Assessment, Prevention and Intervention

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  • This slide set was updated in April 2008.
  • SLIDE INFORMATION SOURCE: Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146. This slide shows mortality trends by gender. While mortality in males has been steadily declining over the past 15-20 years, cardiovascular mortality for women remained flat or increased slightly during the 1980s and 1990s. Mortality rates for women have exceeded those for men over the past 20 years.(1). (1) Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146.
  • SLIDE INFORMATION SOURCE: Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146. This slide shows numbers of U.S. men and women diagnosed with myocardial infarction and fatal CHD by age. Although women in general present at later ages than men, over 10,000 reproductive age women per year are diagnosed with myocardial infarction or suffer fatal CHD (1). (1) Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146.
  • SLIDE INFORMATION SOURCE: Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146.
  • SLIDE INFORMATION SOURCE: Rosamond W, et al. Heart disease and stroke statistics– 2008 Update. Circulation 2008; 117: e25-e146.
  • SLIDE INFORMATION SOURCES: Chandra NC, et al. Observations of the treatment of women in the United States with myocardial infarction; a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998; 158:981-988; Nohria A, et al. Gender differences in coronary artery disease in women: gender differences in mortality after myocardial infarction: why women fare worse than men. Cardiol Clin 1998; 16:45-57. Scott LB, Allen JK. Providers perceptions of factors affecting women’s referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehab 2004; 24:387-391. O’Meara JG, et al. Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Arch Intern Med 2004; 164:1313-1318. Hendrix KH, et al. Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethn Dis 2005; 15:11-16, Cho L, et al. Gender differences in utilization of effective cardiovascular secondary prevention: a Cleveland Clinic Prevention Database study. J Womens Health (Larchmt) 2008; 17: 1-7, Hernandez AF, et al. Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. JAMA 2007; 298: 1535-1532, Chou AF, et al. Gender disparities in the quality of cardiovascular disease care in private managed care plans. Womens Health Issues 2007; 17: 120-130.
  • SLIDE INFORMATION SOURCE: Vaccarino V. et al. Sex-based differences in early mortality after myocardial infarction. National registry of myocardial infarction 2 participants. N Engl J Med 1999; 341(4): 217-225. Based on national registry data including 155,565 women and 229,313 men enrolled between June 1994 and January 1998, overall in-hospital mortality during hospitalization for myocardial infarction is 16.7% for women, compared to 11.5% for men(1) Among persons less than 50 years of age, the rate of mortality for women is twice the rate of mortality for men (1). In contrast, for persons over the age of 74 years, there is no statistically significant difference in mortality rates between women and men(1). (1) Vaccarino V. et al. Sex-based differences in early mortality after myocardial infarction. National registry of myocardial infarction 2 participants. N Engl J Med 1999; 341(4): 217-225.
  • An update to evidence-based guidelines for the prevention of cardiovascular disease in women developed in 2004 were published in Circulation in 2007. For the original 2004 guidelines, over 1270 articles were screened by the panel, and 400 articles were included for evidence tables. For the update, new topics were added, and a systematic search on previously identified topics was performed to include the time period from January 2003- June, 2006. A complete listing of references reviewed by the panel is listed at the website (1)(2). Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. (2) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. A five part approach was supported by currently available evidence.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Grundy SM, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation 2005, accessed at www.circulationaha.org on October 25, 2005. The metabolic syndrome is characterized by a constellation of risk factors in one individual. This syndrome increases the risk for CHD at any given LDL-cholesterol level (1). The definition of metabolic syndrome remains controversial. This is the AHA/NHLBI definition. Patients are diagnosed with metabolic syndrome when three of five criteria are met. Patients receiving drug treatment for elevated triglycerides, reduced HDL, hypertension, or high glucose meet the threshhold for each criteria. A cutoff of 31 inches waist circumference for Asian American women should be used(1) (1) Grundy SM, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation 2005, accessed at www.circulationaha.org on October 25, 2005.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007;115: 1481-501.
