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American Heart Association Releases Scientific Statement on Cardiovascular Disease in Women

VERNA L. ROSE

The American Heart Association (AHA) has issued a statement for health care professionals on cardiovascular disease in women. According to the AHA, there are still misperceptions that cardiovascular disease is not a real problem for women, even though nearly 50 percent of women die of heart disease or stroke. The scientific statement appears in the October 1997 issue of Circulation.

The AHA states that cardiovascular disease, particularly coronary heart disease and stroke, remains the leading cause of death among women in America and, in 1994, accounted for 45.2 percent of all deaths in women. As the population ages, significantly more women will be at increased risk for morbidity and mortality associated with cardiovascular disease.

The AHA believes that health care systems need to shift paradigms to emphasize healthy lifestyles for young women to help prevent the development of risk factors for cardiovascular disease. The AHA report discusses recent advances in knowledge of the occurrence, determinants, risk factors, diagnosis, prevention and treatment of atherosclerotic cardiovascular disease in women, including coronary heart disease, hypertension, stroke and peripheral arterial disease.

Coronary Heart Disease

Studies show that coronary heart disease in women is largely preventable. The major risk factors for coronary heart disease in women are cigarette smoking, hypertension (including isolated systolic hypertension, especially in elderly women), dyslipidemia, diabetes, obesity, sedentary lifestyle and poor nutrition. Cigarette smoking remains the leading preventable cause of heart disease in women, and more than 50 percent of myocardial infarctions in middle-aged women can be attributed to smoking. The report suggests that pharmacologic intervention, including antiplatelet therapy and postmenopausal hormone replacement therapy, may be appropriate in selected patients. The value of aspirin and antioxidant vitamin supplements in women has not been determined.

The AHA recommends that a major emphasis be placed on lifestyle modifications for women, including smoking cessation, regular physical activity, maintenance of healthy weight and consumption of a diet low in saturated fat and high in fruits and vegetables. Further studies are recommended to determine the potential benefits of stress reduction and psychosocial intervention in the prevention of coronary heart disease in women.

The diagnosis of heart disease is more difficult in women than it is in men. Reports from the Framingham heart study showed that chest pain was not of great prognostic value in women. Women with classical angina pectoris had a 71 percent probability of angiographic evidence of disease, compared with 36 percent of women with probable angina. Nonspecific chest pain syndromes in women are rarely associated with significant disease on arteriography.

According to the AHA, chest pain remains the most common initial manifestation of coronary heart disease in women. It is possible to stratify patients into categories of low, intermediate and high likelihood of disease on the basis of the existence of minor and major determinants of heart disease to make diagnostic testing more cost-efficient and informative.

Gender-specific considerations related to diagnostic test performance may influence the choice of procedures used to evaluate chest pain syndromes in women. Data on results of exercise treadmill testing, myocardial perfusion imaging with thallium 201, radionuclide ventriculography and exercise echocardiography suggest that gender has a significant impact on the accuracy of widely available diagnostic tests and should be a consideration in the choice and interpretation of noninvasive tests. New techniques that hold promise, including electron beam computed tomography and three-dimensional imaging with magnetic resonance or positron emission tomography, are still considered experimental.

Stroke

Stroke is the third leading cause of death in the United States and the leading cause of disability. The report notes that almost 4 million stroke survivors are alive today, and 52 percent of these are women. Stroke survivors are at greater risk of dementia and disability than persons without a history of stroke. Age and ethnicity are important predictors of survival among stroke victims. The rate of mortality associated with stroke is higher in blacks than it is in whites.

Many identifiable risk factors for ischemic stroke in both men and women have been fairly consistent over epidemiologic studies. These include hypertension, smoking, diabetes, ischemic heart disease, atrial fibrillation and transient ischemic attacks. Other risk factors may be involved, including hematologic factors, including hematocrit and white blood cell counts, infections and inflammations, psychosocial factors and lifestyle.

Treatment and acute interventions appear to be the same for men and women. In all stroke victims, early detection and treatment are vital. Thrombolytic therapy with recombinant tissue plasminogen activator for acute ischemic stroke can be effective when administered early in the course of the event. Women who have symptomatic carotid stenosis of 70 to 99 percent may benefit from the combination of carotid endarterectomy and aspirin therapy.

