Nearly 3 out of 4 (71.9%) US women (and 72.6% of men) ages 60 to 79 years have cardiovascular disease (CVD)—the leading cause of death despite marked improvement in mortality rates in the last 4 decades. In that same age group, the prevalence of cerebral vascular disease is 8.2% in women and 7.2% in men.1
The age-adjusted death rate for all adults is 135.1 in 100,000 for coronary heart disease (CHD) and 44.1 in 100,000 for cerebral vascular disease. In 2007, CVD caused 34.5% of deaths in women and 32.7% of deaths in men.1
Evidence that CVD frequently manifests differently in women than in men led the American Heart Association (AHA) to issue recommendations for the prevention of CVD in women in 1999, and to follow with guidelines in 2004 and an update in 2007.2-4 However, the recommended interventions were, with a few exceptions, the same as the recommendations for men. But that’s changed.
The latest update of the guidelines, published earlier this year, focuses more on sex-based differences, with the addition of pregnancy complications as a major risk factor, for example. (See “AHA’s 2011 CVD guideline update: What’s new?”.) Highlights of the guidelines,5 including the recommended interventions for all women (TABLE 1) and a comparison of its recommendations with those of the US Preventive Services Task Force (USPSTF)6 (TABLE 2)—are detailed here.
AHA’s 2011 CVD guideline update: What’s new?
The updated guidelines for prevention of CVD in women give more weight to conditions that increase risk for heart disease and stroke primarily or exclusively in women, including gestational diabetes and other complications of pregnancy, lupus, and rheumatoid arthritis. Some of the changes include:
- adding a history of preeclampsia, gestational diabetes, and pregnancy-induced hypertension as criteria for the "at risk" classification
- revising the criterion for "high risk" classification based on risk calculation to ≥10% 10-year predicted risk of CVD (it was previously ≥20%)
- addressing the challenges of diversity, including recommendations that providers develop cultural competence and become aware of, and take steps to reduce, CVD health disparities
- redefining the lowest risk category as "ideal cardiovascular health," for women who have ideal blood pressure, cholesterol, and fasting glucose levels, and adhere to optimal lifestyle/behavioral recommendations.
The AHA indicates that it has changed from evidence-based to effectiveness-based guidelines;5 however, the practical implications within the guidelines themselves are unclear.
TABLE 1
AHA recommends these interventions for all women5
| Avoid smoking (incorporates smoking prevention and cessation advice and assistance, including nicotine replacement, pharmacotherapy, and formal smoking cessation programs) and environmental tobacco smoke |
| Exercise (≥150 minutes of moderate exercise or ≥75 minutes of vigorous exercise per week, with additional benefit gained by more time and higher-level exercise) |
| Consume a healthy diet, rich in fruits and vegetables; whole-grain, high-fiber foods; and fish (at least twice a week); limit intake of saturated fat, cholesterol, alcohol, sodium, and sugar and avoid trans-fatty acids |
| Control your weight (maintain a BMI of <25 kg/m2) |
| Keep blood pressure <120/mm Hg through diet, exercise, and weight control; take medication for BP ≥140/90 mm Hg (or ≥130/80 mm Hg for women with diabetes or chronic kidney disease) |
| Maintain healthy lipid levels (LDL-C <100 mg/dL, HDL-C >50 mg/dL, triglycerides <150 mg/dL, and non-HDL-C [total cholesterol minus HDL] <130 mg/dL) through lifestyle and diet; consider medication for hyperlipidemia based on CVD risk and lipid levels |
| BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. |
TABLE 2
CVD prevention in women: Comparing AHA1and USPSTF recommendations5,6
| AHA | USPSTF | |
|---|---|---|
| Screening for CVD risks | ||
| Hypertension | Implied, but no specific recommendation | Recommends screening for high BP in women ≥18 y |
| Lipid disorders | Implied, but no specific recommendation | Recommends screening women ≥20 y for lipid disorders if they are at increased risk for CHD (evidence is stronger for women ≥45 y) No recommendation for or against routine screening for lipid disorders in women who are not at increased risk for CHD |
| Obesity | Implied, but no specific recommendation | Recommends screening all adult patients for obesity |
| Diabetes | Implied, but no specific recommendation | Recommends screening for asymptomatic adults with sustained BP (treated or untreated) >135/80 mm Hg Insufficient evidence to assess the balance of benefits and harms of screening asymptomatic adults with BP ≤135/80 mm Hg |
