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.