  • SLIDE INFORMSTION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007;115: 1481-501. These are the Class I lifestyle recommendations applicable to all women (1)(2). Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Stampfer, MJ, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000; 343:16-22. In a cohort study of 84,129 U.S. female registered nurses (Nurses’ Health Study), over 40% of coronary events were found to be attributable to smoking. The relative risk of coronary events for nonsmokers compared to smokers is demonstrated on this slide (1). A prospective cohort study in Demark showed a greater relative risk of myocardial infarction for current female smokers (RR=2.24) compared to current male smokers (RR=1.43) (2). (1) Stampfer, MJ, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000; 343:16-22. (2) Prescott E, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998; 316:1043-1047.
  • SLIDE INFORMATION SOURCE: Fiore MC, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000, Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Manson JE, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341:650-658. Research has shown that, after controlling for other factors that affect heart disease risk, women who walk the equivalent of three or more hours per week have a risk of coronary events that is 35% lower than women who walk infrequently(1) . (1) Manson JE, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341:650-658.
  • SLIDE INFORMATION SOURCE: Mosca L et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Manson JE, et al. Body weight and mortality among women. N Engl J Med 1995; 333:677-685. The participants in this part of the Nurses Health Study were 115,195 women free of diagnosed cardiovascular disease and cancer in 1976, who were followed until 1992 (1). This graph demonstrates mortality among non-smoking women at various BMI. The lowest mortality was seen in women who weighed at least 15% less than the U.S. average, and among those whose weight had been stable since early adulthood (1). (1) Manson JE, et al. Body weight and mortality among women. N Engl J Med 1995; 333:677-685.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Akesson A, et al. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med 2007; 167:2122. In this population-based prospective cohort study of 24,444 postmenpausal women in Sweden, after 6.2 years of follow-up, a low risk diet characterized by a high intake of vegetables, fruit, whole grains, fish, and legumes, as well as moderate alcohol consumption, physical activity, maintaining a healthy weight, and not smoking were associated with lower risk of myocardial infarction. A combination of all healthy behaviors was predicted to prevent 77% of myocardial infarctions in the study population. In this study, only 5% of women had all healthy behaviors. (1) (1) Akesson A, et al. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med 2007; 167:2122.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501. Trans fatty acids are found in hydrogenated vegetable oils and some animal fats(1). Major sources are baked foods like crackers, cookies, doughnuts, breads, and food fried in hydrogenated vegetable oil, like french fires and fried chicken(1). Based on data from randomized trials, trans fatty acids raise LDL cholesterol(1). (1) Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115; 1481-501
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501. These guidelines were adopted from the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure, (JNC 7), published in 2004. Systolic BP is often more difficult to control, but is more of a CVD risk factor in those over age 50 (1). Both systolic and diastolic BP need to be treated to goal levels (1). (1)Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002.
  • SLIDE SOURCE: The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. U.S. Department of Health and Human Services. National Institutes of Health. National Heart, Lung, and Blood Institute, NIH Publication No. 04-5230, 2004, Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Eng J Med 2001 344:3-10., Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Eng J Med 2001; 344: 3-10. The DASH diet combined with low sodium intake is particularly effective in reducing blood pressure in African Americans(1). (1) Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Eng J Med 2001; 344: 3-10.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007: 115; 1481-501. In all women with an elevated LDL cholesterol level, therapeutic lifestyle changes should be instituted (1) Trans-fatty acids should provide less than 1% of energy (1) (1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: Grundy SM, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239. In July, 2004, some elements of the Adult Treatment Panel III were revisited, based on the completion of five clinical trials of cholesterol-lowering statin treatment that have been conducted since the release of the previous guidelines (1). Lifestyle changes are still emphasized, including the adoption of a low saturated fat and low cholesterol diet, increased physical activity and weight control (1). The update offers options for more intensive lowering of cholesterol levels for people at very high risk(1). (1) Grundy SM, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239.
