Aspirin and Lipid Lowering Pushed to Prevent Heart Disease in Women

DALLAS, Feb. 19 -- All women age 65 or older, regardless of health, should be considered for daily low-dose (81 mg) aspirin therapy to protect their hearts, according to new American Heart Association guidelines.

And for high risk women, the new guidelines recommend increasing the upper dose limit of aspirin to 325 mg a day, up from the 162 mg recommended previously, the AHA said in its 2007 Guidelines for Preventing Cardiovascular Disease in Women.

The guidelines, published in the Feb. 20 issue of Circulation, Journal of the American Heart Association, which update prevention guidelines issued in 2004, mark a departure from a focus on absolute, short-term risk stratification for women.

Instead, they state "that nearly all women are at risk for [cardiovascular disease], which underscores the importance of a heart-healthy lifestyle," said Lori Mosca, M.D., Ph.D., director of preventive cardiology at New York-Presbyterian Hospital. She chaired the AHA expert panel that wrote the guidelines.

Most women have a very low risk for heart disease during the childbearing years and that low risk can lull them into a sense of complacency, said Sidney Smith, M.D., a co-author of the guidelines and chairman of the World Health Federation's scientific advisory board.

But over a lifetime "the risk for heart attack and stroke is almost 50% for women," Dr. Smith said.

As it stands now, "we tell a woman in her early 30s that she has less than a 10% risk of developing heart disease and then by the time we see her in her 50s or early 60s, the risk is much higher but it is too late for preventive strategies because the horse is already out of the barn," he added.

On cholesterol, the 2007 guidelines reflect recent studies that suggest an aggressive, lower-is-better approach and recommend a goal of less than LDL cholesterol goal of less than 70 mg/dL for women who meet two or more criteria for high risk.

The guidelines recommend classifying women as high risk, at risk, or at optimal risk rather than high risk, intermediate risk, lower risk, and optimal risk, which were the classifications used in 2004.

Dr. Mosca and colleagues defined high risk as established coronary heart disease, cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm, renal disease (end-stage or chronic), diabetes or Framingham risk score of more than 20%.

At risk was defined as one or more of these risk factors: cigarette smoking, poor diet, physical inactivity, obesity -- especially central adiposity -- family history of premature cardiovascular disease (younger than age 55 in male relative or younger than 65 in a female relative), hypertension, or dyslipidmia.

Women with evidence of coronary calcification, metabolic syndrome, poor exercise capacity on a treadmill test or abnormal heart rate recovery after stopping exercise, or both, should also be considered at risk, they said.

Optimal risk was defined as a Framingham risk score of less than 10% and a healthy lifestyle with no risk factors.

The new guidelines also reflect clinical trials results that confirmed no cardiovascular benefit for hormone replacement therapy, selective estrogen receptor modulators such as tamoxifen or raloxifene (Evista), or for supplements such as folic acid, beta carotene, vitamins E or C or the use of aspirin to prevent myocardial infarction in women younger than 65 without coronary heart disease.

Guidelines recommendations include:

• Lifestyle changes to help manage blood pressure include weight control, increased physical activity, alcohol moderation, sodium restriction, and an emphasis on eating fresh fruits, vegetables and low-fat dairy products.
• Use of counseling as well as nicotine-replacement therapies to aid in smoking cessation.
• A minimum of 60 to 90 minutes of moderate-intensity activity (e.g., brisk walking) on most, and preferably all, days of the week to aid weight loss and maintain healthy weight.
• Reduce saturated fats intake to less than 7% of calories if possible.
• Increase consumption of omega-3 fatty acids by consumption of fatty fish at least twice weekly.
• Women with coronary heart disease should consider taking a capsule supplement of 850 to 1,000 mg of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), which should be increased to 2 to 4 g for women with high triglycerides.

Dr. Mosca disclosed no conflicts. Conflicts disclosed by other members of the writing group included: Kathy Berra, M.S.N, N.P, Kos Pharmaceuticals; Rowena J. Dolor, M.D., M.H.S., Pfizer, Wyeth; Theodore G. Ganiats, M.D., Pfizer; Debra Judelson, M.D., Biovail, Kos, Novartis, and Pfizer; L. Kristin Newby, M.D., M.H.S., Bristol-Myers Squibb-Sanofi; Millenium, Schering-Plough, Biosite, Eli Lilly, and Inverness Medical; Suzanne Oparil, M.D., Abbott Laboratories, AstraZeneca, Aventis, Biovail, Boehringer Ingelheim, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, Novartis, Merck, Pfizer, Sankyo Pharma, Sanofi-Synthelabo, Schering-Plough, the Salt Institute, Encysive Pharmaceuticals and BOD; Pamela Ouyang, M.D., CV Therapeutics; Rita Redberg, M.D., M.Sc., CV Therapeutics; Rosalyn Scott, M.D., ABC Center for Women's Health; Katherine Sherif, M.D., Novartis; Sidney Smith, Jr., M.D., Bayer, Bristol-Myers Squibb, Sanofi, Eli Lilly, GlaxoSmithKline, Merck, and AstraZeneca; Neil J. Stone, M.D., Abbott, AstraZeneca, Merck, Pfizer, Sanofi, Schering-Plough, and Reliant; and Nanette Wenger M.D., Eli Lilly, AstraZeneca, Pfizer, Bristol-Myers Squibb, Merck, NitroMed, Novartis, CV Therapeutics, GlaxoSmithKline, and Kos Pharmaceuticals.