Highlights
The American Heart Association’s (AHA) updated prevention guidelines for women outline a bold prescription for prevention of CVD that urges women to start early, with adoption of a healthy lifestyle and sets new target goals for risk-assessment.
There are now 3 categories (“high risk”, “at risk”, and “optimal risk”instead of the 4 (“high”, “intermediate”, “lower”, and “optimal”) in the Framingham global risk model.
The High-Risk Criteria are
- coronary heart disease,
- cerebrovascular disease,
- peripheral arterial disease,
- abdominal aortic aneurysm,
- end-stage or chronic renal disease,
- diabetes mellitus and
- a global risk score of greater than 20%.
The At-Risk Criteria include
- one or more major CVD risk factors
- smoking,
- poor diet,
- physical inactivity,
- obesity,
- family history of premature CVD,
- hypertension, or
- dyslipidaemia
- subclinical disease,
- metabolic syndrome and
- poor exercise capacity on TMT
The Optimal-Risk Criteria are
- a global risk score of less than 10% and
- a healthy lifestyle with no risk factors.
According to the new recommendations, all women aged 20 yr and above need initial CVD risk evaluation (medical history, physical examination, fasting glucose and lipids), Framingham risk assessment, and depression screening for women with CVD.
Women Need to Exercise at Least 30 Minutes Most Days of the Week
- Lifestyle Interventions
- Women should avoid smoking, tobacco and passive smoke. Counseling, nicotine replacement, or other pharmacotherapy should be offered with behavioral interventions for smoking cessation.
- They should engage in a minimum of 30 minutes of moderate-intensity physical activity at least 6/7 days of the week.
- Women with a recent acute coronary or cerebrovascular event should seek a comprehensive rehabilitation program.
- Saturated fat should be limited to no more than 10%, cholesterol intake to less than 300 mg/day, alcohol to no more than 1 drink daily and sodium to less than 2.3 gm daily.
- A BMI between 18.5 and 24.9 kg/m² and a waist circumference less than 35 inches should be maintained.
- Omega-3 capsules may be considered in women with CVD and 2 to 4 gm may be used in those with pertriglyceridemia.
- Screening for and treating depression in women with CVD should be considered.
- Major Risk Factor Interventions
- Optimal BP should be less than 120/80 mm Hg.
- Lipid levels
- LDL cholesterol levels should be < 100 mg/dL;
- HDL cholesterol levels should be > 50 mg/dL;
- triglyceride levels > 150 mg/dL;
- non-HDL cholesterol (LDL + VLDL) levels, < 130 mg/dL.
- Lipid therapy with statins, niacin, or fibrates should be stratified by risk category.
- Lifestyle and pharmacotherapy is indicated for type 2 diabetes mellitus to achieve Hb1Ac levels of less than 7%.
- Preventive Drug Interventions
- Aspirin therapy (75-325 mg/day) should be used in high-risk women unless contraindicated.
- Clopidogrel should be substituted if aspirin is not tolerated.
- In women over 65 years, consider 81 mg daily or 100 mg on alternate days of aspirin if BP is controlled or for prevention of myocardial infarction & stroke.
- In women below 65 years, aspirin is indicated when ischemic stroke prevention outweighs the risk.
- Beta-blockers should be used in women indefinitely after myocardial infarction, acute coronary syndrome or left ventricular dysfunction with or without heart failure.
- ACE inhibitors should be used indefinitely after myocardial infarction and in those with heart failure or left ventricular ejection fraction less than 40% or with diabetes mellitus.
- Aldosterone blockade is indicated in women after myocardial infarction that do not have renal dysfunction or hyperkalaemia, in those who are receiving therapeutic doses of an ACE inhibitor and beta-blocker and in those who have left ventricular ejection fraction of less than 40% diabetes or heart failure.
- Class III Interventions (Not Useful or Harmful)
- Estrogen and selective estrogen-receptor blockers should NOT be used for primary or secondary CVD prevention.
- Antioxidant vitamin supplements (E, C, and beta-carotene) should NOT be used for primary or secondary CVD prevention.
- Folic acid with or without B6 and B12 supplementation should NOT be used for primary or secondary CVD prevention.
- Routine use of aspirin in women below 65 years of age is not recommended for myocardial infarction prevention.