The way to a woman's (healthy) heart

New research on what to do -- and not to do -- to lower women's risk of heart disease provides an updated base for treatment decisions.

By Susan J. Landers — Posted March 12, 2007

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Revised American Heart Assn. guidelines are intended to stop trouble before it starts.

The directive, "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update," urges physicians and their female patients to focus early on lowering risks as the best way to cut the high toll taken by cardiovascular death and disability. The document was posted online Feb. 19 and scheduled to appear in the March 13 Circulation: Journal of the American Heart Assn.

These guidelines also offer the latest thinking on aspirin use, exercise, hormone therapy and dietary supplements in preventing heart disease. Cardiovascular disease is the largest single cause of death among women worldwide, accounting for 38% of all female deaths, according to the authors. Plus, thanks to medical advances, 42 million women are living with cardiovascular disease in the United States, making the need for guidance vital.

The need for such guidelines exists because physicians should take a different approach to women's heart health for reasons both physical and social, said Paula Miller, MD, director of the Women's Heart Program at the University of North Carolina.

Women's vascular systems are different from men's; women's blood vessels are smaller, and estrogen levels are protective until menopause, she noted. Women also tend to be more isolated and may be less affluent and eat less nutritious food. Plus, awareness of risk continues to be low.

"Women still don't know they are at high risk for heart disease. You ask them what they think they'll die of and they say breast cancer. Statistics show that one in every 30 will die of breast cancer but one in every three will die of cardiovascular disease," Dr. Miller said.

The updated guidelines emphasize a woman's lifetime risk, not just the more short-term focus that was taken by the 2004 guidelines, said Lori Mosca, MD, MPH, PhD, director of preventive cardiology at New York-Presbyterian Hospital and chair of the panel that drafted them.

Also included in the guidelines is a new paradigm for assessing long-term risk that includes family history as well as lifestyle factors and the items in the well-regarded Framingham risk assessment -- age, gender, total cholesterol, HDL cholesterol, smoking status, systolic blood pressure and use of medication to lower blood pressure.

The AHA first published a scientific statement on heart disease in women in 1999 and has updated it periodically since then.

Some cautionary advice

In addition, the guidelines provide a dose of what not to do, said panel member Sidney Smith Jr., MD, director of the University of North Carolina's Center for Cardiovascular Science and Medicine. After sifting through recent findings, panelists determined that hormone therapy and selective estrogen receptor modulators should not be used for primary or secondary prevention of cardiovascular disease.

No evidence indicates that antioxidant supplements -- vitamin E, C and beta carotene -- help prevent heart disease, he added. Nor have recent studies supported the claim that the use of folic acid will head off heart disease, although it is still an important preventive for neural tube defects among newborns. Women of childbearing age still should be counseled to take folate, Dr. Smith said.

The guidelines also caution against the routine use of aspirin among women younger than 65. "That's an important message to get out there," he said. "If you are under age 65 and a woman, don't take aspirin to prevent heart disease, as there is no evidence that it will."

But for all women with known cardiovascular disease or for those at high risk, aspirin use, with a dose ranging from 75 mg to 325 mg, should be considered, Dr. Smith said.

Dr. Miller praised the guidelines for clarifying some gray areas. "The good part about them is that they nail down things that have been ambiguous in the past, especially when to start aspirin therapy and how much exercise is enough." The guidelines recommend 30 minutes of exercise every day and, if a woman wants to lose weight, 60 to 90 minutes per day.

Roger Blumenthal, MD, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease in Baltimore, called the guidelines "a great synthesis" of clinical trial data.

"I especially liked that they made the point that you need to look at long-term risk," he said. "Women should start thinking about preventing the development of risk factors in the first place."

Dr. Blumenthal also applauded a second study on women's heart health in the Feb. 14 Journal of the American Medical Association. Researchers in that investigation devised and tested new algorithms for assessing women's cardiovascular disease risk.

The researchers studied 35 risk factors not included in the Framingham risk score and determined that two of them, family history of heart disease and high levels of C-reactive protein, or CRP -- a measure of inflammation -- provided increased accuracy in predicting future troubles.

The new tool they devised, the Reynolds Risk Score, calculates risk by assessing age, systolic blood pressure, current smoking status, total cholesterol, HDL cholesterol, CRP and whether a parent had a heart attack before age 60.

Although family history is an important risk factor in the new AHA guidelines, CRP didn't make the cut. But evidence is still being assembled on CRP, and the guidelines will be revisited periodically, Dr. Smith said.

Dr. Miller said she already measures CRP levels in women she believes to be at high risk but adds that those findings should be viewed with caution, as high levels could be attributable to some other inflammatory cause such as rheumatoid arthritis.

Back to top


Guideline highlights

  • Routine use of aspirin in healthy women younger than 65 is not recommended to prevent myocardial infarction.
  • Aspirin(81 mg daily or 100 mg every other day) should be considered for women older than 65 if blood pressure is controlled and the benefit for ischemic stroke and myocardial infarction prevention is likely to outweigh the risk of gastrointestinal bleeding and hemorrhagic stroke. Aspirin also is appropriate for women younger than 65 when the benefit for ischemic stroke prevention is likely to outweigh adverse effects.
  • Hormone therapy and selective estrogen receptor modulators should not be used for the primary or secondary prevention of cardiovascular disease.
  • Antioxidant vitamin supplements should not be used for primary or secondary prevention of heart disease.
  • Folic acid, with or without B6 and B12 supplementation, should not be used for the primary or secondary prevention of heart disease. It should still be used for women in their childbearing years to prevent neural tube defects.

Source:"Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update," American Heart Assn.

Back to top

External links

"Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update," abstract, Circulation, published online Feb. 19 (link)

"Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women," abstract, Journal of the American Medical Association, Feb. 14 (link)

Reynolds Risk Score, for calculating women's risk for heart disease and stroke (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn