Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women

1
Evidence-Based Guidelines for Cardiovascular
Disease Prevention in Women
2
Objectives

• To present strategies to assess and stratify
  women into high risk, at risk, and optimal risk
  categories for cardiovascular disease
• To summarize lifestyle approaches to the
  prevention of cardiovascular disease in women

3
Objectives

• To review evidence-based approaches to
  cardiovascular disease prevention for patients
  with hypertension, lipid abnormalities, and
  diabetes
• To review an evidence-based approach to
  pharmacological risk intervention for women at
  risk for cardiovascular events

4
Objectives

• To summarize commonly used therapies that
  shouldnot be initiated for the prevention or
  treatment ofheart disease, because they lack
  benefit, or becauserisks outweigh benefits

5
CVD and Other Major Causes of Death for Women in
the United States 2004
Source Adapted from Rosamond 2008
6
Annual Numbers of U.S. Adults Diagnosed with
Myocardial Infarction and Fatal CHD by Age and
Sex Categories 1987-2004
Age in Years
Source Adapted from Rosamond 2008
7
Cardiovascular Disease Mortality U.S. Males and
Females 1980-2004
Source Adapted from Rosamond 2008
8
Racial and Ethnic Groups

• Cardiovascular disease is the leading cause of
  death for African Americans, Latinos, Asian
  Americans, Pacific Islanders, and American
  Indians
• African American women are at the highest risk
  for death from heart disease among all racial,
  ethnic, and gender groups

Source Rosamond 2008
9
Evidence-based Guidelines for Cardiovascular
Disease Prevention in Women 2007 Update

• Mosca L, et al. Circulation 2007 1151481-501.
• http//www.circ.ahajournals.org

10
Cardiovascular Disease Prevention in Women
Current Guidelines

• A five-step approach
• Assess and stratify women into high risk, at
  risk, and optimal risk categories
• Lifestyle approaches recommended for all women
• Other cardiovascular disease interventions
  treatment of HTN, DM, lipid abnormalities
• Highest priority is for interventions in high
  risk patients
• Avoid initiating therapies that have been shown
  to lack benefit, or where risks outweigh
  benefits

Source Adapted from Mosca 2004
11
Risk Stratification

• High Risk
• Diabetes mellitus
• Documented atherosclerotic disease
• Established coronary heart disease
• Peripheral arterial disease
• Cerebrovascular disease
• Abdominal aortic aneurysm
• Includes many patients with chronic kidney
  disease, especially ESRD 10-year Framingham
  global risk gt 20, or high risk based on another
  population-adapted global risk assessment tool

Source Mosca 2007
12
Risk Stratification

• At Risk
• gt 1 major risk factors for CVD, including
• Cigarette smoking
• Hypertension
• Dyslipidemia
• Family history of premature CVD (CVD at lt 55
  years in a male relative, or lt 65 years in a
  female relative)
• Obesity, especially central obesity
• Physical inactivity
• Poor diet
• Metabolic syndrome
• Evidence of subclinical coronary artery disease
  (eg coronary calcification), or poor exercise
  capacity on treadmill test or abnormal heart
  rate recovery after stopping exercise

Source Mosca 2007
13
Definition of Metabolic Syndrome in Women

• Abdominal obesity - waist circumference gt 35 in.
• High triglycerides 150mg/dL
• Low HDL cholesterol lt 50mg/dL
• Elevated BP 130/85mm Hg
• Fasting glucose 100mg/dL

Source AHA/NHLBI 2005
14
Risk Stratification

• Optimal risk
• No risk factors
• Healthy lifestyle
• Framingham global risk lt 10

Source Mosca 2007
15
Lifestyle Interventions

• Smoking cessation
• Physical activity
• Heart healthy diet
• Weight reduction/maintenance

Source Mosca 2007
16
Relative Risk of Coronary Events for Smokers
Compared to Non-Smokers
Source Adapted from Stampfer 2000
17
Smoking

• All women should be consistently encouraged to
  stop smoking and avoid environmental tobacco
• The same treatments benefit both women and men
• Women face different barriers to quitting
• Concomitant depression
• Concerns about weight gain
• Provide counseling, nicotine replacement, and
  other pharmacotherapy as indicated in conjunction
  with a behavioral program or other formal
  smoking cessation program

Source Fiore 2000, Mosca 2007
18
Five As

• Ask about tobacco use at every visit
• Advise in a clear and personalized message
• Assess willingness to quit
• Assist to quit
• Arrange follow-up
• For more information http//www.surgeongene
  ral.gov/tobacco/treating_tobacco_use.pdf

Source Fiore 2000
19
Risk Reduction for CHD Associated with Exercise
in Women
Source Manson 1999
20
Modifiable Risk Factors Sedentary Lifestyle

• 40 of women report no leisure time physical
  activity
• Exercise is less prevalent among white women
  compared to white men
• African American and Hispanic women have the
  lowest prevalence of leisure time physical
  activity

