The American Heart Association released updated guidelines in 2011 for the prevention of cardiovascular disease in women. The new guidelines emphasize risk assessment, a combination of lifestyle and pharmacologic management for the prevention of cardiovascular disease, and an emphasis on following through with evidence-based effective interventions.
The lifetime risk of cardiovascular disease (CVD) approaches 1 in 2 in all women; therefore, prevention is the most important aspect of care.
By Dr. Neil Skolnik and Dr. R. Aimee Ando
Women should be risk stratified into the following three categories:
• High risk. Women at high risk have known CVD, diabetes mellitus, chronic kidney disease, or end-stage kidney disease. The high risk classification now includes women with a Framingham 10-year predicted CVD risk of at least 10%.
This important change from a score of at least 20% takes into account vascular events that include stroke, heart failure, and peripheral arterial disease and is not limited to coronary heart disease (CHD). Stroke accounts for a higher portion of total CVD events than does CHD in women – the opposite of the male CVD disease profile. Each year, 55,000 more women than men die of stroke before they reach the age of 75 years.
• At risk. At-risk women are those with at least one major CVD risk factor, such as tobacco dependence, metabolic syndrome, or poor exercise tolerance.
• Ideal cardiovascular health. The third category includes women who possess a newly defined concept of "ideal cardiovascular health." To be considered at ideal cardiovascular health, all of the following eight requirements must be achieved without medical intervention: absence of clinical CVD, total cholesterol less than 200 mg/dL, blood pressure less than 120/80 mm Hg, fasting blood glucose less than 100 mg/dL, body mass index less than 25 kg/m2, abstinence from tobacco, recommended level of physical activity, and healthy eating habits similar to those recommended by DASH (Dietary Approaches to Stop Hypertension).
The achievement of ideal cardiovascular health is strongly associated with greater quality of life and significantly decreased risks for CVD events.
It should be noted that a history of preeclampsia approximately doubles the risk for subsequent ischemic heart disease, stroke, and venous thromboembolic events, even 5-15 years post partum.
Evidence-Based to Effectiveness-Based
Beyond evidence that documents efficacy in research, the 2011 update emphasizes strategies that demonstrate sufficient evidence of clinical benefit for CVD outcomes. This transformation from evidence-based to effectiveness-based guidelines acknowledges real-world challenges and considerations for both providers and patients, such as cost effectiveness and barriers to adherence.
The guidelines continue to prioritize lifestyle approaches to CVD prevention. The AHA has developed the "Get With the Guidelines – Outpatient" program to improve the implementation of CVD prevention guidelines (www.guidelineadvantage.org/TGA).
Diversity and Disparities
Unjustified differences in cardiovascular health among various populations remain a serious public health issue. There is evidence that black and Latina women fare much worse in comparison with white women in the United States. The highest coronary heart death rates and the highest overall CVD morbidity and mortality occur in black women. Health care providers must consider multiple facets of diversity, including race/ethnic origin, age, socioeconomic status, culture, language, and literacy in order to eliminate disparities in health care delivery.
Bottom Line
When possible, the patient-physician partnership should aim for the "ideal cardiovascular health" risk category. The AHA committee focuses on practical and cost-effective approaches including lifestyle modification and the use of affordable medications such as aspirin and generic statins, when indicated, in order to promote adherence to the guidelines, and to improve cardiovascular preventive care for all women.
In addition, understanding and implementing effective education requires a team-based, patient-centered approach that includes the family and key health care personnel. Health care providers must consider a woman’s longitudinal, long-term risk for CVD, and adapt the AHA guidelines to the various stages along her life’s continuum.
Summary of CVD prevention guidelines
The following lifestyle, risk factor, and drug interventions are important in the prevention of CVD:
• Smoking cessation. Women who smoke should be clearly advised and helped to stop smoking.
• Physical activity. At least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise are recommended, with greater amounts of exercise giving further benefit. Muscle-strengthening exercise should be done at least 2 days a week.
• Diet. A diet rich in fruits and vegetables, as well as whole-grain, high-fiber foods, is recommended along with fish at least twice a week. Intake of saturated fat, cholesterol, alcohol, sodium, and sugar should be limited; and trans-fatty acids should be avoided.