Special Medical Reports

AHA and ACC Issue Scientific Statement on Preventive Cardiology for Women
Verna L. Rose

The American College of Cardiology (ACC) and the American Heart Association (AHA) have issued a scientific statement calling for action against missed opportunities to prevent heart disease in women. The statement, "AHA/ACC Guide to Preventive Cardiology for Women," was produced in conjunction with the American Medical Women's Association, American College of Nurse Practitioners, American College of Obstetricians and Gynecologists and Canadian Cardiovascular Society. The statement, which appears in the May 11, 1999 issue of Circulation and the May 1999 issue of the Journal of the American College of Cardiology, provides updated recommendations intended to help close the gap between what is known to prevent heart disease in women and what actually is being done. The report emphasizes that there is clear evidence that women are not being treated aggressively to prevent heart disease.

The current recommendations were developed from previous guidelines and consensus panel statements along with newer gender-specific data. The scientific bases for these recommendations is available in the 1997 AHA scientific statement "Cardiovascular Disease in Women," published in Circulation 1997;96:2468-82.

The statement includes a table that discusses factors for risk reduction in women, the goals, screening and recommendations. The lifestyle factors include cigarette smoking, physical activity, nutrition, weight management, psychosocial factors, blood pressure, lipids, lipoproteins, diabetes mellitus, and use of hormone replacement therapy, oral contraceptives, antiplatelet agents/anticoagulants, beta blockers and angiotensin-converting enzyme (ACE) inhibitors.

The following are some of the recommendations that are included in the statement:

• A statin or cholesterol-lowering drug should be considered instead of hormone replacement therapy as the first line of drug therapy for lowering high blood levels of cholesterol in postmenopausal women. Hormone replacement therapy is an option for postmenopausal women, but treatment should be individualized and considered with other health risks. In women, the optimal level of triglycerides may be lower (150 mg per dL [1.7 mmol per L] or less), and the optimal level of high-density lipoprotein cholesterol may be higher (at least 45 mg per dL [1.15 mmol per L]).
• At each office visit, strongly encourage patients and their family members to stop smoking. If complete cessation is not achievable, a reduction in intake is beneficial as a step toward cessation. Provide counseling, nicotine replacement and other pharmacotherapy as indicated in conjunction with behavioral therapy or a formal cessation program.
• Because diabetes increases a woman's risk of heart disease three to seven times, it is imperative to increase efforts to identify women who are at risk of coronary disease and provide them with effective treatment. Encourage use of the American Diabetes Association diet (less than 30 percent fat, less than 10 percent saturated fat, 6 to 8 percent polyunsaturated fat, less than 300 mg per day of cholesterol). Encourage regular physical activity and a low-calorie diet to lose weight. Pharmacotherapy with oral agents or insulin should be used when indicated.
• Use of oral contraceptives is relatively contraindicated in women 35 years old or over who smoke. Women with a family history of premature heart disease should have lipid analysis before taking oral contraceptives. Women with significant risk factors for diabetes should have glucose testing before taking oral contraceptives. If a women develops hypertension while using oral contraceptives, she should be advised to stop taking them.
• Beta blockers should be started within hours of hospitalization in women with an evolving myocardial infarction without contraindications. If not started acutely, treatment should begin within a few days of the event and continue indefinitely.
• Start ACE inhibitors early during hospitalization for myocardial infarction unless hypotension or other contraindications exist. Continue indefinitely for all women with left venticular dysfunction or symptoms of congestive heart failure; otherwise, ACE inhibitors may be stopped at six weeks. Discontinue ACE inhibitors if a woman becomes pregnant.

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Advisory Committee on Immunization Practices Updates Recommendations for the Prevention of Varicella
Verna L. Rose

The Advisory Committee on Immunization Practices (ACIP) has updated recommendations for the use of varicella (chickenpox) vaccine. The updated recommendations, published in the May 28, 1999 issue of the reports and recommendations series of Morbidity and Mortality Weekly Report, establish child care and school entry requirements for varicella vaccine, recommend use of the vaccine following exposure and for outbreak control, recommend use of the vaccine for some children infected with the human immunodeficiency virus (HIV), and recommend vaccination of adults and adolescents at high risk for exposure. The report also contains discussions on reporting postlicensure adverse events, development of herpes zoster and transmission of vaccine virus. The following information has been taken from the ACIP report:

• ACIP recommends that all states require children who will be entering day care facilities and elementary schools either receive varicella vaccine or have other reliable evidence of immunity to varicella. Other evidence of immunity is defined by ACIP as a physician's diagnosis of varicella, a reliable history of the disease or serologic evidence of immunity. It is also recommended that states consider having a policy that requires evidence of varicella vaccination or other evidence of immunity for children entering middle school.
• ACIP now recommends that the vaccine be given to susceptible persons following exposure to varicella. If the exposure does not cause varicella infection, the postexposure vaccination should protect against subsequent exposure. Although postexposure use could apply to hospital settings, ACIP recommends routine vaccination of all susceptible health care workers and vaccination is the preferred method for preventing varicella in a health care setting.
• State and local health departments should consider using varicella vaccine for outbreak control either by advising exposed susceptible persons to receive the vaccination from their physician or by offering vaccination through the health department. The National Immunization Program of the Centers for Disease Control and Prevention (CDC) does provide guidelines for varicella outbreak investigation and control.
• ACIP has designated susceptible persons aged 13 years and older who live in households with children as a new high-risk group who need to receive the varicella vaccine. The other high-risk groups include (a) persons who live or work in environments where transmission of varicella zoster virus is likely; (b) persons who live and work in environments where transmission can occur; (c) nonpregnant women of childbearing age; and (d) international travelers.
• ACIP has also recommended that the vaccine be made available to children with humoral immunodeficiencies and selected children with HIV infection (i.e., in CDC Class N1 or A1, with age-specific CD4 T-lymphocyte percentages of 25 percent or more). The recommendations regarding use of varicella vaccine in persons with other conditions associated with altered immunity (e.g., immunosuppressive therapy) or in persons receiving steroid therapy have not changed.

Adverse Events

The Vaccine Adverse Event Reporting System (VAERS) can provide data on potential adverse events. The CDC reports that during March 1995 through July 1998, a total of 9.7 million doses of varicella vaccine were distributed in the United States. VAERS received 6,580 reports of adverse events; 4 percent of these events were serious. Most of the reports were in children under 10 years. The most frequently reported adverse event was rash.

While transmission of the vaccine virus is rare, the CDC has documented three occasions of transmission (out of 15 million doses of varicella vaccine). All three cases resulted in mild disease without complications, according to ACIP. Secondary transmission has not been documented in the absence of a vesicular rash after vaccination.

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