Source U.S. Surgeon General 1996, Rosamond 2008
21
Physical Activity

• Consistently encourage women to accumulate a
  minimum of 30 minutes of moderate intensity
  physical activity on most, or preferably all,
  days of the week
• Women who need to lose weight or sustain weight
  loss should accumulate a minimum of 60-90 minutes
  of moderate-intensity physical activity on most,
  and preferably all, days of the week

Source Mosca 2007
22
Body Weight and CHD Mortality Among Women
P for trend lt 0.001
Source Adapted from Manson 1995
23
Body Weight and CHD Mortality Among Women
P for trend lt 0.001

Source Adapted from Manson 1995
24
Obesity Trends Among U.S. AdultsBehavioral Risk
Factor Surveillance System BRFSS, 1990-2006
1998
1990
(BMI 30, or 30 lbs overweight for
5 4 woman)
2006
No Data lt10 1014
1519 2024 2529
30
Source CDC
25
Weight Maintenance/Reduction Goals

• Women should maintain or lose weight through an
  appropriate balance of physical activity, calorie
  intake, and formal behavioral programs when
  indicated to maintain
• BMI between 18.5 and 24.9 kg/m²
• Waist circumference lt 35 inches

Source Mosca 2007
26
Body Mass Index Definition

• BMI weight in kilograms divided by the square
  of the height in meters (kg/m2)
• BMI chart showing BMI based on weight in pounds
  and height in inches available at
  http//www.nhlbi.nih.gov/guidelines/obesity/ob_hom
  e.htm

Source NHLBI
27
Low Risk Diet is Associated with Lower Risk of
Myocardial Infarction in Women
Relative Risk of MI
Adjusted for other cardiovascular
risk factors
Plt .05 for quintiles 3-5 compared to 1-2
Diet Score by Quintile (1 least vegetables,
fruit, whole grains, fish, legumes)
Source Akesson 2007
28
Diet

• Consistently encourage healthy eating patterns
• Healthy food selections
• Fruits and vegetables
• Whole grains, high fiber
• Fish, especially oily fish, at least twice per
  week
• No more than one drink of alcohol per day
• Less than 2.3 grams of sodium per day
• Saturated fats lt 10 of calories, lt 300mg
  cholesterol
• Limit trans fatty acid intake (main dietary
  sources are baked goods and fried foods made with
  partially hydrogenated vegetable oil)

Source Mosca 2007
29
Major Risk Factor Interventions

• Blood Pressure
• Target BPlt120/80 mmHg
• Pharmacotherapy if BPgt 140/90, or gt 130/80 in
  diabetics or patients with renal disease
• Lipids
• Follow NCEP/ATP III guidelines
• Diabetes
• Target HbA1Clt7, if this can be accomplished
  without significant hypoglycemia

Source Mosca 2007
30
Hypertension

• Encourage an optimal blood pressure of lt 120/80
  mm Hg through lifestyle approaches
• Pharmacologic therapy is indicated when blood
  pressure is gt 140/90 mm Hg or an even lower
  blood pressure in the setting of diabetes or
  target-organ damage (gt 130/80 mm Hg)
• Thiazide diuretics should be part of the drug
  regimenfor most patients unless contraindicated,
  or unless compelling indications exist for other
  agents
• For high risk women, initial treatment should be
  with a beta-blocker or angiotensin converting
  enzyme inhibitor or angiotensin receptor blocker

Source Mosca 2007
31
Lifestyle Approaches to Hypertension in Women

• Maintain ideal body weight
• Weight loss of as little as 10 lbs reduces blood
  pressure
• DASH eating plan
• Even without weight loss, a diet rich in fruits,
  vegetables, and low fat dairy products can reduce
  blood pressure
• Sodium restriction to 2300 mg/d
• Further restriction to 1500 mg/d may be
  beneficial, especially in African American
  patients
• Increase physical activity
• Limit alcohol to one drink per day
• Alcohol raises blood pressure
• One drink 12 oz beer, 5 oz wine, or 1.5 oz
  liquor

Source JNC VII 2004, Sacks 2001, Mosca 2007
32
DASH Eating Plan

• 78 servings of grains, grain products daily
• 45 servings of vegetables daily
• 45 servings of fruits daily
• 23 servings of low-fat or nonfat dairy foods
  daily
• 2 servings of meats, poultry, fish daily
• 45 servings of nuts, seeds, legumes weekly
• Limited intake of fats, sweets

Source NHLBI 1998
33
DASH Diet with Low Sodium Intake in Hypertensive
Individuals Compared to Control Diet with Average
U.S. Sodium Intake
African American Non-African American


Plt.001 from baseline
Source Sacks 2001
34
Lipids

• Optimal levels of lipids and lipoproteins in
  women are as follows (these should be encouraged
  in all women with lifestyle approaches)
• LDL lt 100mg/dL
• HDL gt 50m/dL
• Triglycerides lt 150mg/d
• Non-HDL (total cholesterol minus HDL) lt 130mg/d

