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Prevention of Cardiovascular Disease in Women

Revised guidelines redefine risk for cardiovascular disease and its management in women.

Sponsoring Organization: American Heart Association

Background and Purpose: In reviewing evidence for this update to the 2007 guidelines, the authors widened their focus to include data on effectiveness (observed clinical benefits and risks) as well as on efficacy (results of controlled trials). Consequently, the revision incorporates several new strategies for the prevention of cardiovascular events in women.

Key Points:

1. The classification scheme for assessing cardiovascular risk now stratifies women into "high risk," "at risk," and "ideal cardiovascular health" categories.

2. Women with a 10-year predicted risk for cardiovascular disease of 10% (as opposed to a 10-year risk for coronary heart disease of 20%) are now considered at high risk.

3. In the at-risk category, hypertension and hypercholesterolemia are specifically defined, and evidence of subclinical atherosclerosis now includes carotid plaque and thickened carotid intima–media thickness as well as coronary calcification. In addition, systemic autoimmune collagen-vascular disease and history of preeclampsia, gestational diabetes, or pregnancy-induced hypertension are included as risk factors in this category.

4. Ideal cardiovascular health is defined as meeting all of the following criteria:

• Non-HDL level <130 mg/dL (untreated)
  
• Blood pressure <120/80 mm Hg (untreated)
  
• Fasting blood glucose level <100 mg/dL (untreated)
  
• Body-mass index <25 kg/m²
  
• Abstinence from smoking
  
• Physical activity at goal for adults aged >20
  
• A diet similar to Dietary Approaches to Stop Hypertension (DASH)
  

5. A variety of 10-year risk equations other than the Framingham risk score are now accepted for the prediction of 10-year global cardiovascular risk. Alternatives include the Reynolds risk score for women, which incorporates high-sensitivity C-reactive protein (CRP) level, although the authors do not endorse routine CRP testing.

6. Lifestyle interventions include stronger recommendations for increased exercise. Providers are advised to consistently encourage women to accumulate at least 150 minutes of moderate or 75 minutes of vigorous exercise per week (for additional benefit, 300 minutes of moderate or 150 minutes of vigorous exercise per week are recommended), and to sustain aerobic activities for at least 10 minutes per episode. In addition, women should be encouraged to perform strengthening exercises involving all major muscle groups at least 2 days per week.

7. Diet recommendations are more stringent and prescriptive than in previous guidelines:

• Fruits and vegetables, 4.5 cups per day
  
• Fiber, 30 g per day (1.1 g fiber/10.0 g carbohydrate)
  
• Whole grains, 3 servings per day
  
• Sugar, 5 servings (1 tablespoon) per week
  
• Nuts, 4 servings per week
  
• Saturated fat, <7% of total energy intake
  
• Cholesterol, <150 mg per day
  
• Sodium, <1500 mg (1 teaspoon) per day
  

8. Consumption of omega-3 fatty acids in fish or in capsule form (e.g., 1800 mg/day of eicosapentaenoic acid) may be considered for primary or secondary prevention of cardiovascular events in women with hypercholesterolemia, hypertriglyceridemia, or both.

9. The algorithm for preventive care now includes specific recommendations for stroke prevention in women with atrial fibrillation.

10. Finally, the guidelines continue to emphasize avoidance of therapies without demonstrated benefit or with risks that outweigh their benefits (Class III interventions):

• Noncontraceptive hormone therapy outside of indications for menopausal symptoms
  
• Antioxidant vitamin supplements
  
• Folic acid supplements, except during childbearing years to prevent neural tube defects in offspring
  
• Routine use of aspirin in healthy women aged <65
  

Comment: These guidelines update the algorithm for the prevention of cardiovascular disease and present a new scheme for classification of risk in women. Gone are the terms "low risk" and "intermediate risk"; women now either have ideal cardiovascular health or are at risk for cardiovascular events. The guidelines also set the most aggressive intervention targets to date and highlight the need for sustained population-level initiatives.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology February 23, 2011

Citation(s):

Mosca L et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women — 2011 update: A guideline from the American Heart Association. Circulation 2011 Feb 16 [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIR.0b013e31820faaf8)

Reader Remarks:

Review and add to remarks on this article

• Prevention of CVD in woman
  SL Fernandes, Peso da Régua - Vila Real PORTUGAL, 24 Feb 2011 1:38 PM EST
  Specialty: Internal Medicine
  And for men? Are the guidelines different? Is there any difference apart the concernant to the hormone therapy and so?... [more]

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