Cardiovascular Disease Prevention in Women
Am Fam Physician. 2007 Apr 1;75(7):984-987.
Recently, the American Heart Association (AHA) published an update to its 2004 guidelines for the prevention of cardiovascular disease in women.1 A summary of the update is available in this issue of American Family Physician.2
The updated guidelines have the support of many participating organizations, including the American Academy of Family Physicians (AAFP), and are a combination of evidence-based medicine and consensus opinion. Whenever such guidelines are written, it is important to consider how the balance between evidence and consensus affects the final product and how we, as family physicians, should view the update.
All of the recommendations specifically address women. This is in response to the neglect of issues that specifically address cardiovascular disease prevention in women; the initial evidence base primarily involved men. This history strengthens the importance of more recent studies that include women and increases the importance of these guidelines for the care of women. However, in focusing on the care of women, family physicians should ensure that they do not neglect the care of men.
Some of the AHA recommendations differ from those of the AAFP. We do not see this as a major flaw, but rather as slightly different lines drawn in shifting sand. For example, the updated AHA guidelines recommend that the A1C level should be less than 7.0 in patients with diabetes, but the AAFP recommends that A1C goals be individualized. These are not necessarily different recommendations because the evidence supporting the AHA's statement is based on consensus rather than on hard science, and this can be seen as supporting the AAFP's position of shared decision making.
Similarly, the AHA guidelines recommend that blood pressure be controlled to less than 130/80 mm Hg in patients with diabetes, whereas the AAFP makes no recommendation for blood pressure control in this group. Other organizations have argued for different cutoff points (e.g., 130/85 mm Hg), and, in fact, the threshold is somewhat arbitrary.3 The point is that blood pressure should be more tightly controlled in patients with diabetes than in those without diabetes, regardless of the sex of the patient.
A flow diagram in the updated guidelines provides another source of potential confusion. The reader should view the diagram as an overview and not as something that dictates a single course of action. The diagram states that glucose can be used to assess the risk of cardiovascular disease. This does not mean that blood glucose should be measured in all women, but rather that the glucose level, if obtained, can be used in risk stratification (e.g., patients with elevated glucose have a higher risk).
The most recent AHA statement on the prevention of cardiovascular disease in women is an important guideline that helps highlight this disease as the leading cause of morbidity and mortality in women. The recommendations provide evidence-based statements that can help inform us in our practice.
editor's note: Dr. Ganiats represented the AAFP on the guideline's expert panel/writing group. Dr. Campos-Outcalt is a scientific analyst for the AAFP.
1. Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation [In press].
2. Damlo S. AHA publishes guidelines on CVD prevention in women. Am Fam Physician. 2007;75:1089–92.
3. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al., for the Joint National Committee on Prevention, Detection Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–52.
Copyright © 2007 by the American Academy of Family Physicians.
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