| Tobacco use | Implied, but no specific recommendation | Recommends asking all adults about tobacco use and providing tobacco cessation interventions for those who use tobacco products |
| Nontraditional risk factors | The role that novel CVD risk biomarkers (hs-CRP and advanced lipid testing) and imaging technologies (coronary calcium scoring assessment) is not yet well defined | Insufficient evidence to assess the balance of benefits and harms of using nontraditional risk factors* to screen asymptomatic women with no history of CHD |
| Screening for CVD | ||
| Carotid artery stenosis | Not addressed, but implies it might be useful for classification | Recommends against screening for asymptomatic carotid artery stenosis in the general adult population |
| Peripheral artery disease | Not addressed, but implies it might be useful for classification | Recommends against routine screening for peripheral arterial disease |
| CHD or prediction of CHD | Not addressed, but implies it might be useful for classification | Recommends against routine screening with resting EKG, ETT, or EBCT scanning for coronary calcium for the presence of severe carotid artery stenosis or the prediction of CHD events in adults at low risk for CHD events Insufficient evidence to recommend for or against routine screening with EKG, ETT, or EBCT scanning for coronary calcium for the presence of severe carotid artery stenosis or the prediction of CHD events in adults at increased risk for CHD events |
| Behavioral counseling to reduce risk | ||
| To promote physical activity | Sets physical activity targets but does not address how to achieve them | Insufficient evidence to recommend for or against behavioral counseling in primary care settings to promote physical activity |
| To promote weight loss | Sets ideal weight targets but does not address how to achieve them | Recommends intensive counseling and behavioral interventions+ to promote sustained weight loss for obese adults Insufficient evidence to recommend for or against the use of moderate (monthly) or low-intensity (less than once a month) counseling together with behavioral interventions to promote sustained weight loss in obese adults Insufficient evidence to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults |
| Tobacco use | Recommends smoking prevention and cessation advice and assistance, including nicotine replacement, pharmacotherapy, and formal smoking cessation programs | Recommends tobacco cessation interventions for those who use tobacco products |
| Risk reduction interventions | ||
| Aspirin | Recommends the use of aspirin in women with CHD unless it is contraindicated Says use of aspirin is reasonable in women with diabetes, unless it is contraindicated If aspirin is indicated but not tolerated, clopidogrel should be substituted. Aspirin may be reasonable for women <65 years for stroke prevention, but is not recommended for MI prevention. Aspirin can be useful for women >65 years if BP is controlled; benefit for stroke and MI prevention is likely to outweigh risk of GI bleeding and hemorrhagic stroke | Recommends the use of aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic stroke outweighs the potential harm of an increased risk of GI hemorrhage Insufficient evidence to assess aspirin for cardiovascular disease prevention in women ≥80 years Recommends against the use of aspirin for stroke prevention in women ≤55 years |
| Beta-carotene | Should not be used for prevention of CVD | Recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease |
| Antioxidants and vitamins | Vitamins E, C, B6, B12, and folic acid should not be used for CVD prevention. | Insufficient evidence to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease |
| Hormonal therapy | Hormone therapy and selective estrogen-receptor modulators should not be used for CVD prevention. | Recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women Recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy |
| †;Defined by the USPSTF as >1 individual or group session per month for ≥3 months. *Nontraditional risk factors included in this recommendation are high-sensitivity C-reactive protein, ankle-brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness, coronary artery calcification score on electron-beam computed tomography, homocysteine level, and lipoprotein(a) level. AHA, American Heart Association; BP, blood pressure; CHD, coronary heart disease; CVD, cardiovascular disease; EBCT, electron-beam computed tomography; EKG, electrocardiography; ETT, exercise treadmill test; GI, gastrointestinal; hs-CRP, high-sensitivity C-reactive protein; MI, myocardial infarction; USPSTF, US Preventive Services Task Force. | ||