Matters Of The Heart New AHA Guidelines Take A Personal Approach To Cardiovascular Disease

The American Heart Association has announced new guidelines for preventing heart disease and stroke in women based on a woman’s individual cardiovascular health. The guidelines are published in Circulation: Journal of the American Heart Association. 

Cardiovascular disease (CVD) is the leading cause of death for men and women in the United States. It kills nearly 500,000 women each year.

“For the first time, we are giving clarity about how much we know and how much we don’t know,” said Dr. Lori Mosca, chair of the writing group and director of Preventive Cardiology at New York-Presbyterian Hospital/Columbia University Medical Center. “The concept of cardiovascular disease as a ‘have-or-have-not’ condition has been replaced with the idea that CVD develops over time and every woman is somewhere on the continuum.”

Judging the Risk

The guidelines are based on the highest-quality evidence from all the available research related to CVD prevention.

According to the new recommendations, the aggressiveness of treatment should be linked to whether a woman has low, intermediate, or high risk of having a heart attack in the next 10 years, based on a standardized scoring method developed by the Framingham Heart Study. “This provides a very individual approach to preventing CVD throughout the population,” Mosca said.

Low risk means a woman has a less than 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} chance of having a heart attack in the next 10 years, intermediate risk is a 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} chance, and high risk is a greater than 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} chance.

Aspirin recommendations illustrate how recommended therapy varies across three levels of risk. For all high-risk women and for those who have documented cardiovascular disease, aspirin is recommended, but it is not recommended for low-risk women. Among intermediate-risk women, aspirin can be considered as long as blood pressure is controlled and the benefit is likely to outweigh the risk of side effects such as gastrointestinal bleeding or hemorrhagic stroke.

Lifestyle interventions — such as smoking cessation, regular physical activity, a heart-healthy diet, and weight maintenance — were given a strong priority in all women, not only because of their potential to reduce existing CVD, but also because heart-healthy lifestyles may prevent major risk factors from developing.
ACE inhibitors and beta blockers were recommended for all high-risk women.

The guidelines also include a strong recommendation that high-risk women, even those with low-density lipoprotein (LDL) cholesterol levels below 100 mg/dL, should receive cholesterol-lowering drugs, preferably statins.

Routine statin therapy has not previously been recommended for these women, but recent studies have shown a benefit in this subgroup. The use of niacin and fibrates, other cholesterol-lowering drugs of particular benefit in specific cases, is also discussed.

Fighting Back

For stroke prevention, women with atrial fibrillation and intermediate or high risk for embolic stroke are recommended to take warfarin. If they cannot take warfarin, or if they are at low risk for stroke, they should be given aspirin.

Prevention measures, both lifestyle and medical, were divided into classes based on the strength of the recommendation for each level of risk. Class I is the most strongly recommended intervention, followed by Class IIa and IIb. The guidelines also provide guidance on what not to do, with certain interventions labeled Class III — indicating that an intervention is either not useful or could be harmful, or both.

“The Class III category is important, especially in areas where there has been a lot of confusion, such as hormone therapy and antioxidant supplements. Research has shown that these interventions have no benefit for preventing CVD in women,” Mosca said.

Another example is aspirin use, which is Class III for low-risk women because the side effects may outweigh benefits. Until more research is available, Mosca said it is more prudent to wait before recommending aspirin therapy in this group of women.

“Overwhelming evidence suggests that CVD can be prevented in both women and men,” she said. “These recommendations should help health care providers and the public avoid initial or recurrent heart attacks and strokes.”

The guidelines represent a major collaborative effort by representatives of the American Heart Association and 11 other professional and governmental co-sponsoring organizations. Another 22 organizations, including some lay organizations, endorsed the guidelines.

Log onto www.americanheart.org for more information. The AHA is currently conducting its Go Red for Women initiative, designed to raise awareness of cardiovascular disease, the number-one killer of American women