Practice Guideline Briefs

Am Fam Physician. 2005 Feb 1;71(3):611-612.

Guidelines for Cardiovascular Disease Prevention in Women

The American Heart Association (AHA) has developed new guidelines for the prevention of cardiovascular disease in women who have a wide range of risk factors. The recommendations, “Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women,” are available online at http://circ.ahajournals.org/cgi/content/full/109/5/672.

Lifestyle Interventions. The AHA panel recommends that women be encouraged consistently not to smoke and to avoid environmental smoke. Women should exercise a minimum of 30 minutes most days of the week. Weight maintenance or reduction should be encouraged through a balance of physical activity, caloric intake, and behavior programs when indicated to maintain a body mass index between 18.5 and 24.9 kg per m2 and a waist circumference of less than 35 in (88.9 cm). Healthy eating patterns should be encouraged, including eating a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, and sources of protein that are low in saturated fat. Intake of saturated fat should be limited to less than 10 percent of total calories and cholesterol intake should be kept below 300 mg per day. Omega-3 fatty acid and folic acid supplementation should be considered in high-risk women. Women with recent acute coronary syndrome, coronary intervention, or new-onset or chronic angina should participate in a comprehensive risk-reduction program, such as cardiac rehabilitation or a physician-guided, home- or community-based program.

Major Risk Factor Interventions. Lifestyle approaches should be used to maintain blood pressure below 120/80 mm Hg. Pharmacotherapy is indicated when blood pressure is 140/90 mm Hg or above; this threshold is even lower in women with blood pressure-related target organ damage or diabetes. Thiazide diuretics should be part of the drug regimen in most patients. Lifestyle approaches should be encouraged to maintain optimal levels of lipids and lipoproteins: low-density lipoprotein (LDL) cholesterol levels of less than 100 mg per dL (2.60 mmol per L), high-density lipoprotein (HDL) levels of more than 50 mg per dL (1.30 mmol per L), triglyceride levels less than 150 mg per dL (1.7 mmol per L), and non-HDL-cholesterol levels (i.e., total cholesterol minus HDL cholesterol) of less than 130 mg per dL (3.36 mmol per L).

In high-risk women or when LDL cholesterol levels are elevated, saturated fat intake should be limited to less than 7 percent of total calories, and cholesterol to less than 200 mg per day. Trans fatty acid intake should be reduced. LDL-lowering therapy (preferably statins) and lifestyle interventions should be started simultaneously in high-risk women with LDL cholesterol levels of at least 100 mg per dL. Statin therapy alone should be started in high-risk women with LDL cholesterol levels of less than 100 mg per dL, unless contraindicated. Niacin or fibrate therapy should be started when HDL cholesterol levels are low or non-HDL cholesterol levels are high in high-risk women.

Preventive Drug Regimens. Aspirin (75 to 162 mg per day) or clopidogrel therapy should be used in high-risk women unless contraindicated. In intermediate-risk women, aspirin therapy can be considered as long as blood pressure is controlled. Beta blockers should be used indefinitely in all women who have had a myocardial infarction or who have chronic ischemic syndromes. Angiotensin-converting enzyme (ACE) inhibitors should be used in high-risk women. Angiotensin-receptor blockers should be used in high-risk women with clinical evidence of heart failure or an ejection fraction of less than 40 percent who cannot tolerate ACE inhibitors.

Prevention of Atrial Fibrillation and Stroke. Warfarin should be used in women with chronic or paroxysmal atrial fibrillation to maintain the International Normalized Ratio at 2.0 to 3.0, unless the patient is considered to be at low risk for stroke or high risk for bleeding. Aspirin (325 mg per day) should be used in women with chronic or paroxysmal atrial fibrillation with a contraindication to warfarin or at low risk for stroke.

Class III Interventions. Combined estrogen plus progestin hormone therapy and other forms of menopausal hormone therapy should not be used to prevent cardiovascular disease in postmenopausal women. Antioxidant supplementation should not be used to prevent cardiovascular disease, and routine use of aspirin in low-risk women also is not recommended.

Benefits of Omega-3 Fatty Acids

Consumption of fish oil can help reduce deaths from heart disease, but its effects on other outcomes are inconclusive, according to evidence reports from the Agency for Healthcare Research and Quality (AHRQ). The reports are available online at www.ahrq.gov/clinic/epcindex.htm#dietsup.

