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February 15th, 2011

AHA Releases Updated Guidelines for the Prevention of CV Disease in Women

Newly published online in Circulation, updated AHA guidelines for the prevention of cardiovascular disease in women emphasize practical medical advice. “These recommendations underscore the fact that benefits of preventive measures seen day-to-day in doctors’ offices often fall short of those reported for patients in research settings,” said Lori Mosca, chair of the guidelines writing committee, in an AHA press release. “Many women seen in provider practices are older, sicker, and experience more side effects than patients in research studies. Factors such as poverty, low literacy level, psychiatric illness, poor English skills, and vision and hearing problems can also challenge clinicians trying to improve their patients’ cardiovascular health.” The guidelines state that some once-common therapies are not effective and may be harmful when used for the prevention of cardiovascular disease in women, including:

  • Hormone therapy and selective estrogen-receptor modulators (SERMSs)
  • Antioxidant supplements
  • Folic acid
  • Routine use of aspirin to prevent MI in women <65

The guidelines incorporate information about lupus, rheumatoid arthritis, and pregnancy complications in the evaluation of risk in women. “These have not traditionally been top of mind as risk factors for heart disease,” said Mosca in the press release.

The document also incorporates the impact of racial and ethnic diversity on cardiovascular disease in women, including the significant impact of hypertension in African-American women and diabetes in Hispanic women.

Categories: Prevention
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3 Responses to “AHA Releases Updated Guidelines for the Prevention of CV Disease in Women”

  1. Richard Kones, MD PhD says:
    February 17, 2011 at 2:34 am

    This new update is a welcome educational and reference resource. How far we have come from the dark ages–not too long ago–when women were regarded as “small men!”
    Widened scope and emphasis on practical application makes this “edition” even more valuable.
    Richard Kones

  2. William L Blanchet, MD says:
    February 18, 2011 at 10:39 pm

    I respect the efforts of the authors and the quality of the information going into these guidelines however how does this improve delivery of care? If only 4% of women are considered at “optimal risk”, are we really going to improve the discrimination of risk and the initiation of preventive therapies based on these guidelines?

    Atherosclerosis imaging was give minimal lip service in this publication however the potential immense value of atherosclerosis imaging was not adequately addressed.

    Competing interests pertaining specifically to this post, comment, or both:
    I use EBT CAC and carotid ultrasound to accurately assess coronary risk and I find these tools to be essential in the decision to implement preventive therapies.

  3. Erling Falk, MD, PhD says:
    February 22, 2011 at 10:18 am

    This 2011 Update represents a dramatic change in risk stratification for primary prevention of cardiovascular disease (CVD) in women. The previous 2004 and 2007 guidelines used the definition of High Risk based on hard coronary heart disease (CHD) endpoints, i.e., 10-year risk of myocardial infarction or coronary death >20%. The 2011 updated guideline lowers this threshold to >10% and, furthermore, changes the endpoint from “hard CHD” to the much more common endpoint “all CVD”, including hard CHD, coronary insufficiency, angina, stroke, transient ischemic attack, heart failure, and claudication.

    The SHAPE Task Force welcomes the much needed update of existing guidelines for risk assessment of asymptomatic individuals. However, it raises serious concerns about the new AHA women’s guideline since an arbitrary change in the definition of High Risk is likely to result in massive overtreatment and undue “High Risk” labeling of many otherwise healthy women. For example, a 65year old non-smoking, non-diabetic, non-hypertensive woman with a total cholesterol of 200 mg/dl and HDL of 49 mg/dl who lives an active lifestyle would now be classified as High Risk. In contrast, the same individual would be defined as Low Risk by the 2010 ACCF/AHA and NCEP guidelines. More importantly, the new guidelines do not take into account the fact that such an individual’s risk could be better refined by screening for subclinical atherosclerosis.

    SHAPE recommends that the new AHA women’s guideline be amended to prevent undesired consequences. It should include noninvasive detection of subclinical atherosclerosis, through coronary artery calcium scoring or measurement of carotid plaque and intima-media thickness (IMT), to improve individual risk assessment in this population. Such an amendment would be in line with the 2010 ACCF/AHA guidelines for assessment of cardiovascular risk in asymptomatic adults in which testing for subclinical atherosclerosis (coronary artery calcium scoring and carotid plaque/IMT) received a strong evidence based (level IIa) recommendation.

    The new AHA women’s guideline criticizes the absence of outcome studies for risk assessment based on testing for subclinical atherosclerosis. However, it fails to acknowledge that the approach for risk assessment which uses Framingham Risk Score and NCEP guidelines has also never been demonstrated to improve outcomes in clinical trials.

    In conclusion, given the large, consistent and growing body of evidence showing that testing for subclinical atherosclerosis is a more accurate method of predicting atherosclerotic cardiovascular events than testing only for traditional risk factors of atherosclerosis, the SHAPE Task Force respectfully urges the responsible authorities at the AHA to address the following question:

    Is it reasonable, cost-effective and ethically acceptable to arbitrarily label millions of women as being “High Risk” for atherosclerotic cardiovascular events without testing them for subclinical atherosclerosis?

    On behalf of the Society for Heart Attack Prevention and Eradication (SHAPE) Task Force:

    Erling Falk, MD, Cardiovascular Pathologist, Aarhus, Denmark, Chief of Editorial Committee
    Prediman K. Shah, MD, Cardiologist, Los Angeles, CA, Chair of Scientific Board

    Competing interests pertaining specifically to this post, comment, or both:
    No COI.