Women's New Cardiac Health Guidelines

Summarized by Robert W. Griffith, MD
April 4, 2007

Summary

The American Heart Association has updated its guidelines for the prevention of cardiovascular disease in women. The major recommendations in the 2007 version are listed in this article.

Introduction

In the USA, more women than men die from cardiovascular disease (CVD) every year. Over their lifetime, the risk for heart attack or stroke is almost 50% for women. A woman in her early 30s has a less than 10% risk of developing heart disease, but by the time she's in her 50s or 60s and seen by her physician the risk is much higher. And by then it's too late for most preventive strategies - "the horse is out of the barn". So the American Heart Association's new guidelines to prevent CVD in women are timely. This is a summary of the principal recommendations.

Risk classification

Classifying a woman's risk of CVD should be done in order to recommend optimal preventive measures. The 2004 classifications previously used have been reduced to three classes:

• High Risk - any one of these: established coronary heart disease, cerebrovascular disease, peripheral artery disease, abdominal aortic aneurism, chronic kidney disease, diabetes, or a Framingham risk score above 20% (see link below).
• At Risk - one or more of these: smoking, poor diet, physical inactivity, obesity (waist more than 35 inches), family history of CVD (before 55 in a male or 65 in a female relative), high blood pressure, abnormal blood lipids, coronary artery calcification, poor treadmill exercise capacity, or the metabolic syndrome (see link below).
• Optimal Risk - Framingham Risk Score below 10%, a healthy lifestyle, no risk factors.

The recommendations are grouped into categories: lifestyle interventions, major risk factor interventions, and preventive drug interventions.

Lifestyle Interventions

• No Smoking - use nicotine replacement and counseling, as required. Avoid passive smoke inhalation, too.
• Physical Activity - 30 minutes a day, 5 days a week, for good health, 60 to 90 minutes a day to help lose weight or maintain loss.
• Diet - plenty of fruits and veggies; whole-grain, high-fiber foods; fish twice a week or more; saturated fat less than 10% of calories; low sodium, very low trans-fats.
• Alcohol - no more than 1 drink a day
• Weight - achieve a body mass index (BMI) between 18.5 and 25, waist size 35 inches or less.
• Omega-3 Fatty Acids - if coronary heart disease is present, take a supplement (850 - 1000 mg capsules of EPA & DHA, 2 - 4 gram if high blood triglyceride level).
• Depression - screen women with coronary heart disease for depression.

Major Risk Factor Interventions

• Blood Pressure - achieve lower than 120/80 mmHg through lifestyle improvements (see above). Take medication when it's over 140/90 mmHg (this means if either number is raised). Diuretic ('water pill') first, add beta-blocker and/or ACE inhibitor or ARB (angiotensin receptor blocker).
• Blood Lipids - lifestyle and medication to achieve LDL-C below 100 mg/dL, HDL-C over 50 mg/dL, and triglycerides below 150 mg/dL. ( The actual recommendations are detailed and complicated for different circumstances.)
• Diabetes - lifestyle changes and medication to achieve HbA1c below 7%.¹

Preventive Drug Interventions

• Aspirin - High-Risk women should take 81 to 325 mg aspirin daily; At Risk women and healthy women over 65 can take 81 mg daily (or 100 mg every other day), as long as the benefit of preventing an ischemic stroke appears to outweigh the risk for gastrointestinal bleeding and hemorrhagic stroke.
• Beta-blockers, ACE inhibitors or ARBs, and aldosterone blockers should be taken almost indefinitely after a heart attack or heart failure, unless contraindicated by the cardiologist.

The guidelines no longer recommend hormone replacement therapy, antioxidant supplements, or folic acid to prevent CVD.

Problems of Implementation

There is little doubt that women are not well aware of their individual risk level. As many as 36% did not perceive themselves at risk, 25% said their doctor didn't say that heart health was important, and 20% of doctors failed to explain how a patient can change her risk status. This means health care providers must take greater responsibility for helping to educate their patients.

Almost as important: adherence to CVD preventive and therapeutic medications is not good (see link below - "High Blood Pressure Dropouts"). Think of all the resolutions taken to carry out a strict exercise regime or to diet that are broken in the first 2-3 months . . .

Source

• Evidence-based guidelines for cardiovascular disease prevention in women. L. Mosca, CL. Banka, EJ. Benjamin ,  et al. , Circulation, 2007, vol. 115

Footnotes
1. HbA1c is shorthand for a type of hemoglobin, the oxygen-carrying element in red blood cells. (Hb stands for hemoglobin, and A1c is the designation of the subtype.) It's important because glucose binds to HbA1c and is only released very slowly, so that the HbA1c represents the average blood glucose level over the previous 4 weeks.

Related Links
AHA 2007 Guidelines for Preventing Heart Disease in Women
HealthandAge.com: The Framingham Risk Score
High Blood Pressure Dropouts