Health care professionals should focus on women's lifetime heart disease risk, not just short-term risk, according to updated American Heart Association guidelines.
The 2007 Guidelines for Preventing Cardiovascular Disease in Women published today in a special women's health issue of Circulation: Journal of the American Heart Association also include new directions for using aspirin, hormone therapy and vitamin and mineral supplements in heart disease and stroke prevention in women.
"The updated guidelines emphasize the lifetime risk of women, not just the more short-term focus of the 2004 guidelines," said Lori Mosca, M.D., Ph.D., director of preventive cardiology at New York-Presbyterian Hospital and chair of the American Heart Association expert panel that wrote the guidelines. "We took a long-term view of heart disease prevention because the lifetime risk of dying of cardiovascular disease (CVD) is nearly one in three for women. This underscores the importance of healthy lifestyles in women of all ages to reduce the long-term risk of heart and blood vessel diseases."
The guidelines include a new paradigm for risk assessment based on risk factors and family history, as well as the Framingham risk score. (First published in 1998, the Framingham risk score estimates the risk of developing coronary heart disease within 10 years.)
The new guidelines include expanded recommendations on lifestyle factors such as physical activity, nutrition and smoking cessation, as well as more in-depth recommendations on drug treatments for blood pressure and cholesterol control.
Furthermore, guidelines on hormone and aspirin therapy and antioxidant and folic acid supplements are revised based on recently published data.
"Since the last guidelines were developed, more definitive clinical trials became available to suggest that health care providers should consider aspirin in women to prevent stroke," Mosca said. "In addition, providers should not use menopausal therapies such as hormone replacement therapy (HRT) or selective estrogen receptor modulators (SERMs) such as raloxifene or tamoxifene to prevent heart disease because they have been shown to be ineffective in protecting the heart and may increase the risk of stroke."
A recent American Heart Association survey showed that women are confused about methods to prevent heart disease including the role of aspirin, hormones and dietary supplements.
"The new guidelines reinforce that unregulated dietary supplements are not a method proven to prevent heart disease. For example, recent studies have shown that folic acid is ineffective to protect the heart despite widespread use by patients and physicians hoping for a heart benefit," Mosca said. "These recent findings emphasize the importance of using well-conducted clinical trial data to develop national recommendations to help patients and their doctors use best practices to prevent heart disease practices based on data rather than myth or wishful thinking."
CVD is the largest single cause of mortality among women, accounting for 38 percent of all female deaths. The public health impact of CVD in women is not solely related to mortality, as advances in science and medicine allow many women to survive heart disease. For example, in the United States 42.1 million (36.6 percent) women live with CVD and the population at risk is even larger.
In fact, "nearly all women are at risk for CVD, underscoring the importance of a heart-healthy lifestyle in everyone," the authors wrote. "Some women are at significant risk of future heart attack or stroke because they already have CVD and/or multiple risk factors. These women are candidates for more aggressive preventive therapy and we define them as high risk."
Physicians can easily identify high-risk women, but tools to determine other levels of risk are limited, Mosca said. The authors have aligned their recommendations with treatments proven to work and give strong advice for what not to do, as well.
"Therefore, we have more aggressive recommendations for high-risk women, and strongly emphasize lifestyle strategies to reduce risk in all women," she said.
"Medicine is still an art but these guidelines are meant to guide health care professionals on the best science available."
Highlights of the changes include:
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From the women's focus issue of Circulation: Journal of the American Heart Association
FOR RELEASE: 4 p.m. EST, Feb. 19, 2007
Age, not disparity in care, determines a woman's risk of death after heart attack
While women are typically referred for artery re-opening procedures less often than men after a heart attack, this disparity in care doesn't appear to be the main reason for women's higher rate of death after a heart attack, according to a team of French researchers. Instead, they suggest that a woman's age at the time of her heart attack is the key factor determining her chance of survival.
It's generally accepted that women who have a heart attack are more likely to die than their male counterparts. The reasons given for this difference have been that women are typically older than men when they have heart attacks, they more frequently have other medical conditions in addition to heart disease, and they are less likely to be treated with percutaneous coronary intervention (PCI) a procedure that re-opens blocked arteries. Disparities in care have been suspected as a key culprit for the difference in heart attack deaths between the genders.
