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Progress continues in the advancement of CV prevention in women
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Substantial progress has been made in the awareness, treatment and prevention of CVD in women since the first recommendations for CVD prevention were published by the American Heart Association in 1999. However, despite advancements in the understanding and knowledge of CVD in women, challenges remain.
In 2011, an AHA task force released a necessary update to the Effectiveness-based Guidelines for Cardiovascular Disease Prevention in Women. The female-specific clinical recommendations were first issued in 2004, updated in 2007 and again in 2011.
Two notable updates warrant attention. Women are now classified as “at risk” if they have systemic autoimmune collagen-vascular disease (eg, lupus or rheumatoid arthritis) and/or history of preeclampsia, gestational diabetes or pregnancy-induced hypertension. The guideline recommends screening for women with autoimmune conditions and appropriate referral and monitoring in the years after pregnancy for women with pregnancy-induced complications. Physicians can use the new classification to place a woman in the at-risk group, although she might have a low cholesterol level or Framingham risk score. At the practitioner level, using these two additional risk factors to classify women as at risk will ultimately allow me to treat more women.
C. Noel Bairey Merz
Additionally, the guidelines feature class III interventions deemed not useful or effective and possibly harmful for the prevention of CVD in women. These include: menopausal therapy (hormone therapy and selective estrogen-receptor modulators); antioxidants (vitamin C, E and beta-carotene); folic acid, with or without B6 and B12 supplementation; and aspirin for MI in younger women.
Importantly, the 2011 update includes a new overarching strategy of classifying CVD risk in women: high risk, at risk and ideal CV health. Formerly, the classification was high, intermediate and low risk, and based on time-limited risk prediction (10-year risk). The new classification system tells us about lifetime risk. There is a paradoxical statistic that the majority of US women are at low risk for CVD, yet the majority of US women die of CVD.
These guidelines provide an opportunity to do even better when it comes to the care and prevention of CVD in women. Moving forward, with these guidelines embedded into our systems of care, the electronic health record may now point out that 62-year-old patient who had preeclampsia during her first pregnancy decades ago is at risk for CVD.
CV risk and surgery
Recent data have confirmed that prophylactic bilateral oophorectomy at the time of clinically indicated hysterectomy as a precautionary measure against ovarian cancer jeopardizes long-term health. This issue has been asked and answered throughout the years in a number of ways. Now, a 2013 study published by Parker et al in Obstetrics & Gynecology reiterates the growing concern.
In the prospective cohort study of more than 30,000 Nurses’ Health Study participants, hysterectomy and bilateral oophorectomy was associated with lower mortality risk from ovarian cancer and breast cancer before age 47 years, but heightened risk for death from CHD (HR=1.23), lung cancer (HR=1.29), colorectal cancer (HR=1.49), total cancers (HR=1.16) and all causes (HR=1.13) during an average 28 years of follow-up. Further study of 23,000 healthy women later in life revealed that 80% of CVD deaths and 80% of all deaths occurred 15 or more years after hysterectomy; in these women, oophorectomy was linked to a greater risk for CVD (HR=1.14) and all-cause (HR=1.09) death.
The conclusion was, for women not at markedly elevated risk for ovarian or breast cancer, bilateral oophorectomy should be discouraged. When you remove a woman’s ovaries, the leading cause of death is CVD. Cardiologists should be aware of this. While these data are not completely new, they hammer the nail into the coffin. Future update of CVD prevention guidelines for women will likely list bilateral oophorectomy as a risk factor.
Hormone safety
Emerging research suggests that low-dose estrogen may be safer, which goes in hand with the class III guideline recommendation against use of menopausal therapy for the prevention of CVD in women.
Chrisandra L. Shufelt, MD, MS, the Women’s Health Initiative investigators and I published an abstract in Menopause that analyzed the relationship between estrogen dose and risk for CHD, stroke and venous thromboembolism. The study included more than 93,000 postmenopausal women followed for a mean of 5.5 years. Low-dose estrogen in women assigned estrogen/progestin was associated with a lower risk for CHD and VTE compared with higher-dose estrogen. Progestin dose was not associated with CV events.
Research on the association between hormone therapy dose and CVD outcomes is limited. These results indicate that relatively lower doses of estrogen may lower CV event risk. This study is currently in press. Future analyses and follow-up will focus on the role of different hormone therapy formulations and routes of delivery.
The future of female CVD care
The good news is that we have a much better fund of knowledge about CVD prevention in women than ever before. We continue to gather quantitative and scientific information, and more women are participating in CVD research trials so that more definitive recommendations can be made.
Disclosure: Bairey Merz reports no relevant financial disclosures.