Guidelines tailor heart health message to women

First came the red ribbon, an emblem now linked worldwide with AIDS awareness. Then there were pink ribbons that focused attention on another cause: breast cancer research and treatment.

Now, it's time for the red dress -- a symbol designed to raise the specter of heart disease for women and inform them that cardiovascular illness persists as their No. 1 killer.

Red dress pins have been visible everywhere this month -- American Heart Month -- as part of a National Heart, Lung and Blood Institute public education campaign co-sponsored by more than 70 other organizations about the dire risks women face. In fact, one in three women dies of heart disease, and two-thirds of women who have heart attacks never fully recover.

For physicians, though, a reminder came from an additional source: new American Heart Assn. guidelines to help them help female patients protect against such dangers.

Specifically, the guidelines, published in last month's Circulation, urged physicians to assess all female patients for disease risk. Those at high risk should be treated aggressively with ACE inhibitors, beta-blockers, statins, aspirin and blood pressure-lowering medications.

"What we must have is the [physician] as a facilitator of risk reduction to reduce the epidemic of death and disability among women," said Nanette Wenger, MD, author of an accompanying editorial and professor of medicine in the division of cardiology at Emory University School of Medicine in Atlanta.

The guidelines come as a response to dismal statistics indicating that approaches based on studies with male subjects in the majority were not proving effective. After all, women are more likely than men to die within a year of a cardiovascular event; they present later in the course of their illnesses and have different symptoms from their male counterparts.

Many experts also felt the limited available gender-specific directives, such as AHA's own 1999 guidelines, were not making a dent in the problem.

The new course of action, which has the backing of more than a dozen medical societies and public health agencies, including the Centers for Disease Control and Prevention, is seen as more individualized.

"Women must understand what their risk level is in order to take steps to lower it," said Lori Mosca, MD, PhD, MPH, lead author and director of preventive cardiology at New York-Presbyterian Hospital/Columbia University Medical Center in New York City.

In general, the marching orders are based on a changing idea of how cardiovascular illness affects each gender. Although there was always recognition that women face some degree of heart disease risk, men were considered in much more jeopardy. Additionally, the prevalent thinking was that women were protected from heart disease by estrogen, and that any increased risk brought on by menopause could be addressed with hormone therapy.

Such conventional wisdom was turned on its ear with findings from the Women's Health Initiative. "Hormones were thought to be the very simple answer to all the problems," said Dr. Wenger. "Now that we have seen that there is no evidence for cardiovascular protection and indeed that there may be harm, we're looking once again at the proved ways of preventing cardiovascular disease."

To this end, the guidelines ask physicians to work aggressively to maintain women's heart health. Smoking cessation, healthy eating, physical activity and weight maintenance should be a priority. These have long been on physicians' agendas, but protecting a woman's heart should give an added reason for them to be at the top of the list.

For those who are at high risk for heart disease, borderline numbers should not be allowed to slide, and physicians should not hesitate to prescribe pharmacologic interventions. And because women are at higher risk of depression and this mental health issue may complicate heart health, all women who already have heart disease should be assessed for depression and treated, if necessary.

Now seeing red

The guidelines were widely praised for bringing coherence to numerous studies and focusing much-needed attention on a disease that is often overshadowed by breast cancer and other conditions that have a lower prevalence rate.

"We need to be aggressive about heart disease, and we need to take a responsibility for shifting women's focus off of the traditional 'pink' things we think about and onto the more significant causes of mortality and morbidity," said Karen DeSalvo, MD, MPH, MSc, chief of the section of general internal medicine and geriatrics at Tulane University in New Orleans. "The focus on women and heart disease is great."

In some ways, the guidelines also represent a step forward for men's health. Several aspects are expected to be reflected in future general population heart health recommendations, such as deferring aspirin therapy except for those at high risk because of the risk of complications, and using pharmacology more aggressively.

"These guidelines are excellent," said Steve Kolar, MD, who serves as executive medical director of the HealthEast Clinics in St. Paul, Minn. "This is care we should aspire to for all our patients."

Still, some physicians expressed reservations about the practicality of using the guidelines. If these guidelines are followed, many more women might end up taking daily medications over the long term -- a step that could have a significant cost burden.

Doctors also are urged to use Framingham Heart Study scoring methods to assess risk, which could take extra time few doctors have to spare.

"Using the Framingham heart calculation is a really complicated tool, and it's just not something that many primary care physicians have been able to adopt," Dr. DeSalvo said. "It would have been nice if they had offered a more simplified approach."

The true challenge at hand, however, might not be to convince physicians that heart health is important, but to convince their patients -- particularly younger women.

"The hardest part is trying to get our patients to understand the importance of following weight control and cholesterol guidelines and protect their heart," said Jyothi Mamide Juarez, MD, an internist at Baylor Medical Center in Garland, Texas. "Sometimes their concerns are more what's bothering them now rather than what could affect their future."