Researchers analyzed data from 74,389 heart attack patients in France, 30 percent of whom were women. As expected, women were older than men (75 vs. 63 years) and were more likely to die in the hospital (14.8 percent vs. 6.1 percent). Furthermore, just 4.8 percent of women received PCI, vs. 7.4 percent of men. According to their calculations, researchers determined that women with heart attacks died almost twice as often as men (95 percent higher death rate). The researchers also used the information from the study to simulate data, calculating PCI and death rates as if the women were "treated like men." In their simulation models they found that just 0.46 percent of the women's excess mortality was due to reduced use of PCI. They also found that when PCI was done, women benefited from it less than men did.
They concluded that the difference in death rates between men and women after a heart attack is due largely to the difference in age when the heart attacks occur. They also said that women could benefit from more frequent use of PCI, although these procedures appear less protective than in men. Gender differences in hospital mortality and use of percutaneous coronary intervention in acute myocardial infarction: Microsimulation analysis of the 1999 nationwide French hospitals database
Contact information: Carine Milcent, Ph.D., PSE Paris-Jourdan Sciences Economiques; 011 33 1 43 13 63 31; email@example.com. (Please do not publish contact information.)
Estrogen gene affects risk of breast cancer, but not CVD
A large Danish study rebuts the accepted idea that differences in an estrogen gene (ESR1) affect the risk of heart attack and stroke in response to hormone replacement therapy. However, the study found that the gene may be associated with an increased risk of breast cancer. The two forms of the ESR1 gene, called alleles, are the C allele and the T allele. A person has two copies of any gene; thus, someone can have two copies of the C allele (CC), two of the T allele (TT), or one of each (CT).
Estrogens are important hormones that take action when they come in contact with estrogen receptors on the body's cells. They influence multiple organ systems in men and women, including cardiovascular, reproductive and skeletal systems. Therefore, genetic differences in estrogen receptors could influence risk of cardiovascular disease (CVD), cancer of reproductive organs and osteoporosis-linked bone fracture in the presence of supplemental hormone therapy.
In the largest and statistically most powerful study addressing whether risk of disease is associated with ESR1 gene type, researchers followed 2,495 patients with ischemic heart disease, 856 with ischemic cerebrovascular disease (including stroke) and 1,256 with breast cancer for up to 25 years. They also gathered data on 9,244 people from the Danish general population.
The researchers compared rates of CVD (heart attack, angina, stroke, venous thromboembolism), cancer of reproductive organs (breasts, ovaries, uterus and prostate), and hip fracture among the different groups, according to their ESR1 gene type. In the general population, 21 percent of people were CC, 50 percent were CT and 29 percent were TT.
The researchers found that differences in the ESR1 receptor gene do not influence high density lipoprotein cholesterol response to hormone replacement therapy or risk of CVD, most cancers of reproductive organs or hip fracture. However, the odds for breast cancer in women with TT were 40 percent higher than in women with CC.
Estrogen receptor alpha polymorphism and risk of cardiovascular disease, cancer, and hip fracture: cross-sectional, cohort and case-control studies and a meta-analysis
Contact information: Børge G. Nordestgaard, professor, chief physician, Department Clinical Biochemistry, Herlev University Hospital; Denmark; 011 45-44-883-297; firstname.lastname@example.org. (Please do not publish contact information.)
Prehypertension is "on the map" of cardiovascular risk factors
According to researchers studying postmenopausal women in the Women's Health Initiative, prehypertension exists in about 40 percent of postmenopausal women and it is associated with a 58 percent higher risk of cardiovascular death, regardless of ethnicity, compared to normal blood pressure.
Using the most recent definitions for hypertension, normal blood pressure is systolic pressure (the top number in a blood pressure reading) less than 120 mm Hg and diastolic (bottom number) less than 80 mm Hg; prehypertension is systolic pressure of 120-139 or diastolic 80-89 mm Hg; and hypertension is systolic pressure of 140 mm Hg or higher, or diastolic pressure of 90 mm Hg or higher or currently taking antihypertensive medication.
"Is the cardiovascular risk with blood pressures slightly above 120/80 mm Hg clinically important enough to justify the label of prehypertension?" asked the study authors. "The increased cardiovascular risk with prehypertension is certainly smaller than the risk associated with having diabetes (158 percent higher risk), but is greater than that associated with smoking (34 percent higher). Since smoking is pretty much unchallenged as a cardiovascular risk factor, perhaps prehypertension should be afforded the same acceptance."
