Preventing Cardiovascular Disease in Women: American Heart Association Guidelines

Awareness of the risks and consequences of heart disease in women has been growing. The percentage of women who were aware that cardiovascular disease (CVD) is their leading cause of death nearly doubled between 1997 and 2006, from 30% to 55%.¹ Most women also reported taking steps to lower CVD risk in family members and themselves.¹ Unfortunately, 45% of women still don't know that CVD is their greatest health risk, and awareness is much lower among African American and Hispanic women than white women (38% and 34% vs 62%, respectively).¹

In a 2005 survey, physicians did not rate themselves as very effective in helping their patients prevent CVD.² While physicians recommend lifestyle and preventive pharmacotherapy based on their perceived risk levels for their patients, primary care physicians (PCPs) were significantly more likely to assign intermediate-risk women to a lower risk category than men with identical risk profiles.² Additionally, only 60% of PCPs were even aware of the American Heart Association (AHA) women's CVD prevention guidelines.² Therefore, it's crucial that PCPs adopt a more aggressive approach to addressing CVD in women. This issue of Know Her Heart presents an overview of the AHA's "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update,"³ highlighting some key changes from the 2004 guidelines.

Updated Classification of CVD Risk in Women

The classification of women's risk has been changed for the 2007 guidelines:

The 2004 classification was based on clinical criteria and/or the Framingham risk score.³ The rationale for changing the classification scheme includes several factors:

1. Because the average lifetime risk for CVD in women is very high (39%), prevention is important in all women.^3,5
2. Most clinical trial data used to formulate the recommendations included women at high risk because of known CVD or apparently healthy women with a spectrum of risk, which allowed the current scheme to align the guidelines with the evidence.³
3. There has been growing awareness of the limitations of Framingham risk stratification in diverse female populations, including a narrow focus on short-term cardiac-event risk, exclusion of family history, overestimation/underestimation of risk in nonwhite populations, and the documentation of subclinical disease among many women who score as low risk.^3,6

Notable Guideline Changes

The key changes from the 2004 guidelines are summarized below³:

1. The approach to risk stratification of women places greater emphasis on lifetime risk rather than on short-term absolute risk.
2. Revisions reflect the more definitive data published in recent years about menopausal, aspirin, and folic acid therapies.
3. An algorithm is included to help healthcare providers evaluate CVD risk in women and prioritize preventive interventions.

New Algorithm for CVD Preventive Care in Women^3*

*ACE=angiotensin-converting enzyme; BMI = body mass index; BP = blood pressure; HDL = high-density lipoprotein cholesterol; LDL = low-density lipoprotein cholesterol.

†Class I: Intervention is useful and effective. Class II: Weight of evidence/opinion is in favor of usefulness/efficacy; or usefulness/efficacy is less well established by evidence/opinion.

Adapted from Mosca L, et al. Circulation. 2007;115(11):1481-1501.
 

Addressing Barriers to CVD Prevention

According to the AHA, healthcare providers and policymakers should address barriers to optimal health in women.¹ Lack of adherence to prevention guidelines should be discussed with women.³ Low awareness among some populations remains an obvious barrier. Other important barriers, identified in a recent study, include¹:

• Too much confusion regarding CV health in the media (49%)
• The belief that a higher power determines one's health (44%)
• Family obligations/others to take care of (42%)
• Some women don't perceive themselves to be at risk (36%)
• Women's healthcare providers did not explain that CV health was important (25%), or they did not clearly explain how to change their risk (19%)

Improving women's CV health will take a concerted effort. Healthcare providers, policymakers, and patients all have roles to play in maximizing adherence to CVD preventive interventions and reducing the burden of CVD.³
 

References
1. Mosca L, Mochari H, Christian A, et al. National study of women's awareness, preventive action, and barriers to cardiovascular health. Circulation. 2006;113(4):525-534. 2. Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111(4):499-510. 3. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115(11):1481-1501. 4. Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109(5):672-693. 5. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006;113(6):791-798. 6. Sibley C, Blumenthal RS, Bairey Merz CN, Mosca L. Limitations of current cardiovascular disease risk assessment strategies in women. J Womens Health (Larchmt). 2006;15(1):54-56.