Updated guidelines for CVD prevention in women encompass clinical practice findings

The 2011 update to the American Heart Association’s guidelines for the prevention of cardiovascular disease in women has incorporated benefits and risks associated with clinical practice findings in addition to those observed in clinical research.

The AHA first published women-specific clinical recommendations for prevention of CVD in 1999. One of the major changes with the present guidelines compared with earlier ones was that the benefits and risks observed in clinical practice of preventive therapies were strongly considered and recommendations were not limited to evidence of benefits observed in clinical research.

“These recommendations underscore the fact that benefits of preventive measures seen day to day in doctors’ offices often fall short of those reported in research settings,” Lori Mosca, MD, MPH, PhD, chair of the guidelines writing committee, said in a press release. “Many women seen in provider practices are older, sicker and experience more side effects than patients in research studies. Factors such as poverty, low literacy level, psychiatric illness, poor English skills, and vision and hearing problems can also challenge clinicians trying to improve their patients’ CV health.”

Criteria for risk

The updated guidelines now include modifications to the risk classification algorithm that acknowledge several 10-year risk equations for predicting 10-year global CVD risk, such as the updated Framingham CVD risk profile and Reynolds risk score for women. The new threshold for defining high risk is ≥10% 10-year risk of all CVD, instead of ≥20% Framingham 10-year predicted risk for CHD alone, which had previously identified women at high risk in the 2007 update.

“Indeed, it is difficult for a woman [younger than] 75 years of age, even with several markedly elevated risk factors, to exceed a 10% (let alone a 20%) 10-year predicted risk for CHD with the Adult Treatment Panel III risk estimator,” the guideline authors wrote.

In addition to recognizing the importance of racial, ethnic and socioeconomic traits in determining a patient’s risk for CVD, the guidelines include several illnesses that put a woman at risk, including gestational diabetes, preeclampsia and pregnancy-induced hypertension, as well as those that put them at high risk, including clinically manifest coronary heart disease and diabetes.

Now the update also includes depression screening as part of an overall evaluation of women for CV risk. Although treating depression has not been shown to directly improve CV risk, depression may affect whether women follow their physicians’ advice.

New considerations

Because most data used to develop these guidelines were based on trials of CHD prevention, the authors said future guidelines “should consider recommendations for specific outcomes of particular importance to women, such as stroke.” This, they said, is particularly critical because 55,000 more women die of stroke than men every year and before they reach the age of 75 years.

“These guidelines are a critical weapon in the war against heart disease,” Mosca said. “They are an important evolution in our understanding of women and heart disease.”

For more information:

• Mosca L. Circulation. 2011;doi: 10.1161/CIR.0b013e31820faaf8.

Disclosure: Read the full document in Circulation for a full list of relevant financial disclosures.

The guidelines are not substantially different from the 2007 version. The authors choose to focus on strategies for guideline implementation and cost-utility description in these updated guidelines.

– C. Noel Bairey Merz, MD

Director, Women’s Heart Center

Director, Preventive and Rehabilitative Cardiac Center, Cedars-Sinai Medical Center

Disclosure: Dr. Bairey Merz reports no relevant financial disclosures.