An analysis of 10 randomized controlled trials (RCTs) and nine other studies addressed the effects of omega-3 fatty acids on respiratory outcomes. The AHRQ could not conclude whether omega-3 fatty acids are an efficacious adjuvant or monotherapy in improving respiratory outcomes in adults or children.

Six studies were analyzed to determine the role of omega-3 fatty acids in primary prevention of asthma. Dietary fish consumption appears to serve as primary prevention for asthma in pediatric populations. However, asthma prevalence and fish intake were significantly and positively related in studies that included Asian adolescents. Another study found no association between adult asthma onset and dietary fish intake.

In terms of cardiovascular benefits, a number of studies show that fish consumption and fish and α linolenic acid (ALA) supplementation reduces all-cause mortality and various cardiovascular outcomes, although the evidence is strongest for fish and fish oil. The effects on specific outcomes (especially myocardial infarction [MI] and stroke) are uncertain, and the optimal quantity and type of omega-3 fatty acid, and the optimal ratio of omega-3 to omega-6 fatty acid remain unknown. The most significant benefit may be in reducing sudden cardiac death. Four of six RCTs found a benefit, one found no benefit, and one found harm, although all six were thought to be poorly designed. Adverse events from fish oil and ALA supplementation appear to be minor.

Overall, strong evidence shows that fish oils have a strong, dose-dependent beneficial effect on triglyceride levels. There also is evidence of possible small beneficial effects on blood pressure and coronary artery restenosis after angioplasty, exercise capacity in patients with coronary atherosclerosis, and heart rate variability, particularly in patients with recent MI. Omega-3 fatty acids do not appear to affect total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting blood sugar, or glycosylated hemoglobin levels, and they had no effect on plasma insulin levels and insulin resistance in patients with type 2 diabetes.

Assisted Reproductive Technology Statistics

More than 40,000 infants were born in 2001 as a result of assisted-reproductive technology (ART) procedures, according to data from the Centers for Disease Control and Prevention. The report, “Assisted Reproductive Technology Surveillance—United States, 2001,” is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5301a1.htm.

Most of the women who underwent ART used freshly fertilized embryos from their own eggs (75 percent of the 107,587 ART procedures performed in 2001). A total of 14 percent used thawed embryos from their own eggs, 8 percent used freshly fertilized embryos from donor eggs, and 3 percent used thawed embryos from donor eggs. Although the average live-birth rate for ART-transfer procedures performed among women who used their own freshly fertilized eggs was 33 percent, live-birth rates ranged from 41 percent among women younger than 35 years to 7 percent among women older than 42 years. The highest success rates were reported in patients who used donor eggs and freshly fertilized embryos (56 percent pregnancy rate, 47 percent live-birth rate, and 27 percent singleton live-birth rate).

Nearly one half of ART procedures using freshly fertilized embryos from the patient's own eggs were performed in women younger than 35. Tubal factor, male factor, and endometriosis were more common in younger women; overall, 10 to 13 percent of couples had unexplained infertility, 10 to 17 percent had multiple female factors, and 17 to 21 percent had both male and female factors.

In all, the 29, 344 live-birth deliveries resulted in 40,687 infants; the number of infants born was higher than the number of deliveries because of multiple-birth deliveries.

AHA Report on Response to Cardiac Arrest

The American Heart Association (AHA) has developed a medical emergency response plan for schools to reduce the incidence of life-threatening emergencies and maximize the chances of survival. The report, “Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies,” is available online at http://circ.ahajournals.org/cgi/content/full/109/2/278.

Life-threatening emergencies can occur in students and adults and can be the result of preexisting health problems, violence, unintentional injuries, natural disasters, and toxins. Each year, more than one third of schools may have an emergency that involves an adult and requires the activation of the emergency medical services system. Schools now have fewer nurses, and nurses often rotate between schools, leaving some schools without professional medical care for hours or days each week. The AHA and other professional organizations have recommended school emergency response plans to increase the potential of saving lives and make the most efficient use of school equipment and personnel.

The core elements of the plan include effective and efficient communication throughout the school campus; a coordinated and practiced response plan; risk reduction through safety precautions and identification of potential high-risk situations; training and equipment for first aid and cardiopulmonary resuscitation; and implementation of a lay rescuer automated external defibrillator program in schools that have an established need.


Copyright © 2005 by the American Academy of Family Physicians.
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