Peripheral Artery Disease

The AHA report lists smoking as the most consistently associated risk factor for peripheral artery disease, and prevalence rates in nonsmokers are less than one half of the rates in smokers. Other risk factors include glucose intolerance, increased body mass index, elevated blood pressure and elevated fibrinogen levels. The association between peripheral artery disease and lipid levels is not as clear. Peripheral artery disease itself is a strong risk factor for other cardiovascular events and mortality. According to the AHA, there is a threefold to fourfold increase in relative risk for all-cause mortality associated with peripheral arterial disease that is the same in both sexes.

Smoking cessation is recommended by the AHA for any patient diagnosed with peripheral artery disease. Antiplatelet therapy may be effective in some patients, and surgery is indicated in cases of severe disease, although a comprehensive program of atherosclerotic risk reduction and exercise is also necessary. Even though the role of lipid levels in the development of peripheral artery disease is unclear, lipid-lowering therapy is recommended by the AHA.

Hormones and Cardiovascular Disease

The AHA report also discusses the association of hormones and cardiovascular disease, including oral contraceptives and postmenopausal estrogen therapy. Overall, the report notes that the risk-benefit ratio for oral contraceptives is excellent except in women who smoke. The potential benefits and risks of postmenopausal estrogen therapy still need to be confirmed in randomized controlled clinical trials. Until these data are available, the AHA recommends that physicians individualize therapy based on a woman's baseline risk for cardiovascular disease and weigh the potential net benefit on overall health.

Conclusion

In conclusion, the AHA suggests that health care professionals be more sensitive to gender differences in presentation, prognosis and responsiveness to treatment of cardiovascular disease. More research in minority women is of particular importance. Health educators have an important role in communicating and interpreting scientific developments concerning heart disease in women.

The report, "Cardiovascular Disease in Women" was approved by the American Heart Association Science Advisory and Coordinating Committee. A single reprint is available by calling 800-242-8721 or writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for reprint No. 71-0119.

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AAP Issues Recommendations for the Use of Soy Protein­Based Formulas in Infant Feeding

VERNA L. ROSE

The use of soy protein­based formulas in infant feeding has increased in recent years and now accounts for nearly 25 percent of infant formula marketed in the United States. For this reason, the Committee on Nutrition of the American Academy of Pediatrics (AAP) has updated a 1983 AAP review of soy protein­based formulas and made recommendations on their appropriate use. Even though the AAP strongly recommends breast milk as the ideal source of nutrition for infants, the AAP recognizes that most infants receive formula by the time they are two months old.

The most recent AAP statement on soy protein­based formula, published in the January 1998 issue of Pediatrics, discusses the composition of isolated soy protein­based formulas; their use in term and preterm infants, disorders of carbohydrate metabolism, and acute diarrhea and secondary lactase deficiency; the antigenicity of soy protein­ based formulas; allergenicity of soy protein­based formulas; and the treatment of colic with soy protein­based formulas.

Recommendations

The following conclusions and recommendations have been excerpted from the AAP review:

• Isolated soy protein­based formulas are considered by the AAP to be safe and effective alternatives to provide appropriate nutrition for normal growth and development in term infants whose nutritional needs are not being met from maternal breast milk or cow's milk­based formulas. Isolated soy protein­based formula has no advantage over cow's milk protein­based formula as a supplement for breast-fed infants.
• Because soy protein­based formulas are lactose-free, they may be used in infants with galactosemia and inherited lactase deficiency.
• Physicians can recommend the use of isolated soy protein­based formulas for term infants whose parents prefer a vegetarian-based diet for their infants.
• Most previously healthy infants with acute gastroenteritis can be managed after rehydration with continued use of breast milk or standard dilutions of cow's milk­ based formulas. Isolated soy protein­based formulas are indicated when lactose intolerance has been documented.
• The routine use of isolated soy protein­based formula has no proven value in the prevention or management of infantile colic. The AAP believes that parental counseling as to the cause and duration of colic can be more valuable than switching to soy formula. According to the AAP, most colic diminishes spontaneously between four and six months of age.
• The routine use of isolated soy protein­based formula has no proven value in the prevention of atopic disease in healthy or high-risk infants.
• Infants with documented enteropathy or enterocolitis induced by cow's milk protein frequently are as sensitive to soy protein and should not be given isolated soy protein­based formula routinely. They should be provided with formula derived from hydrolyzed protein or synthetic amino acid.
• Most infants with documented IgE-mediated allergy to cow's milk protein will do well on isolated soy protein­ based formula.
• Soy protein­based formulas are not designed or recommended for preterm infants who weigh less than 1,800 g (4 lb). The AAP states that the newer cow's milk protein­based formulas designed for preterm infants are better.

Copyright © 1998 by the American Academy of Family Physicians.
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