Lifelong CVD Prevention

Lifelong risk—and how to assess, communicate, and minimize that risk—is the mantra of the American Heart Association (AHA) 2007 guidelines for preventing cardiovascular disease (CVD) in women.

Developed by a multidisciplinary group of authors, these guidelines incorporate the most recent, high-quality research data and suggest a lifelong approach for preventing and treating CVD in the female population.¹

“The lifetime risk of dying of cardiovascular disease is nearly one in three for women,” notes lead author Lori Mosca, MD, PhD, director of preventive cardiology at New York-Presbyterian Hospital, in an AHA written statement.²

It's never too early to start preventing heart disease, reminds guidelines co-author Nora Keenan, PhD, an epidemiologist at the Centers for Disease Control and Prevention's division for heart disease and stroke prevention. “These recommendations pertain to adult women who should limit CVD risk factors beginning at age 20.”

“No question, there is a price to be paid for our behavior in our 20s,” says Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA, of Northwestern University in Evanston, Ill. “Young people with worse lifestyles and worse risk factors in their 20s have substantially more atherosclerosis in their 30s and 40s.”³

Therefore, it is critical for patients to understand lifetime risk, adds Lloyd-Jones, of Northwestern's department of preventive medicine and Bluhm Cardiovascular Institute in Chicago. Equally important is that clinicians continue to communicate lifetime risk factors to their patients, he adds.

FIRST, CALCULATE RISK LEVEL

Determining lifetime risk status involves factors beyond the traditional Framingham risk score—a remarkable tool for predicting absolute 10-year risk for a major coronary event, says Lloyd-Jones. “But for anybody under age 50, and for many women under age 60, it is going to be a low number simply because they are young.”

And “telling someone their heart attack risk in the next 10 years is 3% is not likely to motivate them to change their behavior,” Lloyd-Jones adds.³

What might persuade people to alter their lifestyle, however, is a longer-term perspective of risk that accounts for their individual history of diet, level of physical activity, weight, and smoking status; family medical history; symptoms of cardiovascular disease; physical examination of blood pressure, body mass index (BMI), and waist size; laboratory assessments of lipoproteins and glucose; a Framingham risk assessment; and screening for depression.¹

The AHA guidelines provide an algorithm for care that lists women at high risk if they have established coronary heart disease, cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm, end-stage or chronic renal disease, diabetes mellitus, or a 10-year Framingham global risk >20%.

Women with one or more major CVD risk factors—cigarette smoking, poor diet, physical inactivity, obesity (especially central adiposity), hypertension, dyslipidemia, or a family history of CVD in a male relative <55 years and/or a female relative <65 years; or with subclinical vascular disease, cardiometabolic risk, or tests indicating poor exercise capacity—all fit into the at risk category.

Women with none of the above listed major CVD risk factors, a Framingham global risk of <10%, and a healthy lifestyle have optimal risk.

Ultimately, however, “nearly all women are at risk for CVD,” the authors of the guidelines write, “which underscores the importance of a heart-healthy lifestyle.”¹

Such a lifestyle requires smoking cessation and avoidance of tobacco smoke; maintaining a diet rich in vegetables, fruits, and whole-grain/high-fiber foods and eating oily fish twice a week; limiting daily total saturated fat to <10% (<7% optimally) of energy and trans fat to <1%, cholesterol to <300 mg, and sodium to <2.3 g (about 1 tsp salt); and drinking no more than one alcoholic drink per day.

A heart-healthy lifestyle also incorporates 30 minutes of moderate-intensity exercise daily (60–90 minutes to lose or sustain weight loss), and maintaining BMI of 18.5–24.9 and waist circumference ≤35 in (88.9 cm).

PHARMACOTHERAPY FOR SOME

The guidelines suggest the use of aspirin therapy, unless contraindicated, in women at high risk of CVD and for women ≥65 years with controlled blood pressure, provided ischemic stroke/myocardial infarction (MI) prevention benefits outweigh gastrointestinal bleeding and hemorrhagic stroke risk. They also list specific pharmacotherapy interventions for women unable to maintain optimal blood pressure (<120/80 mmHg) and optimal lipid levels (LDL cholesterol <100mg/dl; HDL cholesterol >50 mg/dl; triglycerides <150 mg/dl, non-HDL cholesterol <130 mg/dl) through lifestyle interventions, and for women with diabetes mellitus who are unable to achieve glycated hemoglobin (A1C) <7% without significant hypoglycemia through lifestyle interventions and antidiabetic medications.

Conversely, the guidelines do not recommend hormone therapy or selective estrogen-receptor modulators, antioxidant vitamins, or folic acid with or without vitamin B6 and B12 supplementation, or aspirin for MI prevention in healthy women <65 years.

“The goal is to get more people to middle age with good-looking risk factors,” says Lloyd-Jones, and “this really comes down to risk communication.” Fifty-year-old women who run the optimal risk have an 8% risk of any CVD over their remaining lifespan regardless of how long that may be, he notes. Their peers with two or more major risk factors, however, have a 50% risk.³ ▪

CVD Facts

1. Among 2,679 men and women, those maintaining a stable body mass index (BMI) had a 2.2% incidence of cardiometabolic risk over 15 years, compared with 18.8% among those with increased BMI.¹

2. Among women identifying barriers to making changes to improve their cardiovascular health, 25% said their health care provider did not say such action was important. But of those who took action to lower cardiovascular disease risk, 46% did so at the suggestion of their health care provider.²