Source Mosca 2007
35
Lipids

• In high-risk women or when LDL is elevated
• Saturated fat lt 7 of calories
• Cholesterol lt 200mg/day
• Reduce trans-fatty acids
• Major dietary sources are foods baked and fried
  with partially hydrogenated vegetable oil

Source Mosca 2007
36
Approximate and Cumulative LDL Cholesterol
Reduction Achievable By Dietary Modification
Dietary Component Dietary Change Approximate
LDL
Reduction Major Saturated fat lt7 of
calories 8-10 Dietary cholesterol lt200
mg/day 3-5 Weight reduction Lose 10
lbs 5-8 Other LDL-lowering options Viscous
fiber 5-10 g/day 3-5 Plant/sterol 2g/day 6
-15 stanol esters Cumulative
estimate 20-30
Source Adapted from ATP III 2002
37
Lipids

• Treat high risk women aggressively with
  pharmacotherapy
• LDL-lowering pharmacotherapy (preferably a
  statin) should be initiated simultaneously with
  lifestyle modification for women with LDLgt100mg/dl

Source Mosca 2007
38
Coronary Disease Mortality and Diabetes in Women
Source Krolewski 1991
39
Race/Ethnicity and Diabetes

• At high risk
• Latinas
• American Indians
• African Americans
• Asian Americans
• Pacific Islanders

Source American Diabetes Association 2001
40
Preventive Drug Interventions

• Aspirin High risk women
• 75-325 mg/day, or clopidogrel if patient
  intolerant to aspirin, should be used in
  high-risk women unless contraindicated
• Aspirin- Other at-risk or healthy women
• Consider aspirin therapy (81 mg/day or 100 mg
  every other day) if blood pressure is controlled
  and benefit is likely to outweigh risk of GI side
  effects and hemorrhagic stroke
• Benefits include ischemic stroke and MI
  prevention in women aged gt 65 years, and ischemic
  stroke prevention in women lt 65 years

Source Mosca 2007
41
Womens Health Initiative Estrogen and Progestin
Arm Absolute Excess Risk

• Excess CHD events 7/10,000 woman-years
• Excess stroke events 8/10,000 woman-years
• Excess pulmonary emboli 8/10,000 woman-years
• Excess invasive breast cancer 8/10,000
  woman-years

Source Writing Group for the WHI
Investigators 2002
42
Womens Health Initiative Estrogen and Progestin
Arm Absolute Benefits

• Fewer colorectal cancers 6/10,000 woman-years
• Fewer hip fractures 5/10,000 woman-years

Source Writing Group for the WHI
Investigators 2002
43
Womens Health Initiative Estrogen Alone in
Postmenopausal Women Compared to Placebo Major
Clinical Outcomes


P lt .05
Favors Treatment
Favors Placebo
Source Adapted from WHI Steering Committee
2004
44
Menopausal Hormone Therapy, SERMs and CVD
Summary of Major Randomized Trials

• Use of estrogen plus progestin associated with a
  small but significant risk of CHD and stroke
• Use of estrogen without progestin associated with
  a small but significant risk of stroke
• Use of all hormone preparations should be limited
  to short term menopausal symptom relief
• Use of a selective estrogen receptor modulator
  (raloxifene) does not affect risk of CHD or
  stroke, but is associated with an increased risk
  of fatal stroke

Source Hulley 1998, Rossouw 2002, Anderson 2004,
Barrett-Connor 2006
45
Interventions that are not useful/effective and
may be harmful for the prevention of heart
disease

• Hormone therapy and selective estrogen-receptor
  modulators (SERMs) should not be used for the
  primary or secondary prevention of CVD

Source Mosca 2007
46
Interventions that are not useful/effective and
may be harmful for the prevention of heart
disease

• Antioxidant supplements and folic acid
  supplements
• No cardiovascular benefit in randomized trials of
  primary and secondary prevention

Source Mosca 2007
47
The NORVIT Trial Homocysteine Lowering Did Not
Reduce Cardiovascular Events in Women with Prior
MI
Relative Risk of CVD Event
Compared to B12 alone
Compared to placebo


Source Bonaa 2006
48
Reproductive Age Women and CHD

• Over 10,000 reproductive age women suffer MI or
  fatal CHD each year
• All women of reproductive age prescribed drug
  therapy should be counseled about preconception
  planning, as many recommended drugs are
  contraindicated during pregnancy
• Reproductive age women with CHD who are pregnant
  or planning pregnancy should be cared for by
  health care providers with expertise in both
  cardiovascular disease and obstetrics (team
  approach)

Source American Heart Association 2008,
Pregler 2005
49
The Heart Truth Professional Education Campaign
Website
http//www.womenshealth.gov/hearttruth
50
Conclusions

• Gender differences exist in diagnosis, treatment,
  and prognosis of CHD
• Knowledge of gender differences is essential for
  appropriate therapy
• Evidence-based guidelines provide a framework for
  prevention and treatment of cardiovascular
  disease in women