assessment, prevention and intervention
TRANSCRIPT
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Evidence-Based Guidelines for Cardiovascular Disease
Prevention in Women
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Objectives
To present strategies to assess and stratify women into high risk, at risk, and optimal risk categories for cardiovascular disease
To summarize lifestyle approaches to the prevention of cardiovascular disease in women
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Objectives
To review evidence-based approaches to cardiovascular disease prevention for patients with hypertension, lipid abnormalities, and diabetes
To review an evidence-based approach to pharmacological risk intervention for women at risk for cardiovascular events
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Objectives
To summarize commonly used therapies that shouldnot be initiated for the prevention or treatment ofheart disease, because they lack benefit, or becauserisks outweigh benefits
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Cardiovascular Disease Mortality: U.S. Males and Females 1980-2004
400,000
450,000
500,000
550,000
1980 1985 1990 1995 2000 2004
MenWomen
Source: Adapted from Rosamond 2008
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Annual Numbers of U.S. Adults Diagnosed with Myocardial Infarction and Fatal CHD by Age and Sex Categories: 1987-2004
0
100,000
200,000
300,000
35-44 45-64 65-74 75+
MenWomen
Source: Adapted from Rosamond 2008
Age in Years
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Racial and Ethnic Groups
Cardiovascular disease is the leading cause of death for African Americans, Latinos, Asian Americans, Pacific Islanders, and American Indians
African American women are at the highest risk for death from heart disease among all racial, ethnic, and gender groups
Source: Rosamond 2008
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Age-adjusted Death Rates for Leading Causes of Death in White and Black/African American Women: U.S. 2004
0
50
100
150
CHD Stroke LungCancer
BreastCancer
Black/AfricanAmerican WomenWhite Women
Source: Adapted from American Heart Association 2008
Per100,000Population
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Women Received Less Interventions to Prevent and Treat Heart Disease Less cholesterol screening Less lipid-lowering therapies Less use of heparin, beta-blockers and
aspirin during myocardial infarction Less antiplatelet therapy
for secondary prevention Fewer referrals to cardiac rehabilitation Fewer implantable cardioverter-defibrillators compared
to men with the same recognized indications
Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008
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Acute MI Mortality by Age and Sex
0
5
10
15
20
25
30
<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age
Death During Hospitalization
(%)
Men
Women
Source: Adapted from Vaccarino 1999
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Evidence-based Guidelines for Cardiovascular Disease Prevention
in Women: 2007 UpdateMosca L, et al. Circulation 2007; 115:1481-501.
http://www.circ.ahajournals.org
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Cardiovascular Disease Prevention in Women: Current Guidelines A five-step approach
Assess and stratify women into high risk, at risk, and optimal risk categories
Lifestyle approaches recommended for all women Other cardiovascular disease interventions:
treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk
patients Avoid initiating therapies that have been shown
to lack benefit, or where risks outweigh benefits
Source: Adapted from Mosca 2004
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Risk Stratification: High Risk
Diabetes mellitus Documented atherosclerotic disease
Established coronary heart disease Peripheral arterial disease Cerebrovascular disease Abdominal aortic aneurysm
Includes many patients with chronic kidney disease, especially ESRD 10-year Framingham global risk > 20%, or high risk based on another population-adapted global risk assessment tool
Source: Mosca 2007
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Risk Stratification: At Risk:
> 1 major risk factors for CVD, including: Cigarette smoking Hypertension Dyslipidemia Family history of premature CVD (CVD at < 55 years
in a male relative, or < 65 years in a female relative) Obesity, especially central obesity Physical inactivity Poor diet
Metabolic syndrome Evidence of subclinical coronary artery disease (eg coronary
calcification), or poor exercise capacity on treadmill test or abnormal heart rate recovery after stopping exercise
Source: Mosca 2007
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Definition of Metabolic Syndrome in Women
Abdominal obesity - waist circumference > 35 in. High triglycerides ≥ 150mg/dL Low HDL cholesterol < 50mg/dL Elevated BP ≥ 130/85mm Hg Fasting glucose ≥ 100mg/dL
Source: AHA/NHLBI 2005
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Risk Stratification:
Optimal risk: No risk factors Healthy lifestyle Framingham global risk < 10%
Source: Mosca 2007
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Risk Stratification
Calculate 10 year risk for all patients with two or more risk factors that do not already meet criteria for CHD equivalent
Use electronic calculator for most precise estimate: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Source: Mosca 2004
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Lifestyle Interventions
Smoking cessation Physical activity Heart healthy diet Weight reduction/maintenance
Source: Mosca 2007
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Relative Risk of Coronary Events for Smokers Compared to Non-Smokers