  • SLIDE INFORMATION SOURCE: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239. A new category of “very high risk” was added in the update to ATP III in 2004(1). ATP III was updated based on the publication of five major clinical trials of statin therapy(1). For women determined to be in a this “very-high risk” category lowering the LDL cholesterol to less than 100mg/dl, and as low as 70 mg/dl, may be considered (1) (1) Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239.
  • SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239
  • SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239; Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239; . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239; . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCE: . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCE: Krolewski AS, et al. Evolving natural history of coronary artery disease in diabetes mellitus. Am J Med 1991; 90: 56S-61S. This graph represents results from a study of 116,000 subjects, aged 30-55, who were followed for 8 years (1). The risk of nonfatal and fatal CHD was >6 fold that of women without diabetes (1). Risks for all forms of CVD are elevated in type 1 and type 2 diabetics(2). Diabetics with CHD are more likely to die than non-diabetics with CHD(2). (1) Krolewski AS, et al. Evolving natural history of coronary artery disease in diabetes mellitus. Am J Med 1991; 90: 56S-61S. (2) Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), NIH, NHLBI, 2002.
  • SLIDE SOURCE: American Diabetes Association. Screening for Diabetes. Diabetes Care 2001; 24 Suppl 1:521-4; www.diabetes.org accessed on March 8, 2005. Women of color are at particularly high risk for type 2 diabetes(1). Recommendations for screening for type 2 diabetes can be found at the web site of the American Diabetes Association. (1) www.diabetes.org accessed on March 8, 2005
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501.
  • SLIDE INFORMATION SOURCE: . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCE: Harpaz D, et al. Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Am J Cardiol 1996; 78:1215-1219. This graph shows results of a prospective cohort study of 2,418 women with CAD. Aspirin use significantly decreased both CVD and overall mortality at 3 years of follow-up (1). In the randomized ISIS-2 trial, aspirin use decreased 5-week vascular mortality in women by 16.5% compared to placebo (2).. An overview of randomized trials of antiplatelet therapies published before 1990 suggested that women with prior vascular events randomized to antiplatelet therapy had a 25% reduction in subsequent vascular events (3). (1) Harpaz D, et al. Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Am J Cardiol 1996; 78:1215-1219. (2) ISIS-2 Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither. Lancet 1988; 8607:349-360. (3) Antiplatelet Trialists’ Collaboration. Collaborative overview of randomized trials of antiplatelet therapies in various categories of patients. BMJ 1994; 308:81-106.
  • SLIDE INFORMATION SOURCE: . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501
  • SLIDE INFORMATION SOURCE: . Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007;115: 1481-501
  • SLIDE INFORMATION SOURCES: Hulley S, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998; 280 :605;613.; Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002; 288:321-333.; Women’s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA 2004; 291:1701-1712.,;ACOG Task Force for Hormone Therapy. Summary of Balancing Risks and Benefits. Obstet Gynecol 2004; 104 (4 Suppl): 1S-129S; Barrett-Connor E, et al. Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women N Engl J Med 2006; 355: 125-37.
