New guidelines announced for preventing heart disease in women

Recommendations should help reduce gender gap’

The American Heart Association (AHA) in Dallas has released new guidelines for preventing heart disease and stroke in women that are tailored to each individual’s cardiac event risk.

In the guidelines, women age 20 and older are treated based on whether they are high, intermediate, or low risk for having a heart attack in the next 10 years (see explanation of risk, below). "The concept of CVD [cardiovascular disease] as a categorical, have-or-have-not’ condition has been replaced with a growing appreciation for the existence of a continuum of CVD risk," according to the AHA panel and writing group.

CVD risk for women explained

The American Heart Association guidelines categorize women age 20 and older by their risk of cardiovascular disease (CVD). The risk groups are defined by their absolute probability of having a coronary event in 10 years, according to a scoring method developed by the Framingham Heart Study, which began in 1948 and was sponsored by the National Heart, Lung, and Blood Institute. The risk groups include:

  • High risk. These are women with a greater than 20% risk of having a coronary event in 10 years. Some clinical examples include established CHD, diabetes, and chronic kidney disease.
  • Intermediate risk. These women have a 10%-20% risk of having a coronary event in 10 years. Some clinical examples include multiple risk factors and first-degree relative(s) with early onset atherosclerotic CVD.
  • Lower risk. These women have less than 10% risk of having a coronary event in 10 years. This may include women with one or no risk factors.

The guidelines, published in the Feb. 10 issue of the journal Circulation, call attention to the leading killer of women, reports C. Noel Bairey Merz, MD, medical director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles and associate professor of clinical medicine for the Department of Medicine at the University of California, Los Angeles, School of Medicine. "There has been sufficient amount of new data that were specific to women that we could use to craft more specific recommendations."

The difference now is management, she says. "We’ve known about risk factors since Framingham [Heart Study], which was 50% women. We have always had good risk factor data. What’s new is that we can manage the risk factors better and prevent more disease."

Treatment by risk category

The risk scheme allows health care providers to match the intensity of risk intervention to the baseline level of CVD risk. Here are some of the treatment recommendations for each risk category:

• High risk.

  • Cholesterol-lowering therapy (preferably a statin) should be initiated simultaneously with lifestyle therapy in high-risk women, even if their LDL-C levels are below 100 mg/dL, unless contraindicated.
  • Aspirin therapy (75-162 mg), or clopidogrel if patient is intolerant to aspirin, should be used in high-risk women unless contraindicated.
  • Beta-blockers should be used indefinitely in all women who have had a myocardial infarction or who have chronic ischemic syndromes unless contraindicated.
  • ACE (angiotensin-converting enzyme) inhibitors should be used in high-risk women, unless contraindicated. ARBs (angiotensin receptor blockers) should be used in high-risk women with clinical evidence of heart failure or an ejection fraction of less than 40% who are intolerant to ACE inhibitors.
  • Women with CVD should be evaluated for depression and refer/treat when indicated.
  • Omega-3 fatty-acid and folic acid diet supplementation may be considered.

• Intermediate risk.

  • Cholesterol-lowering therapy (preferably a statin) should be initiated if LDL-C level is 130 mg/dL or greater on lifestyle therapy, or niacin or fibrate therapy when HDL-C is low or non-HDL-C elevated after LDL-C goal is reached.
  • Aspirin therapy (75-162 mg) should be considered in intermediate-risk women as long as blood pressure is controlled and the benefit is likely to outweigh risk of gastrointestinal side effects.

• Lower risk.

  • Cholesterol-lowering therapy should be considered in low-risk women with 0 or 1 risk factor when LDL-C level is 190 mg/dL or greater, or if multiple risk factors are present when LDL-C is 160 mg/dL or greater, or niacin or fibrate therapy when HDL-C is low or non-HDL-C elevated after LDL-C goal is reached.
  • Routine use of aspirin in lower-risk women is not recommended pending the results of ongoing trials.

Other notable recommendations

The guidelines also recommended:

  • Pharmacotherapy is indicated when blood pressure is 140/90 mm Hg or greater. The blood pressure can even be lower in the setting of blood pressure-related target-organ damage or diabetes. Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated.
  • Among women with chronic or paroxysmal atrial fibrillation, warfarin should be used to maintain the INR (international normalized ratio) at 2.0-3.0 unless the women are considered to be at low risk for stroke or high risk of bleeding. Aspirin (325 mg) should be used in women with chronic or paroxysmal atrial fibrillation with a contraindication to warfarin or at low risk for stroke.
  • Hormone therapy and antioxidant supplements should not be used to prevent CVD.

Bairey Merz hopes these recommendations will reduce the treatment gender gap between men and women. "Ace inhibitors and beta-blockers were previously recommended, but high-risk women are anywhere from 5% to 20% less likely to be prescribed these pills."

High-risk women should be identified and treated, she continues. "We should not be faced with these gender gaps the next time we look five to 10 years down the line."