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Guidelines for Protecting Women's Hearts

April 1, 2005

Article

Cardiovascular disease is the chief cause of death among women. Nevertheless, in a recent survey of women, only 13% responded that their own greatest health threat was heart disease.

Cardiovascular disease is the chief cause of death among women. Nevertheless, in a recent survey of women, only 13% responded that their own greatest health threat was heart disease.¹ Although the manifestations of heart disease develop later in women than in men, inadequate preventive measures, sex-based disparities in treatment, and the aging of the US population result in the deaths of more than 500,000 women from this disease every year.

The first evidence-based recommendations for cardiovascular disease prevention in women were published in 2004 (Table).² Tool kits based on these guidelines were distributed to 80,000 physicians as part of the Go Red for Women campaign of the American Heart Association, which seeks to raise awareness of women's cardiovascular risks and the measures that can be implemented to reduce them.

Table - Clinical recommendations for prevention of cardiovascular disease in women

Lifestyle interventions

Cigarette smoking
Consistently encourage women not to smoke and to avoid environmental tobacco smoke.

Physical activity
Consistently encourage women to accumulate a minimum of 30 min of moderate-intensity physical activity (eg, brisk walking) on most, and preferably all, days of the week.

Cardiac rehabilitation
Advise women with a recent acute coronary syndrome or coronary intervention, or new-onset or chronic angina, to participate in a comprehensive risk-reduction regimen, such as cardiac rehabilitation or a physician-guided home- or community-based program.

Heart-healthy diet
Consistently encourage an overall healthful eating pattern that includes intake of a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, and sources of protein low in saturated fat (eg, poultry, lean meats, plant sources). Limit saturated fat intake to < 10% of calories, limit cholesterol intake to < 300 mg/d, and limit intake of trans fatty acids.

Weight maintenance/reduction
Consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m2 and a waist circumference< 35 in.

Psychosocial factors
Evaluate women with CVD for depression andrefer/treat when indicated.

Omega-3 fatty acids
As an adjunct to diet, omega-3 fatty acid supplementsmay be considered in high-risk* women.

Folic acid
As an adjunct to diet, folic acid supplementation maybe considered in high-risk* women (except after arevascularization procedure) if a higher than normallevel of homocysteine has been detected.

Major risk factor interventions

Blood pressure-lifestyle Encourage an optimal blood pressure of < 120/80 mm Hg through lifestyle approaches. Blood pressure-drugs Pharmacotherapy is indicated when blood pressure is ≥ 140/90 mm Hg (or lower in the setting of blood pressure–related target-organ damage or iabetes). Thiazide diuretics should be part of the drug regimen for most patients, unless contraindicated. Lipids, lipoproteins Optimal levels of lipids and lipoproteins in women are LDL-C < 100 mg/dL; HDL-C > 50 mg/dL; triglycerides< 150 mg/dL; and non–HDL-C (total cholesterol minus HDL-C) < 130 mg/dL. These levels should be encouraged through lifestyle approaches. Lipids-diet therapy In high-risk* women or when LDL-C is elevated, saturated fat intake should be reduced to < 7% of calories, trans fatty acid intake should be reduced, and cholesterol level should be reduced to < 200 mg/dL. Lipids-pharmacotherapy, high risk Initiate LDL-C–lowering therapy (preferably a statin) simultaneously with lifestyle therapy in high-risk* women with LDL-C ≥ 100 mg/dL, and initiate statin therapy in high-risk* women with LDL-C < 100 mg/dL, unless contraindicated. Initiate niacin

Preventive drug interventions

Aspirin-high risk* Use aspirin, 75 to 162 mg, or clopidogrel (if patient cannot tolerate aspirin) in high-risk women, unless contraindicated. Aspirin-intermediate risk‡ Consider aspirin, 75 to 162 mg, in intermediate-risk women, as long as blood pressure is controlled and benefit is likely to outweigh the risk of GI side effects. β-Blockers Use these agents indefinitely in all women who havehad an MI or who have chronic ischemic syndromes,unless contraindicated. ACE inhibitors Use these agents in high-risk* women, unlesscontraindicated. ARBs Use these agents in high-risk* women with clinicalevidence of heart failure or an ejection fraction< 40% who are intolerant of ACE inhibitors. Atrial fibrillation/stroke prevention Warfarin-atrial fibrillation Warfarin is used to maintain the INR at 2.0 - 3.0 inwomen with chronic or paroxysmal atrial fibrillation,unless they are considered to be at low risk for stroke(< 1%/y) or at high risk for bleeding. Aspirin-atrial fibrillation Use aspirin, 325 mg, in women with chronic orparoxysmal atrial fibrillation in whom warfarin iscontraindicated or who are at low risk for stroke(< 1%/y).

Interventions considered not useful/effective and possibly harmful

Hormone therapy Combined estrogen and progestin hormone therapy should not be initiated or continued to prevent CVD in postmenopausal women. Other forms of menopausal hormone therapy (eg, unopposed estrogen) should not be initiated or continued to prevent CVD in postmenopausal women. Antioxidant supplements Antioxidant vitamin supplements should not be used to prevent CVD, pending the results of ongoing trials. Aspirin-lower risk

References:

REFERENCES:

Mosca L, Ferris A, Fabunmi R, Robertson RM; American Heart Association. Tracking women's awareness of heart disease: an American Heart Association national study.

Circulation.

2004;109:573-579.

Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women.

Circulation.

2004;109:672-693.