  • SLIDE INFORMATION SOURCE:Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115: 1481-501. Both the American College of Obstetricians and Gynecologists (ACOG) and the United States Food and Drug Administration (FDA) have concluded that hormone therapy should not be initiated or continued to prevent CVD in post-menopausal women(1,2). The RUTH trial (Raloxifene Use for the Heart) found that raloxifene did not significantly affect the risk of CHD or stroke, but did find an association between the use of raloxifene and fatal stroke, compared to placebo (hazard ratio 1.49, confidence interval 1.00-2.24) (3). (1) American College of Obstetricians and Gynecologists Task Force for Hormone Therapy. Executive summary. Obstet Gynecol 2004; 104(4 Suppl): 1S-4S. FDA approves new labels for estrogen and estrogen plus progestin therapies for postmenopausal women following review of Women’s Health Initiative data. Rockville, Md: Food and Drug Administration, January 8, 2003. Barrett-Connor E,, et al. Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women N Engl J Med 2006; 355: 125-37.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007:;115: 1481-501. The Women’s Health Study, a 10-year randomized double-blind, placebo controlled trial of nearly 40,000 healthy women aged 45 years and older showed no cardiovascular benefit or risk to vitamin E supplementation (600 IU every other day)(1). The HOPE and HOPE-TOO trials performed in patients with CHD equivalent risk also found no benefit(2). Multiple trials have shown no CHD benefit or a trend to harm for folic acid supplementation in patients with coronary artery disease or significant CHD risk(3)(4). (1)Lee IM, et al. Vitamin E in the primary prevention of cardiovascular disease and cancer. JAMA 2005; 294:56-65. (2) Lonn E, et al. Effects of long-term vitamin E supplementation on cardiovascular events and cancer. JAMA 2005;293:1338-1347. (3) Bonaa KH et al. Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med 2006;354:1578-88. (4) Loscalzo J. Homocysteine trials – clear outcomes for complex reasons. N Engl J Med 2006; 354:1629-1632.
  • SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007;115: 1481-501.
  • Information for healthcare providers, including links to resources discussed in this presentation, are available at this site. Also included are links to web-based CME, and resources for health care professional educators, including slide sets and problem-based learning and standardized patient cases.
  • Assessment, Prevention and Intervention

    1. 1. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women
    2. 2. Objectives <ul><li>To present strategies to assess and stratify women into high risk, at risk, and optimal risk categories for cardiovascular disease </li></ul><ul><li>To summarize lifestyle approaches to the prevention of cardiovascular disease in women </li></ul>
    3. 3. Objectives <ul><li>To review evidence-based approaches to cardiovascular disease prevention for patients with hypertension, lipid abnormalities, and diabetes </li></ul><ul><li>To review an evidence-based approach to pharmacological risk intervention for women at risk for cardiovascular events </li></ul>
    4. 4. Objectives <ul><li>To summarize commonly used therapies that should not be initiated for the prevention or treatment of heart disease, because they lack benefit, or because risks outweigh benefits </li></ul>
    5. 5. Cardiovascular Disease Mortality: U.S. Males and Females 1980-2004 Source: Adapted from Rosamond 2008
    6. 6. Annual Numbers of U.S. Adults Diagnosed with Myocardial Infarction and Fatal CHD by Age and Sex Categories: 1987-2004 Source: Adapted from Rosamond 2008 Age in Years
