cardiovascular disease prevention in women

Cardiovascular Disease Prevention in Women

A Paradigm Shift in Risk Assessmentfrom the 2011 Guideline Update

Karen E. Aspry, M.D., M.S., ABCL, FACCAsst. Professor of Medicine—Alpert Medical School

Rhode Island Cardiology Center

>10% Risk of CVD / 10 YrsPregnancy ComplicationsLow Exercise Tolerance Poor DietObesityLupus

Normal BPNormal BMINo Smoking

Normal LipidsDASH-Like Diet

Exercise 150 Min/Week

Sources: CDC/NCHS, AHA Heart Disease and Stroke Statistics, 2011

Cardiovascular Disease Mortality in Women and Men in the U.S.

Recent Progress − 1999 - 2007

Coronary disease mortality rates have increased among middle aged women, and in-hospital mortality during AMI remains higher in women vs. men < 75 years

Stroke prevalence is higher in women, with 55,000 more women experiencing a stroke each year

CV risk factors (obesity, hypertension, hyperlipidemia, physical inactivity) are more prevalent in women

Awareness of CV risk among women remains low, with only 16% identifying CHD as their # 1 health threat

Cardiovascular Disease Morbidity and Mortality in Women

Current and Future Challenges

AHA Guidelines for CV Disease Prevention in Women

Prevention scope is wider

Risk assessment shifts to prediction of global CVD

Low risk category is strictly defined

High and intermediate risk categories expand

Interventions are valued for clinical effectiveness

Diversity and disparities are recognized

Education and adherence are addressed

Cost efficacy is discussed

Key Features of the 2011 Update

Cardiovascular Risk Assessment

and Risk Classification in Women

2011 AHA Guideline Update

Estimated 10 Yr Risk of CHD (via ATP III Risk Score) in a 55 Year Old Female Smoker with Abnormal Blood Lipids and Blood Pressure

www. nhlbi.nih.gov

Cavanaugh-Hussey, MW et al. Preventive

Medicine 2008:47:619.

2011 Guideline Update CHD Risk Scores Underestimate

Global CV Risk in Primary Prevention Women

NATIONAL CHOLESTEROL EDUCATION PROGRAMThird Report of the Expert Panel on

Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

Estimated 10 Year Risk of CVD (via updated Framingham Score) in a 55 Year Old Female Smoker with Abnormal Blood Lipids and Blood Pressure

www.framinghamheartstudy.org

10 Year Risk

2011 Guideline Update Use a Global Cardiovascular Risk Score

To Predict Risk in Primary Prevention Women

Estimated 10 Year Risk of CVD (via the Reynolds Risk Score) in a 55 Year Old Female Smoker with Abnormal Blood Lipids and Blood Pressure

www.reynoldsriskscore.org

2011 Guideline Update Use a Global Cardiovascular Risk Score

To Predict Risk in Primary Prevention Women

Gender O Male Female

Age

Did your Mother or Father have a heart attack before age 60? Yes O No

Systolic Blood Pressure mmHg

HDL or “Good” Cholesterol mg/dL

Do you currently smoke? Yes O No

55

150

Total Cholesterol mg/dL22045

High Sensitivity mg/LC-Reactive Protein (hsCRP) 6

10 Year Risk (age 55) of a heart attackstroke or other heart disease event is 14%

Ideal CV Health (all)

Normal BP, Lipids, FBS, BMI, DASH-Type Diet, Non-Smoker, Exercise 75-150 min / week

Risk Categories and Criteria – 2011 CVD Prevention in Women

NEW

At Risk (any 1) Cigarette SmokingBP > 120 / >80 mmHg, or on treatmentCholesterol > 200 mg/dl or HDL<50 mg/dl, or treatedPremature CAD in 1st degree relativeObesity or Metabolic SyndromePoor DietPhysical InactivityAdvanced Subclinical Atherosclerosis on ImagingPoor Exercise Tolerance on ETTPregnancy-Induced HTN, Pre-Eclampsia or DMCollagen Vascular Disease (RA or SLE)NEW

NEW

High Risk (any 1) CHD, Cerebrovascular disease, PAD or AAADiabetes MellitusESRD or CKD10 Yr Predicted CVD Risk > 10%NEW

Mosca, L. et al. JACC

2011; 57:1404.

2011 Guideline Update Lowering the Threshold for ‘High Risk’*

Reflects the High Lifetime Incidence of CVD in Middle Age Women With Risk Factors

Lloyd-Jones D M et al. Prediction of Lifetime Risk of CVD by Risk Factor Burden

at Age 50. Circulation2006;113:791-798.

