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New Guidelines for CVD Prevention in Women

by Arline Kaplan

Geriatric Times

March/April 2004

Vol. V

Issue 2

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Every minute, one woman in the United States dies from some form of cardiovascular disease (CVD), most frequently coronary heart disease (CHD). Recognizing the need to critically review and document strategies to prevent CVD in women, the American Heart Association (AHA) recently issued "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women" (Mosca et al., 2004). The guidelines represent a collaborative effort by AHA representatives and 11 other professional and government co-sponsoring organizations, including the American College of Cardiology.

"The concept of cardiovascular disease as a 'have-or-have-not' condition has been replaced with the idea that CVD develops over time, and every woman is somewhere on the continuum," said Lori Mosca, M.D., Ph.D., chair of the guideline group and director of preventive cardiology at New York-Presbyterian Hospital/Columbia University Medical Center, in a press statement.

With the new recommendations, the aggressiveness of treatment is linked to whether a woman has a low, intermediate or high risk of having a coronary event in the next 10 years, according to the Framingham Risk Score for women. Low risk means a woman has <10% risk; intermediate risk, 10% to 20%; and high risk, >20% risk. For use in clinical practice, a scoring sheet to calculate absolute 10-year CHD risk in women was provided in the guidelines (Mosca et al., 2004).

The guidelines and scoring method provide an individual approach to preventing CVD throughout the population, Mosca said.

The guidelines were based on the evidence from the available research related to CVD prevention. A rating system was devised to classify the strength of the recommendations and the level of evidence. For example, Class I interventions should be administered unless contraindicated, whereas Class III interventions should not be administered for CVD prevention.

For women at high risk of having a coronary event within 10 years, the Class I recommendations for prevention were smoking cessation, physical activity/cardiac rehabilitation, diet therapy, weight maintenance/reduction, blood pressure control, lipid control/statin therapy, aspirin therapy, ß-blocker therapy, angiotensin-converting enzyme (ACE) inhibitor therapy (angiotensin receptor blockers [ARBs] if contraindicated) and, in patients with diabetes, glycemic control.

The Class IIa recommendation (evidence in favor of usefulness/efficacy) was to evaluate for and treat depression. The Class IIb recommendations (usefulness/efficacy less well established) were omega-3 fatty-acid and folic acid supplementation (Mosca et al., 2004).

The guidelines included a strong recommendation that high-risk women who have low-density lipoprotein (LDL) cholesterol levels <100 mg/dL should also receive cholesterol-lowering drugs (preferably statins) unless contraindicated. Previously, routine statin therapy had not been recommended for these women, but recent studies have shown a benefit in this subgroup (AHA, 2004).

For stroke prevention, warfarin (Coumadin) was recommended for women with atrial fibrillation and intermediate or high risk for embolic stroke. For women at low risk for stroke or who could not take warfarin, aspirin was recommended. Recommendations on the use of aspirin varied depending on the level of risk. "Although there was good consensus on the use of aspirin (75 mg to 162 mg) in high-risk women, recommendations for aspirin therapy in intermediate- and lower-risk women were more challenging," according to the expert panel/writing group (Mosca et al., 2004).

The challenge in developing the aspirin recommendation came from the lack of data from primary prevention trials that included women and the possibility that data on men may not necessarily be extrapolated to women.

"Uncontrolled hypertension is not uncommon in women, and aspirin therapy may increase the risk of hemorrhagic stroke in this setting. Moreover, the risk of gastrointestinal bleeding and other side effects may outweigh the potential benefits of aspirin in women at lower risk for CVD," the expert panel/writing group said.

With regard to hormone therapy and antioxidant vitamin supplementation, the expert panel/writing group said the Class III recommendations were based on recent clinical trials showing no benefit for CVD prevention and possible adverse effects of these interventions.

References

American Heart Association (2004), New guidelines take a personal approach to preventing cardiovascular disease in women. Available at: www.americanheart.org/presenter.jhtml?identifier=3018804. Accessed Feb. 6.

Mosca L, Appel LJ, Benjamin EJ et al. (2004), Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 109(5):672-693.