    7. 7. Racial and Ethnic Groups <ul><li>Cardiovascular disease is the leading cause of death for African Americans, Latinos, Asian Americans, Pacific Islanders, and American Indians </li></ul><ul><li>African American women are at the highest risk for death from heart disease among all racial, ethnic, and gender groups </li></ul>Source: Rosamond 2008
    8. 8. Age-adjusted Death Rates for Leading Causes of Death in White and Black/African American Women: U.S. 2004 Source: Adapted from American Heart Association 2008 Per 100,000 Population
    9. 9. Women Received Less Interventions to Prevent and Treat Heart Disease <ul><li>Less cholesterol screening </li></ul><ul><li>Less lipid-lowering therapies </li></ul><ul><li>Less use of heparin, beta-blockers and aspirin during myocardial infarction </li></ul><ul><li>Less antiplatelet therapy for secondary prevention </li></ul><ul><li>Fewer referrals to cardiac rehabilitation </li></ul><ul><li>Fewer implantable cardioverter-defibrillators compared to men with the same recognized indications </li></ul>Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008
    10. 10. Acute MI Mortality by Age and Sex Source: Adapted from Vaccarino 1999
    11. 11. Evidence-based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update <ul><li>Mosca L, et al. Circulation 2007; 115:1481-501. </li></ul><ul><li>http:// www.circ.ahajournals.org </li></ul>
    12. 12. Cardiovascular Disease Prevention in Women: Current Guidelines <ul><li>A five-step approach </li></ul><ul><ul><li>A ssess and stratify women into high risk, at risk, and optimal risk categories </li></ul></ul><ul><ul><li>L ifestyle approaches recommended for all women </li></ul></ul><ul><ul><li>O ther cardiovascular disease interventions: treatment of HTN, DM, lipid abnormalities </li></ul></ul><ul><ul><li>H ighest priority is for interventions in high risk patients </li></ul></ul><ul><ul><li>A void initiating therapies that have been shown to lack benefit, or where risks outweigh benefits </li></ul></ul>Source: Adapted from Mosca 2004
    13. 13. Risk Stratification: <ul><li>High Risk </li></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Documented atherosclerotic disease </li></ul></ul><ul><ul><ul><li>Established coronary heart disease </li></ul></ul></ul><ul><ul><ul><li>Peripheral arterial disease </li></ul></ul></ul><ul><ul><ul><li>Cerebrovascular disease </li></ul></ul></ul><ul><ul><ul><li>Abdominal aortic aneurysm </li></ul></ul></ul><ul><ul><li>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 </li></ul></ul>Source: Mosca 2007
    14. 14. Risk Stratification: <ul><li>At Risk: </li></ul><ul><ul><li>> 1 major risk factors for CVD, including: </li></ul></ul><ul><ul><ul><li>Cigarette smoking </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Dyslipidemia </li></ul></ul></ul><ul><ul><ul><li>Family history of premature CVD (CVD at < 55 years in a male relative, or < 65 years in a female relative) </li></ul></ul></ul><ul><ul><ul><li>Obesity, especially central obesity </li></ul></ul></ul><ul><ul><ul><li>Physical inactivity </li></ul></ul></ul><ul><ul><ul><li>Poor diet </li></ul></ul></ul><ul><ul><li>Metabolic syndrome </li></ul></ul><ul><ul><li>Evidence of subclinical coronary artery disease (eg coronary calcification), or poor exercise capacity on treadmill test or abnormal heart rate recovery after stopping exercise </li></ul></ul>Source: Mosca 2007
    15. 15. Definition of Metabolic Syndrome in Women <ul><li>Abdominal obesity - waist circumference > 35 in. </li></ul><ul><li>High triglycerides ≥ 150mg/dL </li></ul><ul><li>Low HDL cholesterol < 50mg/dL </li></ul><ul><li>Elevated BP ≥ 130/85mm Hg </li></ul><ul><li>Fasting glucose ≥ 100mg/dL </li></ul>Source: AHA/NHLBI 2005
    16. 16. Risk Stratification: <ul><li>Optimal risk: </li></ul><ul><ul><li>No risk factors </li></ul></ul><ul><ul><li>Healthy lifestyle </li></ul></ul><ul><ul><li>Framingham global risk < 10% </li></ul></ul>Source: Mosca 2007
