May 14th, 2010
To Treat or Not to Treat: A Poll on Primary Prevention for a Hypothetical Woman
JoAnne M. Foody, MD
Rita Redberg’s recent post, Why I Don’t Recommend Statins for Primary Prevention in Women, has gotten some attention on CardioExchange. In comments on the post, CardioExchange members and contributors support various approaches to preventive interventions for women.
Here’s your chance to weigh in: How would you handle a 65-year-old woman who has reasonably controlled hypertension and is taking amlodipine and HCTZ? She is a nonsmoker and has no history of diabetes and no family history of CAD. LDL, 145; HDL, 48.
And. what if the patient were 59 years old instead of 65? Add a comment to let us know!
One Response to “To Treat or Not to Treat: A Poll on Primary Prevention for a Hypothetical Woman”
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More information is needed. Without knowing her total cholesterol and blood pressure, recommendations are difficult. However, assuming her triglycerides are normal at about 100 mg/dL, and her well controlled BP is 130/80, then her 10 year Framingham risk is 5%. With 2+ risk factors and a 10 year Framingham risk score <10%, her LDL goal is 160. Therefore, the most appropriate intervention here would be intensive counseling and education regarding therapeutic lifestyle changes aimed at diet, exercise and attainment or maintenance of a normal weight.
That is the traditional answer. However, as an aggressive preventive cardiologist, I am worried about my female patients. Women often do not present with “typical” symptoms and are offered appropriate screening and treatment less often. When a woman dies of sudden cardiac death, it is the first presentation of heart disease more than half the time, far more than in men. We are beyond guidelines at this point, so one possible test that could be very revealing would be a carotid IMT or a coronary calcium CT. The former has the advantages of low cost and no radiation. If her arterial age were significantly older than chronologic, and/or if soft plaque were present, then I might consider adding pharmacologic therapy. Also, emerging genomic tests, such as KIF6 or 9p21 might also sway me in favor of a more aggressive treatment stance.
Competing interests pertaining specifically to this post, comment, or both:
consultant to Berkeley HeartLab