Preventing Cardiovascular Disease in Women
Nieca Goldberg Medical Director, New York University Women’s Heart Program, New York University School of Medicine
The updated American Heart Association (AHA) guidelines for women set a
framework for practicing physicians in all disciplines to evaluate and treat
CVD risk factors in women. The guidelines cover both the primary and
secondary prevention of cardiovascular disease. Lifestyle changes, such as
smoking cessation, diet, and exercise, are recommended to all women. The
dietary recommendations are consistent with previous AHA
recommendations.15 The recommended diet contains fruits, vegetables,
wholegrains, high fiber, and oily fish at least twice a week. Saturated fat
should be less than 10% of daily caloric intake for primary prevention and
less than 7% of total intake for secondary prevention. All women should
reduce transfat intake to less than 1% of calories daily. At least 30 minutes
of brisk activity is recommended daily and 60–90 minutes is recommended
for losing and sustaining weight loss. When counseling patients on exercise,
it is important to stress moderate physical activity at regular intervals for the
greatest gain in CVD prevention.16
It is also important to give patients reasonable expectations when using
diet and exercise as part of a lipid-lowering program. In studies of
middle-aged women, the average reduction in LDL cholesterol is
14.5mg/dl.17 This may be adequate for those women with mildly elevated
cholesterol, but may require the addition of pharmaceutical intervention
for those with moderate to high levels of cholesterol depending on their
level of risk. HDL cholesterol increases with increasing levels of aerobic
activity in women;18 however, in middle-aged women it may take up to a
year to make significant increases.20
Optimal cholesterol levels are LDL <100mg/dl, HDL >50mg/dl, triglycerides
<150mg/dl, and non-HDL cholesterol of <130mg/dl. Pharmaceutical
therapy with statin drugs is recommended at an LDL cholesterol
>100mg/dl level to all women at high risk for congenital heart disease
(CHD) to achieve an LDL cholesterol <100mg/dl, 130mg/dl for those
women at intermediate Framingham risk, and at a level of 160mg/dl if the
10-year FRS is <10% and LDL of 190mg/dl in low-risk women. Although
women have been under-represented in the majority of lipid-lowering
trials, meta-analyses have shown similar cardiovascular benefits in men
and women. It is important to remember that statins cannot be used
during pregnancy, and prior to starting a woman of childbearing age on
a statin pregnancy testing should be performed. HDL is a secondary target
for treatment, and niacin or fibrate therapy is recommended in high-risk
women after the LDL target is achieved. Omega 3 fish oil is recommended
(850–1000mg) for women with CHD, with higher does recommended for
those women with hypertriglyceridemia.
Optimal blood pressure is <120/80. The guidelines recommended
antihypertensive therapy at blood-pressure levels of 140/90 in non-diabetic
women and initiation of pharmaceutical therapy at blood pressures greater
than 130/80 for those women with diabetes or chronic kidney disease.
Thiazide diuretics are recommended as first-line therapy, unless the woman
is at high risk, where initial therapy would be an angiotensin-converting
enzyme (ACE)-inhibitor/angiotensin receptor-blocker, or beta-blocker.
Aspirin recommendations for women have been updated based on the
Women’s Health study and other studies.21,22 A dose range of 75–325mg is
recommended for high-risk women. Aspirin therapy (81–100mg) is
recommended for the primary prevention of CHD and stroke in women over
the age of 65. Aspirin therapy is also recommended for stroke prophylaxis
for healthy women under the age of 65, if the benefit of ischemic stoke
outweighs the risk.
Although the recommendations for CVD prevention are comprehensive
and recommend early screening, these guidelines are limited in terms of
accounting for concerns of women of childbearing age. Most of the
evidence-based data for risk factor modification are based on
interventions in women at midlife. Recent research also indicates that
there may be risk markers in women of childbearing age that predict laterlife
heart disease. Women who have pre-eclampsia, hypertension of
pregnancy, and other maternal-placental syndromes may have a two- to
eight-fold increased CVD risk.23–25 Although the mechanism is not yet
known, insulin resistance has been a proposed mechanism for these
conditions and CVD risk in women.
Lifestyle interventions are important for women of all ages. One concern is
that the guidelines may result in more aggressive use of pharmaceutical
therapy in women in whom the data are not as strong for benefit.26 The
greatest investment a woman can make in her heart health is prevention.
As clinicians, it is important that we individualize the guidelines to the needs
of our patients, instituting lifestyle changes early, with pharmacotherapy
initiated for those women at high risk or with already established CHD.
Future research should focus on identifying risk earlier and setting
guidelines for risk-factor evaluation and intervention for women throughout
their lifecycle, from the childbearing years through menopause.
