from its predecessors (Table 1). Lori Mosca, MD, PhD, who chaired the AHA panel that wrote the guidelines, explains that “the experts wanted to emphasize the importance of lifestyle and preventing risk factors in the first place so that more aggressive interventions are reserved for the highest-risk women.”

      Risk Assessment

      Most notably, the 2007 guidelines include a new paradigm for risk assessment, which merges traditional assessments based on the Framingham risk score with risk factors and family history (Table 2). Some women are at increased risk of heart attack or stroke because they already have CVD and/or multiple risk factors. Others, however, may have subclinical evidence for CVD, such as coronary calcification, but are not classified as intermediate- or high-risk patients based upon Framingham risk calculation alone. “Appropriate risk stratification in clinical practice is critical because it’s used to help guide therapy,” Dr. Mosca says. “It’s our hope that the new risk assessment paradigm will help capture all at-risk women who are in need of preventive interventions.”

      Prevention Throughout Life

      The public health impact of CVD in women is not solely related to mortality, as advances in science and medicine allow many women to survive heart disease. For example, 42 million, or about 37%, of American women live with CVD, and the population considered to be “at risk” is even larger. “Nearly all women are at risk for CVD, underscoring the importance of living a heart-healthy lifestyle,” says Dr. Mosca.

      In addition, the new guidelines include expanded recommendations on modifiable lifestyle factors. These include guidance on physical activity, nutrition, and smoking cessation, and more in-depth recommendations are available on drug treatments for blood pressure and cholesterol control.

      Major Guideline Changes

      Lastly, recommendations for hormone therapy, aspirin therapy, antioxidants, and folic acid supplements have been revised based on recently published data. “Since the last guidelines were developed, more definitive clinical trials have become available,” Dr. Mosca says. “Healthcare providers should consider aspirin in women to prevent stroke, carefully weighing the potential benefits and risks. However, for the prevention of heart disease, aspirin therapy is recommended for those aged 65 and older, independent of risk level, when the benefits outweigh the risks. Furthermore, providers shouldn’t use menopausal therapies such as hormone replacement therapy or selective estrogen receptor modulators (eg, raloxifene or tamoxifene) to prevent heart disease. These therapies have been shown to be ineffective in protecting the heart and may actually increase the risk of some types of stroke.”

      A recent AHA survey showed that many women are confused about methods to prevent heart disease and about the role of aspirin, hormones, and dietary supplements. “The new guidelines clarify the role of dietary supplements and other agents,” says Dr. Mosca. “They reinforce the methods that have proven to be ineffective and potentially harmful among women in their fight against heart disease.”

      Lori Mosca, MD, PhD, has indicated to Physician’s Weekly that she has served as a consultant and is on the advisory board/speaker’s bureau for Abbott Laboratories, Anthera, Eli Lilly Research Laboratories, McNeil Consumer Healthcare, Merck, Organon, Pfizer Inc, Schering-Plough, Unilever, Waterfront Media, and Wyeth-Agmen.