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Am Fam Physician. 1999;60(6):1846

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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Copyright © 1999 by the American Academy of Family Physicians.

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