Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.
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Transcript of Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.
Evidence-Based Guidelines for Cardiovascular Disease
Prevention in Women
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
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
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
CVD and Other Major Causes of Death for Women in the United States: 2004
0
100,000
200,000
300,000
400,000
500,000
Total CVD CHD Cancer Stroke Asthma +COPD
Source: Adapted from Rosamond 2008
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
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
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
Evidence-based Guidelines for Cardiovascular Disease Prevention
in Women: 2007 UpdateMosca L, et al. Circulation 2007; 115:1481-501.
http://www.circ.ahajournals.org
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
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
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
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
Risk Stratification:
Optimal risk: No risk factors Healthy lifestyle Framingham global risk < 10%
Source: Mosca 2007
Lifestyle Interventions
Smoking cessation Physical activity Heart healthy diet Weight reduction/maintenance
Source: Mosca 2007
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
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
Five A’s
Ask about tobacco use at every visit Advise in a clear and personalized message Assess willingness to quit Assist to quit Arrange follow-up
For more information: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf
Source: Fiore 2000
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
Modifiable Risk Factors: Sedentary Lifestyle 40% of women report no leisure time physical activity
Exercise is less prevalent among white women compared to white men
African American and Hispanic women have the lowest prevalence of leisure time physical activity
Source: U.S. Surgeon General 1996, Rosamond 2008
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
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
Body Weight and CHD Mortality Among Women
7.4
2.6
0
1
2
3
4
5
6
7
8
Wt Gain 10-19kg Wt Gain 20kg
Weight Gain Since Age 18
Relative Risk of CHD
Mortality
P for trend < 0.001
≥
Source: Adapted from Manson 1995
1998
2006
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBehavioral Risk Factor Surveillance SystemBRFSS, 1990-2006
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)
Source: CDC
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
Body Mass Index: Definition
BMI = weight in kilograms divided by the square of the height in meters (kg/m2)
BMI chart showing BMI based on weight in pounds and height in inches available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm
Source: NHLBI
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
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
Major Risk Factor Interventions
Blood Pressure Target BP<120/80 mmHg Pharmacotherapy if BP> 140/90, or > 130/80 in diabetics or
patients with renal disease Lipids
Follow NCEP/ATP III guidelines Diabetes
Target HbA1C<7%, if this can be accomplished without significant hypoglycemia
Source: Mosca 2007
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
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
DASH Eating Plan
7–8 servings of grains, grain products daily
4–5 servings of vegetables daily
4–5 servings of fruits daily
2–3 servings of low-fat or nonfat dairy foods daily
≤ 2 servings of meats, poultry, fish daily
4–5 servings of nuts, seeds, legumes weekly
Limited intake of fats, sweets
Source: NHLBI 1998
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
*
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
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
Approximate and Cumulative LDL Cholesterol Reduction Achievable By Dietary ModificationDietary Component Dietary Change Approximate
LDL Reduction
MajorSaturated fat <7% of calories 8-10%Dietary cholesterol <200 mg/day 3-5%Weight reduction Lose 10 lbs 5-8%
Other LDL-lowering optionsViscous fiber 5-10 g/day 3-5%Plant/sterol 2g/day 6-15% stanol esters
Cumulative estimate 20-30%
Source: Adapted from ATP III 2002
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
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
Race/Ethnicity and Diabetes
At high risk: Latinas American Indians African Americans Asian Americans Pacific Islanders
Source: American Diabetes Association 2001
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
Women’s Health Initiative Estrogen and Progestin Arm: Absolute Excess Risk
Excess CHD events: 7/10,000 woman-years
Excess stroke events : 8/10,000 woman-years
Excess pulmonary emboli: 8/10,000 woman-years
Excess invasive breast cancer: 8/10,000 woman-years
Source: Writing Group for the WHI Investigators 2002
Women’s Health Initiative Estrogen and Progestin Arm: Absolute Benefits
Fewer colorectal cancers: 6/10,000 woman-years
Fewer hip fractures: 5/10,000 woman-years
Source: Writing Group for the WHI Investigators 2002
Women’s Health Initiative: Estrogen Alone in Postmenopausal Women Compared to Placebo: Major Clinical Outcomes
0.61
0.77
0.91
1.04
1.08
1.39
0 0.5 1 1.5 2
Stroke
Colorectal Cancer
Total Mortality
CHD
Breast Cancer
Hip Fracture
Relative Risk Compared to Placebo
*
* P < .05*
Favors Treatment Favors Placebo
Source: Adapted from WHI Steering Committee 2004
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 is associated with an increased risk of fatal stroke
Source: Hulley 1998, Rossouw 2002, Anderson 2004, Barrett-Connor 2006
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
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
The NORVIT Trial: Homocysteine Lowering Did Not Reduce Cardiovascular Events in Women with Prior MI
0
0.2
0.4
0.6
0.8
1
1.2
Folic Acid and B12 Folic Acid, B12, and B6
RelativeRisk of CVD Event
*Compared to B12 alone
Source: Bonaa 2006
* **
**Compared to placebo
Reproductive Age Women and CHD
Over 10,000 reproductive age women suffer MI or fatal CHD each year
All women of reproductive age prescribed drug therapy should be counseled about preconception planning, as many recommended drugs are contraindicated during pregnancy
Reproductive age women with CHD who are pregnant or planning pregnancy should be cared for by health care providers with expertise in both cardiovascular disease and obstetrics (team approach)
Source: American Heart Association 2008, Pregler 2005
The Heart Truth Professional Education Campaign Website
http://www.womenshealth.gov/hearttruth
Conclusions
Gender differences exist in diagnosis, treatment, and prognosis of CHD
Knowledge of gender differences is essential for appropriate therapy
Evidence-based guidelines provide a framework for prevention and treatment of cardiovascular disease in women