Broader Classification

The American Heart Association’s new 2007 guidelines update the 2004 recommendations for preventing cardiovascular disease (CVD) in women aged 20 and older.

Woman heart disease image About 34% of US women are living with heart disease and an even larger percentage at risk for developing it. The American Heart Association (AHA) advises a broader approach to classify the likelihood of developing CVD—one that goes beyond the Framingham global risk score. The Framingham score places women in categories (from high risk to optimal) based on factors like age, total cholesterol, and blood pressure. The total score has been to calculate a woman’s 10-year risk of developing the disease. The problem with this is that a low score doesn’t necessarily reflect risk over the course of a lifetime.

With that in mind, the AHA recommends doctors take a more comprehensive view of cardiovascular risk. Adding to the Framingham score, doctors should examine the patient’s medical and lifestyle history, family history of CVD, as well as other genetic conditions. The AHA aims to tackle heart disease in women by evaluating lifetime risk and determining the most appropriate preventive measures. The goals also include more aggressive tactics for those at high risk.

The new classification focuses on three categories: high risk, at risk, and optimal risk. As stated in the guidelines, women in the “high risk” category meet the following criteria:

Those “at risk” have:

  • One or more risk factors for CVD, such as:
    • Cigarette smoking
    • Poor diet
    • Physical inactivity
    • Obesity
    • Family history of CVD (eg, CVD less than age 55 in a male relative, CVD less than age 65 in a female relative)
  • Hypertension (high blood pressure)
  • Dyslipidemia (cholesterol problems or high triglycerides)
  • Evidence of subclinical (asymptomatic) vascular disease (eg, coronary calcification)
  • Metabolic syndrome (combination of usually mild to moderate hypertension, dyslipidemia, overweight, as well as pre-diabetes)
  • Poor exercise capacity on treadmill test and/or abnormal heart rate after stopping exercise

Women in the optimal risk category have a low Framingham score (less than 10% chance of developing CVD) and a healthy lifestyle (no risk factors).

Major Recommendations

In addition to the new, broader classification, other major recommendations based on the latest research findings advise that doctors should:

  • Avoid aspirin therapy in healthy women less than age 65, and use selectively in all others
  • Not prescribe menopausal therapies (eg, hormone therapy and selective estrogen-receptor modulators) to prevent heart disease
  • Not recommend antioxidant vitamin supplements, such as vitamin E, C, and beta carotene, to prevent heart disease
  • Not recommend folic acid as a preventive measure for heart disease since there is no evidence that the supplement offers any heart benefits

Intervention: Lifestyle Changes, Supplements, and Medications

All Women

The AHA encourages women at all risk levels to make necessary lifestyle changes, like reducing alcohol intake, quitting smoking through cessation therapies, and increasing physical activity.

For example, those who need to lose weight or keep the weight off should engage in 60-90 minutes of moderate-intensity exercise on most (or all) days of the week in an effort to achieve and maintain a body mass index (BMI) in the normal range (18.5-24.9).

In addition, women are encouraged to eat a high fiber diet rich in fruits, vegetables, whole grains, which also includes at least two servings of oily fish (like salmon and tuna) per week.

Current Disease

Women already diagnosed with heart disease should consider taking an omega-3 fatty acid supplement and should be screened for the possibility of depression. Also, those women who have recently suffered a cardiovascular event (eg, angina, heart attack, stroke, peripheral artery disease) or who are experiencing symptoms of heart failure should undergo a comprehensive rehabilitative program to manage their condition and lower their risk of recurrence or other future complications.

At Risk or High Risk

Interventions for women who are considered “at risk” or at “high risk” for CVD can include a combination of lifestyle changes and medications. The goals are to achieve:

  • An optimal blood pressure reading (<120/80 mmHg)
  • Healthy levels of high-density lipoprotein (HDL) cholesterol ( more than 50 mg/dL [1.3 mmol/L])
  • Low-density lipoprotein (LDL) cholesterol (less than 100 mg/dL [2.6 mmol/L])
It is also important to aggressively control blood pressure levels in patients with diabetes.

All women at “high risk” should be taking daily aspirin (75-325 mg) unless there is a compelling reason not to (eg, history of bleeding stomach ulcers). “At risk” women 65 and older should be considered for aspirin therapy if the benefits outweigh the risks. In addition, all women who have had a heart attack or similar coronary event should be considered for drug treatment with a beta-blocker, and in the event of heart failure or diabetes, should also be considered for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.