Researchers studied 60,785 postmenopausal women in the Women's Health Initiative during a 7.7-year follow-up. At the start of the study, 26 percent had normal blood pressure, 39 percent had prehypertension and 35 percent had hypertension. Prehypertension rates among women of different ethnic groups were 39.5 percent for whites, 32.1 for blacks, 42.6 for Hispanics, 38.7 for American Indians and 40.3 percent for Asians.
Women with higher blood pressures were more likely to be older, have higher body mass index, diabetes or high cholesterol. Smoking was more common among women with normal blood pressure (10 percent).
The 10-year incidence of cardiovascular events was 3.63 percent for women with normal blood pressure, 7.11 percent for women with prehypertension; and 14.16 percent for women with high blood pressure.
Compared to women with normal blood pressure, prehypertensive women of any ethnicity had a 58 percent higher risk of cardiovascular death: 76 percent higher risk of heart attack; 93 percent higher risk of stroke; 36 percent higher risk for being hospitalized with heart failure; and 66 percent higher risk for any cardiovascular event. Even after adjusting for age, body mass index, diabetes, high cholesterol and smoking status, prehypertension was independently associated with a higher risk of cardiovascular events.
Prehypertension and cardiovascular disease risk in the women's health initiative
Contact information: Judith Hsia, M.D., George Washington University, (202) 741-2323, email@example.com. (Please do not publish contact information.)
Calcium and vitamin D supplements don't affect heart disease risk
Calcium/vitamin D supplementation neither increased nor decreased heart disease and stroke risk in generally healthy postmenopausal women over seven years of use.
While calcification in blood vessels and heart valves increases a person's risk for coronary events, the relationship between dietary calcium and cardiovascular events is uncertain.
Researchers evaluated the risk of coronary and cerebrovascular events in 36,282 postmenopausal women in the Women's Health Initiative randomized trial of calcium plus vitamin D supplementation. The women were 50-79 years old. Half took 500mg calcium carbonate with 200 IU vitamin D twice daily; the other half took a placebo.
After seven years, the rates of heart attack and stroke were similar in both groups. There were 499 heart attacks and 362 strokes among women taking calcium/vitamin D and 475 heart attacks and 377 strokes among women taking placebo.
"Calcium and vitamin D supplementation did not increase the risk for heart attack, CHD death, stroke, coronary revascularization, hospitalization for chest pain, heart failure or transient ischemic attack," said the study authors. "Thus, women taking these supplements need not fear adverse cardiovascular consequences while protecting their bone health."
Calcium/vitamin D supplementation and cardiovascular events
Contact information: Judith Hsia, M.D., George Washington University, (202) 741-2323, firstname.lastname@example.org. (Please do not publish contact information.)
Hormone therapy may be safer with patch than pill
Transdermal estrogen, delivered by a patch or gel, is not associated with an increased risk of blood clots in veins, according to French researchers. The blood clots, called venous thromboembolism (VTE), are only a risk when taking estrogen by mouth.
Data from this multicenter case-control study of VTE among postmenopausal women also suggest that micronised progesterone and pregnane derivatives (medroxyprogesterone acetate) appear safe with respect to thrombotic risk. However, norpregnane derivatives cause clots.
The researchers looked at data on 271 women with first-ever VTE, and compared them to 610 women without VTE. The women in the EStrogen and THromboEmbolism Risk (ESTHER) study, which involved women 45 to 70 years old and was conducted between 1999 and 2005 in France.
Compared with women not taking estrogen replacement, those who used oral estrogen had a 4.2 times higher risk of VTE, while women using transdermal estrogen had 0.9 times the risk. The researchers found no significant association of VTE with micronised progesterone and pregnane derivatives. By contrast, norpregnane derivatives were associated with a 4-fold-increased VTE risk.
"If confirmed," said the authors, "these findings could benefit women in the management of their menopausal symptoms."
Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens. The ESTHER Study Contact information: Pierre-Yves Scarabin, M.D., Inserm Unit 780, Cardiovascular Epidemiology Section, 011 33 1 45 59 51 66; email@example.com. (Please do not publish contact information.)