3.12
5.48
1
0
1
2
3
4
5
6
Never Smoked 1-14 Cigarettes perday
15 Cigarettes perday
Relative Risk
Source: Adapted from Stampfer 2000
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Smoking
All women should be consistently encouraged to stop smoking and avoid environmental tobacco The same treatments benefit both women and men Women face different barriers to quitting
Concomitant depression Concerns about weight gain
Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or other formal smoking cessation program
Source: Fiore 2000, Mosca 2007
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Risk Reduction for CHD Associated with Exercise in Women
00.10.20.30.40.50.60.70.80.9
1
1 2 3 4 5Quintile Group for Activity (MET - hr/wk)
Walking
Any PhysicalExercise
Source: Manson 1999
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Physical Activity
Consistently encourage women to accumulate a minimum of 30 minutes of moderate intensity physical activity on most, or preferably all, days of the week
Women who need to lose weight or sustain weight loss should accumulate a minimum of 60-90 minutes of moderate-intensity physical activity on most, and preferably all, days of the week
Source: Mosca 2007
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Body Weight and CHD Mortality Among Women
5.8
4.6
3.1
1.411
0
1
2
3
4
5
6
19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32
BMI
Relative Risk of CHD
Mortality Compared to
BMI<19
P for trend < 0.001
Source: Adapted from Manson 1995
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Weight Maintenance/Reduction Goals
Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavioral programs when indicated to maintain: BMI between 18.5 and 24.9 kg/m² Waist circumference < 35 inches
Source: Mosca 2007
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Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
1 2 3 4 5
Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes)
RelativeRisk of MI*
*Adjusted for other cardiovascular risk factors
Source: Akesson 2007
P< .05 for quintiles 3-5 comparedto 1-2
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Diet Consistently encourage healthy eating patterns
Healthy food selections: Fruits and vegetables Whole grains, high fiber Fish, especially oily fish, at least twice per week No more than one drink of alcohol per day Less than 2.3 grams of sodium per day
Saturated fats < 10% of calories, < 300mg cholesterol Limit trans fatty acid intake (main dietary sources are baked
goods and fried foods made with partially hydrogenated vegetable oil)
Source: Mosca 2007
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Major Risk Factor Interventions Blood Pressure Lipids Diabetes
Source: Mosca 2007
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Hypertension
Encourage an optimal blood pressure of < 120/80 mm Hg through lifestyle approaches
Pharmacologic therapy is indicated when blood pressure is > 140/90 mm Hg or an even lower blood pressure in the setting of diabetes or target-organ damage (> 130/80 mm Hg)
Thiazide diuretics should be part of the drug regimenfor most patients unless contraindicated, or unless compelling indications exist for other agents
For high risk women, initial treatment should be with a beta-blocker or angiotensin converting enzyme inhibitor or angiotensin receptor blocker
Source: Mosca 2007
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Lifestyle Approaches to Hypertension in Women
Source: JNC VII 2004, Sacks 2001, Mosca 2007
Maintain ideal body weight Weight loss of as little as 10 lbs reduces blood pressure
DASH eating plan Even without weight loss, a diet rich in fruits, vegetables, and low
fat dairy products can reduce blood pressure
Sodium restriction to 2300 mg/d Further restriction to 1500 mg/d may be beneficial, especially in
African American patients
Increase physical activity
Limit alcohol to one drink per day Alcohol raises blood pressure One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor
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DASH Diet with Low Sodium Intake in Hypertensive Individuals Compared to Control Diet with Average U.S. Sodium Intake
-12.6
-9.5
-14
-12
-10
-8
-6
-4
-2
0
Change in BP
(mm Hg)
Systolic BP
African American Non-African American
* P<.001 from baseline*
Source: Sacks 2001
*
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Lipids
Optimal levels of lipids and lipoproteins in women are as follows (these should be encouraged in all women with lifestyle approaches): LDL < 100mg/dL HDL > 50m/dL Triglycerides < 150mg/d Non-HDL (total cholesterol minus HDL) < 130mg/d
Source: Mosca 2007
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Lipids
In high-risk women or when LDL is elevated: Saturated fat < 7% of calories Cholesterol < 200mg/day Reduce trans-fatty acids
Major dietary sources are foods baked and fried with partially hydrogenated vegetable oil
Source: Mosca 2007
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Lipids
Treat high risk women aggressively with pharmacotherapy LDL-lowering pharmacotherapy (preferably a statin)
should be initiated simultaneously with lifestyle modification for women with LDL>100mg/dl
Source: Mosca 2007
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2004 Update of ATP III
5 recent clinical trials suggest added benefit of optional lowering of cholesterol more than ATP III recommended
Lifestyle changes remain cornerstone of treatment Advises that intensity of LDL-lowering
drug treatment in high-risk and moderately high-risk patients achieve at least 30% reduction in LDL levels
Source: Grundy 2004
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Very High Risk Women
Recent heart attack or known CAD, along with one or more of the following: Multiple major risk factors, particularly in diabetics Severe or poorly controlled risk factors (i.e., continued smoking) Multiple risk factors of the metabolic syndrome, especially
TG > 200 mg/dL AND HDL < 40 mg/dL LDL goal of < 100mg/dL Consider statin, even if LDL < 100mg/dL Optional LDL goal of < 70mg/dL per ATP III 2004 update
Source: Grundy 2004
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High Risk Women
> 20% 10-year risk of CHD CHD, large vessel atherosclerotic disease, DM Goal LDL < 100mg/dL, consider statin
even if LDL< 100 mg/dL
Source: Grundy 2004
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At-Risk Women: Multiple or Severe Risk Factors, 10-20% 10-Year CHD Risk
Initiate drug therapy if LDL > 130 mg/dL after lifestyle therapy
Goal LDL < 100 mg/dL, consider drug therapy if LDL ≥ 100 mg/dL
Source: Grundy 2004, Mosca 2007
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At-Risk Women: Multiple Risk Factors, 10-Year CHD Risk < 10%
Initiate drug therapy if LDL > 160 mg/dL after lifestyle therapy
Source: Grundy 2004, Mosca 2007
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At-Risk Women: No Other Risk Factors, 10-Year CHD Risk < 10%
Initiate drug therapy if LDL > 190 mg/dL after lifestyle therapy
Drug therapy optional for LDL 160-189 mg/dL after lifestyle therapy
Source: Grundy 2004, Mosca 2007
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Diabetes Recommendation: Lifestyle and pharmacotherapy
should be used as indicated in women with diabetes to achieve a HbA1C < 7%, if this can be accomplished without significant hypoglycemia
Source: Mosca 2007
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Coronary Disease Mortality and Diabetes in Women
0
10
20
30
40
50
60
0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23
Duration of Follow-up (yrs)
DiabeticWomenNondiabeticWomen
Source: Krolewski 1991
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Race/Ethnicity and Diabetes
At high risk: Latinas American Indians African Americans Asian Americans Pacific Islanders
Source: American Diabetes Association 2001
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Preventive Drug Interventions
Aspirin – High risk women 75-325 mg/day, or clopidogrel if patient intolerant to aspirin,
should be used in high-risk women unless contraindicated
Aspirin- Other at-risk or healthy women Consider aspirin therapy (81 mg/day or 100 mg every other
day) if blood pressure is controlled and benefit is likely to outweigh risk of GI side effects and hemorrhagic stroke
Benefits include ischemic stroke and MI prevention in women aged > 65 years, and ischemic stroke prevention in women < 65 years
Source: Mosca 2007
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Preventive Drug Interventions for Women with CHD Aspirin Beta-blockers Angiotensin converting enzyme inhibitors Angiotensin receptor blockers
Source: Mosca 2007
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Benefits of ASA in Women with Established CAD
2.7
5.15.1
9.1
0123456789
10
Aspirin No Aspirin
Mortality at 3 Years
Follow-Up (%)
CVDMortality
All CauseMortality
* P = 0.002 **P = 0.0001
*
**
Source: Adapted from Harpaz 1996
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Preventive Drug Interventions
Beta-Blockers Should be used indefinitely in all women after MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated
Source: Mosca 2007
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Preventive Drug Interventions
Angiotensin-Converting Enzyme InhibitorsShould be used (unless contraindicated) after MI, and in those women with clinical evidence of heart failure or an LVEF < 40% or diabetes mellitus
Angiotensin-receptor blockersShould be used in women who cannot tolerate angiotensin-converting enzyme inhibitors after MI, and in those women with clinical evidence of heart failure or an LVEF < 40% or diabetes mellitus, unless contraindicated
Source: Mosca 2007
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Menopausal Hormone Therapy, SERMs and CVD: Summary of Major Randomized Trials Use of estrogen plus progestin associated with
a small but significant risk of CHD and stroke Use of estrogen without progestin associated with
a small but significant risk of stroke Use of all hormone preparations should be limited
to short term menopausal symptom relief Use of a selective estrogen receptor modulator
(raloxifene) does not affect risk of CHD or stroke, but associated with an increased risk of fatal stroke
Source: Hulley 1998, Rossouw 2002, Anderson 2004, Barrett-Connor 2006
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Interventions that are not useful/effective and may be harmful for the prevention of heart disease
Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD
Source: Mosca 2007
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Interventions that are not useful/effective and may be harmful for the prevention of heart disease Antioxidant supplements and folic acid
supplements No cardiovascular benefit in randomized trials of primary
and secondary prevention
Source: Mosca 2007
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Stratify women into high, at risk, and optimal risk categories
Encourage lifestyle approaches
Treat hypertension, lipid abnormalities, and diabetes
Implement pharmacologic interventions for women at high and intermediate risk, pharmacologic interventions may be appropriate for some lower risk women
Avoid initiating therapies without benefit, or where risks outweigh benefits
Prevention of Cardiovascular Disease in Women
Source: Mosca 2007
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The Heart Truth Professional Education Campaign Website
http://www.womenshealth.gov/hearttruth