Prevention Guidelines in Women Broaden the Definition of CV Risk

Anne Jacobson

doi:10.1177/155989771115019

Summary

In 2011, the American Heart Association published updated guidelines for the prevention of cardiovascular disease in women [Mosca L et al. Circulation 2011]. This article reviews the major updates in the new guidelines.

Cardiology Guidelines
Prevention & Screening

In 2011, the American Heart Association (AHA) published updated guidelines for the prevention of cardiovascular disease (CVD) in women [Mosca L et al. Circulation 2011]. Lori Mosca, MD, Columbia University Medical Center, New York, New York, USA, reviewed the major updates in the new guidelines.

One key change compared with earlier guidelines is the approach to risk stratification. Historically, the term “high risk” has been defined as patients whose 10-year risk of coronary heart disease (CHD) was >20%. However, this definition underestimates the true risk of CVD in women. The 2011 AHA guideline shifts the focus from coronary risk alone to incorporate broader risk factors for CVD. In the new CVD prevention guideline for women, “high risk” now describes patients with any of the following features:

Established atherosclerotic disease, including:
- ♦ Clinically manifest CHD, peripheral arterial disease, or cerebrovascular disease
- ♦ Abdominal aortic aneurysm
Estimated 10-year cardiovascular disease risk >10%, based on traditional CV risk factors
Diabetes mellitus
End-stage renal disease (ESRD) or chronic kidney disease (CKD)

In previous prevention guidelines, the term “at risk” was used to describe patients with one or more traditional risk factors for CVD, such as cigarette smoking, hypertension, dyslipidemia, obesity, physical activity, poor diet, and physical inactivity. The 2011 AHA guideline for the prevention of CVD in women adds two more risk factors to this list:

Systemic autoimmune collagen vascular disease (eg, lupus and rheumatoid arthritis), and
Pregnancy-related risk factors, including a history of pregnancy-induced hypertension, gestational diabetes, preeclampsia, or polycystic ovary syndrome.

These risk factors were added to reflect the unique underlying pathophysiology of CVD in women as compared with men. Notably, these are risk factors that tend to present more frequently in younger women. Although it is an intense focus of current research, it remains to be demonstrated that initiating lifestyle or pharmacological interventions in these patients changes the natural history of their progression to incident CVD.

Lifestyle Interventions

Lifestyle modifications are essential to cardiovascular risk reduction for all at-risk patients. Earlier guidelines used abstract concepts (eg, “moderate exercise”) that were difficult for patients to follow. To help physicians educate patients about lifestyle interventions, the 2011 guidelines include specific and relevant examples. For instance, moderate exercise can include dancing fast for 30 minutes, raking leaves for 30 minutes, gardening for 30–45 minutes, or pushing a stroller 1 mile in 30 minutes.

Pharmacological Interventions

Aspirin is the only drug intervention with gender-specific recommendations. Among high-risk women (see above), aspirin (75 to 325 mg/day) is recommended unless it is contraindicated for those with established CHD (Class I recommendation) and is reasonable for those with diabetes, ESRD/CKD, or >10% estimated 10 year CVD risk (Class IIa recommendation). Clopidogrel should be substituted when aspirin is indicated but not tolerated (Class I recommendation).

Aspirin recommendations for other at-risk and healthy low-risk women without established CVD require weighing the benefits of preventive antiplatelet therapy against the risks. For women aged ≥65 years, aspirin (81 mg/day or 100 mg every other day) is considered useful (if blood pressure is controlled) for prevention of incident ischemic stroke and myocardial infarction when the risks of gastrointestinal bleeding and hemorrhagic stroke are considered low (Class IIa recommendation). For women aged <65 years, there is conflicting evidence whether aspirin can prevent ischemic stroke (Class IIb recommendation).

Future trials of primary and secondary prevention strategies in CVD should enroll diverse populations of female patients. With additional evidence, guidelines can be refined further to meet the specific needs of women who are at risk for adverse cardiovascular outcomes.