0.7

0.6

0.5

0.4

0.3

0.2

0.1

Attained Age, Years

50 60 70 80 90

50%

39%

27%

8%

Cumulative Incidence of CVD by Risk Factor (RF) Burden at Age 50 In Women in the Framingham Study (N=4,362)

BP >160/100, TC>240, Smoking, or DM BP 140/90-160/100, TC 200-240, non-smoker, no DMBP <140/90, TC<200 non-smoker, no DMBP <120/80, TC< 180, non-smoker, no DM

*to >10% / 10 Yrs= >30% / 30 Yrs

Except for those with DM, all

would have a <20% 10 Yr Risk of CVD at age 50

2011 Guideline Update Classification of Pre-Eclampsia as

a Risk Factor is Supported by Observational Studies Showing Increased CHD Rates

From:

Bellamy L et al. BMJ 2007;

335:974.

Systematic Review of Pre-Eclampsia and Relative Risk of CHDin 8 Cohort Studies (n=121,487 cases) with Mean FU 11.7 YrsStudy Total # Cases /

Women with Pre-Eclampsia

Total # Cases / Women With No Pre-Eclampsia

Hannaford, 1997 69 / 2371 216 / 14,831

Irgens, 2001 27 / 24,155 325 / 602,117

Smith, 2001 12 / 22,781 31 / 106,509

Wilson, 2003 26 / 1,043 10 / 796

Kestenbaum, 2003 35/20,552 64/92,902

Funai, 2005 41 / 1,070 269 / 35,991

Ray, 2005 228 / 36,982 1,262 / 950,885

Wirkstrom, 2005 176 / 12,533 2,306 / 383,081

Total (95% CI)Heterogeneity Test

Test for Overall Effect

614 / 121,487X2=9.6, P 0.21

Z=10.00, P 0.001

4,483 / 2,187,112

2011 Guideline Update Classification of RA and SLE as Risk Factors

is Supported by Observational Studies Showing Increased Relative Risk of MI*

Adjusted* Relative Risk of First MI Among Women with Confirmed RA In the Nurses’ Health Study (N=114,342)

Solomon, DH et al. Circulation 2003; 107:1303-07.

Myocardial Infarctions No RA RA P

Incidence/100,000 person-years 96 272

Adjusted RR 1.0 (ref) 2.0 0.0025

**Adjusted for Age, DM, Hyperlipidemia, Hypertension, Parental history of MI, Smoking, Physical activity, BMI, use of ASA, steroids, and NSAIDS, and intakes of vitamin E, folate and Omega-3-FAs

Interventions for Preventionof CV Disease in Women

2011 AHA Guideline Update

Class I

Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa

Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb

Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III

Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administeredSINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A: Multiple randomized clinical trials or meta-analyses provide dataMultiple populations evaluated

Level B: Single randomized trial or nonrandomized studies provide data Limited populations evaluated

Level C: Consensus of opinion, case studies, or standard of care provide data Very limited populations evaluated

Recommendation Classification and Level of Evidence

Level of Evidence (LOE):

Interventions Level of Evidence

Menopausal TherapyHormone Replacement Therapy or SERMs

III A

Anti-Oxidant SupplementsVitamin E, Vitamin C, Beta-Carotene

III A

Folic Acid III A

Aspirin in At Risk Women Age < 65 III B

Class III RecommendationsTreatment Not Useful and May Be HarmfulClass III RecommendationsTreatment Not Useful and May Be Harmful

JACC 2011; 57:1404-23

Diet and Lifestyle Interventions Class, LOE

Smoking Cessation Counsel and provide nicotine replacement and pharmacotherapy I, BPhysical Activity Advise 150 min/week of moderate or 75min/week of vigorous exercise, and muscle strengthening 2 days/week

I, B

Diet and Supplements Advise a diet rich in fruits, vegetables, whole grains, high fiber foods, and oily fish; low in saturated fat, cholesterol, alcohol, sodium, and sugar; and free of trans-fatsConsider Omega-3-Fatty Acid supplementation

I, B

II b, BWeight MaintenanceAdvise weight loss through exercise, calorie reduction, or behavioral programs to maintain BMI < 25 and waist <35” I, BCardiac Rehabilitation Advise formal on-site or in-home exercise training after a CHD event or CVA, or with symptomatic PAD or chronic angina

I, AJACC 2011; 57:1404-23

Class I and II RecommendationsTreatment Should Be Provided (Class I)

or Is Reasonable (Class IIa) or Can Be Considered (IIb)



Major Risk Factor Interventions Class, LOE

Blood Pressure Control to <120/80mmHgAdvise DASH-diet and lifestyle interventions in allAdvise drugs if BP >140/90 (>130/80 with DM or CKD)

I, BI, A

Lipid Control to LDL<100, TG <150, HDL >50 and Non-HDL to <130mg/dlAdvise diet and lifestyle interventions in allDrugs useful to achieve LDL <100 with CHD Drugs useful to achieve LDL <100 with DM, PVD or Risk >20% Niacin/fibrates useful if HDL<50 or non-HDL>130 in high risk Drugs useful if LDL >130 and Risk is 10-20%Drugs useful if LDL >160 even if Risk is <10%Drugs useful if LDL >190 regardless of risk levelDrugs can be considered if age >60, LDL<130 and hsCRP>2

I, BI, A I, B

IIb, B I, BI, BI, B

IIb, BBlood Glucose Control in Diabetics Advise diet with or without drugs to achieve HgbA1C<7% IIa, B





High Risk

At Risk

?

Preventive Drug Interventions Class, LOE

AspirinShould be used in all women with CHD, unless contraindicatedIs reasonable in women with DM, unless contraindicatedCan be useful in women > 65 years, if BP is controlled May be reasonable for women <65 years for CVA preventionShould be used in women with AF unable to take anti-coagulants

I, AIIa, BIIa, BIIb, BI, A

Anti-Coagulant Therapy for Atrial Fibrillation Should be used in women with AF, stroke risk and low bleeding risk I, ABeta BlockersShould be used for up to 3 years post ACS with normal LVEFShould be used indefinitely with LV failureMay be considered in other women with CHD or vascular disease

I, BI, A

IIb, C ACE Inhibitors or ARBSShould be used if MI, CHF, LVEF<40%, or DM, unless contraindicated I, AAldosterone AntagonistsShould be used post MI with heart failure, unless contraindicated 1, B





Yes

Recent CV Event?

Refer to Cardiac Rehab

Implement Class I Risk Factor and Drug

RecommendationsASA

Beta BlockerACEI or ARB

LDL control to <100

Algorithm for CVD Prevention In Women per

the 2011 Guideline Update

Modified from: JACC 2011; 57:1404-23.

Risk AssessmentCV Symptoms and Depression ScreeningMedical, Pregnancy and Family History

PE including BMI and Waist SizeLabs including FBS and Lipids

CVD Risk Scoring if no CHD, PAD or DM

History of Arial Fibrillation ?

Implement ASA or Anti-Coagulant Therapy

Yes

Implement Diet and Lifestyle Interventions (Class I) For AllSmoking Cessation DASH-type Diet Physical Activity Weight Control

High Risk ?CHD, CVA, PAD or AAA

DM or CKD>10% Predicted Risk of CVD in 10 Yrs

Yes

Yes

Yes

Consider Class II Recommendations

LDL control to <70Drugs to target non-HDL + HDL

Omega-3 fatty acids

At Risk ?Any 1 Risk Factor From Table

Implement Class I Risk Factor

RecommendationsBP control

LDL control to goal

Consider Class II Recommendations

ASATherapy for non-HDL + HDL

(in selected women)

No

Closing the Prevention Gap in Practice Maintain Cost Efficacy Diet and lifestyle changes, aspirin, anti-hypertensive therapies and

generic statins are cost effective in ‘high risk’ women

Make Systems Changes to Implement Guidelines Develop interventions that are multifaceted, interactive,

and incorporate decision support and regular feedback Consider quality reporting to improve performance

Educate Patients to Promote Adherence Recognize low health literacy, cognitive impairment,

psychiatric illness, and caregiver roles as barriers in women Use education, counseling, motivational interviewing,

self monitoring, group visits, and computerized reminders

Recognize Diversity and Disparities Recognize cultural, socioeconomic and age diversity of women and

deliver culturally sensitive care

RequireDelivery System

Re-Design

Summary CV disease mortality in women has decreased in the

last decade but challenges remain

Higher mortality during acute CHD events, higher stroke rates, a higher burden of CV risk factors, and lower awareness of CV risk mandate more aggressive prevention efforts in women

The 2011 update shifts to global CV risk assessment, redefines optimal risk, lowers the threshold for high risk, and adds ‘gender specific’ risk factors

Prevention efforts are likely to be more successful if they incorporate elements of the Chronic Care Model, including team approaches, decision support, patient education, and regular feedback; recognize and respect patient diversity, and maintain cost efficacy

cardiovascular disease prevention in women

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