Statements and conclusions of study authors published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
This 2007 update provides the most current clinical recommendations for preventing CVD in women 20 and older and are based on a systematic search of the highest quality science interpreted by experts in the fields of cardiology, epidemiology, family medicine, gynecology, internal medicine, neurology, nursing, public health, statistics and surgery.
The authors note that these guidelines cover the primary and secondary prevention of chronic atherosclerotic vascular diseases. Recommendations for managing vascular disease before or after cardiac procedures or post-hospital and valvular heart disease are covered in other American Heart Association guidelines.
Co-authors of the 2007 guidelines are Carole L. Banka, Ph.D.; Emelia J. Benjamin, M.D.; Kathy Berra, M.S.N., N.P.; Cheryl Bushnell, M.D.; Rowena J. Dolor, M.D., M.H.S.; Theodore G. Ganiats, M.D.; Antoinette S. Gomes, M.D.; Heather L. Gornik, M.D., M.H.S.; Clarissa Gracia, M.D., M.S.C.E.; Martha Gulati, M.D., M.S.; Constance K. Haan, M.D.; Debra R. Judelson, M.D.; Nora Keenan, Ph.D.; Ellie Kelepouris, M.D.; Erin D. Michos, M.D.; L. Kristin Newby, M.D., M.H.S.; Suzanne Oparil, M.D.; Pamela Ouyang, M.D.; Mehmet Oz, M.D.; Diana Petitti, M.D., M.P.H.; Vivian W. Pinn, M.D.; Rita Redberg, M.D., M.Sc.; Rosalyn Scott, M.D.; Katherine Sherif, M.D.; Sidney Smith, Jr, M.D.; George Sopko, M.D., M.P.H.; Robin H. Steinhorn, M.D.; Neil J. Stone, M.D.; Kathryn Taubert, Ph.D.; Barbara A. Todd, M.S.N., C.R.N.P.; Elaine Urbina, M.D. and Nanette Wenger, M.D. This writing group includes representatives of the following participating organizations and major co-sponsors: The American Heart Association, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Cardiology Foundation, Society of Thoracic Surgeons, American Medical Women's Association, Centers for Disease Control and Prevention, Ad Hoc Writing Group Member, Office of Research on Women's Health, Association of Black Cardiologists, World Heart Federation, National Heart, Lung, and Blood Institute, and American College of Nurse Practitioners, with representation from the American College of Physicians. (Representation does not imply endorsement by the American College of Physicians.)
In addition, this report has been endorsed by: American Academy of Physician Assistants; American Association for Clinical Chemistry; American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Emergency Physicians; American Diabetes Association; American Geriatrics Society; American Society for Preventive Cardiology; American Society of Echocardiography; American Society of Nuclear Cardiology; Association of Women's Health, Obstetric and Neonatal Nurses; Global Alliance for Women's Health; The Mended Hearts, Inc; National Black Nurses Association; National Black Women's Health Imperative; National Women's Health Resource Center; North American Menopause Society; The Partnership for Gender-Specific Medicine at Columbia University; Preventive Cardiovascular Nurses Association; Society for Vascular Medicine and Biology; Society for Women's Health Research; Society of Geriatric Cardiology; Women in Thoracic Surgery; and WomenHeart: the National Coalition for Women with Heart Disease.
Editors Note: In 2004, the American Heart Association launched its multi-tiered cause marketing Go Red For Women movement to raise women's awareness of their risk for heart disease and to help them take action to reduce their risk. For more information on heart disease and stroke or the Go Red For Women movement, call 1-888-MY-HEART or visit goredforwomen.org. The American Heart Association urges Congress to make the No. 1 killer of women a national priority by passing the HEART for Women Act this year. The HEART for Women Act is bipartisan federal legislation that would improve the prevention, diagnosis and treatment of cardiovascular disease in women. For more information, please visit www.heartforwomen.org.
NR07 1118 (Circ/Women's Guidelines 2007/Mosca) Contact information: Dr. Mosca can be reached via her assistant Lisa Rehm at (212) 305-4866 or firstname.lastname@example.org or by calling Bryan Dotson, NewYork-Presbyterian Hospital/Columbia, 212-305-5587, email@example.com. (Please do not publish contact information.)
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