    17. 17. Risk Stratification <ul><ul><li>Calculate 10 year risk for all patients with two or more risk factors that do not already meet criteria for CHD equivalent </li></ul></ul><ul><ul><li>Use electronic calculator for most precise estimate: http:// www.nhlbi.nih.gov/guidelines/cholesterol/index.htm </li></ul></ul>Source: Mosca 2004
    18. 18. Lifestyle Interventions <ul><li>Smoking cessation </li></ul><ul><li>Physical activity </li></ul><ul><li>Heart healthy diet </li></ul><ul><li>Weight reduction/maintenance </li></ul>Source: Mosca 2007
    19. 19. Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Source: Adapted from Stampfer 2000
    20. 20. Smoking <ul><li>All women should be consistently encouraged to stop smoking and avoid environmental tobacco </li></ul><ul><ul><li>The same treatments benefit both women and men </li></ul></ul><ul><ul><li>Women face different barriers to quitting </li></ul></ul><ul><ul><ul><li>Concomitant depression </li></ul></ul></ul><ul><ul><ul><li>Concerns about weight gain </li></ul></ul></ul><ul><li>Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or other formal smoking cessation program </li></ul>Source: Fiore 2000, Mosca 2007
    21. 21. Risk Reduction for CHD Associated with Exercise in Women Source: Manson 1999
    22. 22. Physical Activity <ul><li>Consistently encourage women to accumulate a minimum of 30 minutes of moderate intensity physical activity on most, or preferably all, days of the week </li></ul><ul><li>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 </li></ul>Source: Mosca 2007
    23. 23. Body Weight and CHD Mortality Among Women P for trend < 0.001 Source: Adapted from Manson 1995
    24. 24. Weight Maintenance/Reduction Goals <ul><li>Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavioral programs when indicated to maintain: </li></ul><ul><ul><li>BMI between 18.5 and 24.9 kg/m ² </li></ul></ul><ul><ul><li>Waist circumference < 35 inches </li></ul></ul>Source: Mosca 2007
    25. 25. Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes) Relative Risk of MI* *Adjusted for other cardiovascular risk factors Source: Akesson 2007 P< .05 for quintiles 3-5 compared to 1-2
    26. 26. Diet <ul><li>Consistently encourage healthy eating patterns </li></ul><ul><ul><li>Healthy food selections: </li></ul></ul><ul><ul><ul><li>Fruits and vegetables </li></ul></ul></ul><ul><ul><ul><li>Whole grains, high fiber </li></ul></ul></ul><ul><ul><ul><li>Fish, especially oily fish, at least twice per week </li></ul></ul></ul><ul><ul><ul><li>No more than one drink of alcohol per day </li></ul></ul></ul><ul><ul><ul><li>Less than 2.3 grams of sodium per day </li></ul></ul></ul><ul><ul><li>Saturated fats < 10% of calories, < 300mg cholesterol </li></ul></ul><ul><ul><li>Limit trans fatty acid intake (main dietary sources are baked goods and fried foods made with partially hydrogenated vegetable oil) </li></ul></ul>Source: Mosca 2007
    27. 27. Major Risk Factor Interventions <ul><li>Blood Pressure </li></ul><ul><li>Lipids </li></ul><ul><li>Diabetes </li></ul>Source: Mosca 2007
    28. 28. Hypertension <ul><li>Encourage an optimal blood pressure of < 120/80 mm Hg through lifestyle approaches </li></ul><ul><li>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) </li></ul><ul><li>Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated, or unless compelling indications exist for other agents </li></ul><ul><li>For high risk women, initial treatment should be with a beta-blocker or angiotensin converting enzyme inhibitor or angiotensin receptor blocker </li></ul>Source: Mosca 2007
    29. 29. Lifestyle Approaches to Hypertension in Women Source: JNC VII 2004, Sacks 2001, Mosca 2007 <ul><li>Maintain ideal body weight </li></ul><ul><ul><li>Weight loss of as little as 10 lbs reduces blood pressure </li></ul></ul><ul><li>DASH eating plan </li></ul><ul><ul><li>Even without weight loss, a diet rich in fruits, vegetables, and low fat dairy products can reduce blood pressure </li></ul></ul><ul><li>Sodium restriction to 2300 mg/d </li></ul><ul><ul><li>Further restriction to 1500 mg/d may be beneficial, especially in African American patients </li></ul></ul><ul><ul><li> </li></ul></ul><ul><li>Increase physical activity </li></ul><ul><li> </li></ul><ul><li>Limit alcohol to one drink per day </li></ul><ul><ul><li>Alcohol raises blood pressure </li></ul></ul><ul><ul><li>One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor </li></ul></ul>
    30. 30. DASH Diet with Low Sodium Intake in Hypertensive Individuals Compared to Control Diet with Average U.S. Sodium Intake African American Non-African American * P<.001 from baseline * Source: Sacks 2001 *
    31. 31. Lipids <ul><li>Optimal levels of lipids and lipoproteins in women are as follows (these should be encouraged in all women with lifestyle approaches): </li></ul><ul><ul><li>LDL < 100mg/dL </li></ul></ul><ul><ul><li>HDL > 50m/dL </li></ul></ul><ul><ul><li>Triglycerides < 150mg/d </li></ul></ul><ul><ul><li>Non-HDL (total cholesterol minus HDL) < 130mg/d </li></ul></ul>Source: Mosca 2007
    32. 32. Lipids <ul><li>In high-risk women or when LDL is elevated: </li></ul><ul><ul><li>Saturated fat < 7% of calories </li></ul></ul><ul><ul><li>Cholesterol < 200mg/day </li></ul></ul><ul><ul><li>Reduce trans-fatty acids </li></ul></ul><ul><ul><ul><li>Major dietary sources are foods baked and fried with partially hydrogenated vegetable oil </li></ul></ul></ul>Source: Mosca 2007
    33. 33. Lipids <ul><li>Treat high risk women aggressively with pharmacotherapy </li></ul><ul><ul><li>LDL-lowering pharmacotherapy (preferably a statin) should be initiated simultaneously with lifestyle modification for women with LDL>100mg/dl </li></ul></ul>Source: Mosca 2007
    34. 34. 2004 Update of ATP III <ul><li>5 recent clinical trials suggest added benefit of optional lowering of cholesterol more than ATP III recommended </li></ul><ul><li>Lifestyle changes remain cornerstone of treatment </li></ul><ul><li>Advises that intensity of LDL-lowering drug treatment in high-risk and moderately high-risk patients achieve at least 30% reduction in LDL levels </li></ul>Source: Grundy 2004
    35. 35. Very High Risk Women <ul><li>Recent heart attack or known CAD, along with one or more of the following: </li></ul><ul><ul><li>Multiple major risk factors, particularly in diabetics </li></ul></ul><ul><ul><li>Severe or poorly controlled risk factors (i.e., continued smoking) </li></ul></ul><ul><ul><li>Multiple risk factors of the metabolic syndrome, especially TG > 200 mg/dL AND HDL < 40 mg/dL </li></ul></ul><ul><li>LDL goal of < 100mg/dL </li></ul><ul><li>Consider statin, even if LDL < 100mg/dL </li></ul><ul><li>Optional LDL goal of < 70mg/dL per ATP III 2004 update </li></ul>Source: Grundy 2004
    36. 36. High Risk Women <ul><li>> 20% 10-year risk of CHD </li></ul><ul><li>CHD, large vessel atherosclerotic disease, DM </li></ul><ul><li>Goal LDL < 100mg/dL, consider statin even if LDL< 100 mg/dL </li></ul>Source: Grundy 2004
    37. 37. At-Risk Women: Multiple or Severe Risk Factors, 10-20% 10-Year CHD Risk <ul><li>Initiate drug therapy if LDL > 130 mg/dL after lifestyle therapy </li></ul><ul><li>Goal LDL < 100 mg/dL, consider drug therapy if LDL ≥ 100 mg/dL </li></ul>Source: Grundy 2004, Mosca 2007
    38. 38. At-Risk Women: Multiple Risk Factors, 10-Year CHD Risk < 10% <ul><li>Initiate drug therapy if LDL > 160 mg/dL after lifestyle therapy </li></ul>Source: Grundy 2004, Mosca 2007
    39. 39. At-Risk Women: No Other Risk Factors, 10-Year CHD Risk < 10% <ul><li>Initiate drug therapy if LDL > 190 mg/dL after lifestyle therapy </li></ul><ul><li>Drug therapy optional for LDL 160-189 mg/dL after lifestyle therapy </li></ul>Source: Grundy 2004, Mosca 2007
    40. 40. Diabetes <ul><li>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 </li></ul>Source: Mosca 2007
    41. 41. Coronary Disease Mortality and Diabetes in Women Source: Krolewski 1991
    42. 42. Race/Ethnicity and Diabetes <ul><li>At high risk: </li></ul><ul><ul><li>Latinas </li></ul></ul><ul><ul><li>American Indians </li></ul></ul><ul><ul><li>African Americans </li></ul></ul><ul><ul><li>Asian Americans </li></ul></ul><ul><ul><li>Pacific Islanders </li></ul></ul>Source: American Diabetes Association 2001
    43. 43. Preventive Drug Interventions <ul><li>Aspirin – High risk women </li></ul><ul><ul><li>75-325 mg/day, or clopidogrel if patient intolerant to aspirin, should be used in high-risk women unless contraindicated </li></ul></ul><ul><li>Aspirin- Other at-risk or healthy women </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Benefits include ischemic stroke and MI prevention in women aged > 65 years, and ischemic stroke prevention in women < 65 years </li></ul></ul>Source: Mosca 2007
    44. 44. Preventive Drug Interventions for Women with CHD <ul><li>Aspirin </li></ul><ul><li>Beta-blockers </li></ul><ul><li>Angiotensin converting enzyme inhibitors </li></ul><ul><li>Angiotensin receptor blockers </li></ul>Source: Mosca 2007
    45. 45. Benefits of ASA in Women with Established CAD * P = 0.002 **P = 0.0001 * ** Source: Adapted from Harpaz 1996
    46. 46. Preventive Drug Interventions <ul><li>Beta-Blockers </li></ul><ul><li>Should be used indefinitely in all women after MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated </li></ul>Source: Mosca 2007
    47. 47. Preventive Drug Interventions <ul><li>Angiotensin-Converting Enzyme Inhibitors Should be used (unless contraindicated) after MI, and in those women with clinical evidence of heart failure or an LVEF < 40% or diabetes mellitus </li></ul><ul><li>Angiotensin-receptor blockers </li></ul><ul><li>Should 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 </li></ul>Source: Mosca 2007
    48. 48. Menopausal Hormone Therapy, SERMs and CVD: Summary of Major Randomized Trials <ul><li>Use of estrogen plus progestin associated with a small but significant risk of CHD and stroke </li></ul><ul><li>Use of estrogen without progestin associated with a small but significant risk of stroke </li></ul><ul><li>Use of all hormone preparations should be limited to short term menopausal symptom relief </li></ul><ul><li>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 </li></ul>Source: Hulley 1998, Rossouw 2002, Anderson 2004, Barrett-Connor 2006
    49. 49. Interventions that are not useful/effective and may be harmful for the prevention of heart disease <ul><li>Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD </li></ul>Source: Mosca 2007
    50. 50. Interventions that are not useful/effective and may be harmful for the prevention of heart disease <ul><li>Antioxidant supplements and folic acid supplements </li></ul><ul><ul><li>No cardiovascular benefit in randomized trials of primary and secondary prevention </li></ul></ul>Source: Mosca 2007
    51. 51. <ul><li>Stratify women into high, at risk, and optimal risk categories </li></ul><ul><li>Encourage lifestyle approaches </li></ul><ul><li>Treat hypertension, lipid abnormalities, and diabetes </li></ul><ul><li>Implement pharmacologic interventions for women at high and intermediate risk, pharmacologic interventions may be appropriate for some lower risk women </li></ul><ul><li>Avoid initiating therapies without benefit, or where risks outweigh benefits </li></ul>Prevention of Cardiovascular Disease in Women Source: Mosca 2007
    52. 52. The Heart Truth Professional Education Campaign Website http:// www.womenshealth.gov/hearttruth
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