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Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.

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Presentation on theme: "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women."— Presentation transcript:

1 Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women

2 Objectives  To present strategies to assess and stratify women into high risk, at risk, and optimal risk categories for cardiovascular disease  To summarize lifestyle approaches to the prevention of cardiovascular disease in women

3 Objectives  To review evidence-based approaches to cardiovascular disease prevention for patients with hypertension, lipid abnormalities, and diabetes  To review an evidence-based approach to pharmacological risk intervention for women at risk for cardiovascular events

4 Objectives  To summarize commonly used therapies that should not be initiated for the prevention or treatment of heart disease, because they lack benefit, or because risks outweigh benefits

5 CVD and Other Major Causes of Death for Women in the United States: 2004 Source: Adapted from Rosamond 2008

6 Annual Numbers of U.S. Adults Diagnosed with Myocardial Infarction and Fatal CHD by Age and Sex Categories: Source: Adapted from Rosamond 2008 Age in Years

7 Cardiovascular Disease Mortality: U.S. Males and Females Source: Adapted from Rosamond 2008

8 Racial and Ethnic Groups  Cardiovascular disease is the leading cause of death for African Americans, Latinos, Asian Americans, Pacific Islanders, and American Indians  African American women are at the highest risk for death from heart disease among all racial, ethnic, and gender groups Source: Rosamond 2008

9 Evidence-based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update Mosca L, et al. Circulation 2007; 115:

10 Cardiovascular Disease Prevention in Women: Current Guidelines  A five-step approach  A ssess and stratify women into high risk, at risk, and optimal risk categories  L ifestyle approaches recommended for all women  O ther cardiovascular disease interventions: treatment of HTN, DM, lipid abnormalities  H ighest priority is for interventions in high risk patients  A void initiating therapies that have been shown to lack benefit, or where risks outweigh benefits Source: Adapted from Mosca 2004

11 Risk Stratification:  High Risk  Diabetes mellitus  Documented atherosclerotic disease  Established coronary heart disease  Peripheral arterial disease  Cerebrovascular disease  Abdominal aortic aneurysm  Includes many patients with chronic kidney disease, especially ESRD 10-year Framingham global risk > 20%, or high risk based on another population-adapted global risk assessment tool Source: Mosca 2007

12 Risk Stratification:  At Risk:  > 1 major risk factors for CVD, including:  Cigarette smoking  Hypertension  Dyslipidemia  Family history of premature CVD (CVD at < 55 years in a male relative, or < 65 years in a female relative)  Obesity, especially central obesity  Physical inactivity  Poor diet  Metabolic syndrome  Evidence of subclinical coronary artery disease (eg coronary calcification), or poor exercise capacity on treadmill test or abnormal heart rate recovery after stopping exercise Source: Mosca 2007

13 Definition of Metabolic Syndrome in Women  Abdominal obesity - waist circumference > 35 in.  High triglycerides ≥ 150mg/dL  Low HDL cholesterol < 50mg/dL  Elevated BP ≥ 130/85mm Hg  Fasting glucose ≥ 100mg/dL Source: AHA/NHLBI 2005

14 Risk Stratification:  Optimal risk:  No risk factors  Healthy lifestyle  Framingham global risk < 10% Source: Mosca 2007

15 Lifestyle Interventions  Smoking cessation  Physical activity  Heart healthy diet  Weight reduction/maintenance Source: Mosca 2007

16 Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Source: Adapted from Stampfer 2000

17 Smoking  All women should be consistently encouraged to stop smoking and avoid environmental tobacco  The same treatments benefit both women and men  Women face different barriers to quitting  Concomitant depression  Concerns about weight gain  Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or other formal smoking cessation program Source: Fiore 2000, Mosca 2007

18 Five A’s  Ask about tobacco use at every visit  Advise in a clear and personalized message  Assess willingness to quit  Assist to quit  Arrange follow-up  For more information: Source: Fiore 2000

19 Risk Reduction for CHD Associated with Exercise in Women Source: Manson 1999

20 Modifiable Risk Factors: Sedentary Lifestyle  40% of women report no leisure time physical activity  Exercise is less prevalent among white women compared to white men  African American and Hispanic women have the lowest prevalence of leisure time physical activity Source: U.S. Surgeon General 1996, Rosamond 2008

21 Physical Activity  Consistently encourage women to accumulate a minimum of 30 minutes of moderate intensity physical activity on most, or preferably all, days of the week  Women who need to lose weight or sustain weight loss should accumulate a minimum of minutes of moderate-intensity physical activity on most, and preferably all, days of the week Source: Mosca 2007

22 Body Weight and CHD Mortality Among Women P for trend < Source: Adapted from Manson 1995

23 Body Weight and CHD Mortality Among Women P for trend < ≥ Source: Adapted from Manson 1995

24 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. Adults Behavioral Risk Factor Surveillance System BRFSS, (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) Source: CDC

25 Weight Maintenance/Reduction Goals  Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavioral programs when indicated to maintain:  BMI between 18.5 and 24.9 kg/m²  Waist circumference < 35 inches Source: Mosca 2007

26 Body Mass Index: Definition  BMI = weight in kilograms divided by the square of the height in meters (kg/m2)  BMI chart showing BMI based on weight in pounds and height in inches available at: Source: NHLBI

27 Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes) Relative Risk of MI* *Adjusted for other cardiovascular risk factors Source: Akesson 2007 P<.05 for quintiles 3-5 compared to 1-2

28 Diet  Consistently encourage healthy eating patterns  Healthy food selections:  Fruits and vegetables  Whole grains, high fiber  Fish, especially oily fish, at least twice per week  No more than one drink of alcohol per day  Less than 2.3 grams of sodium per day  Saturated fats < 10% of calories, < 300mg cholesterol  Limit trans fatty acid intake (main dietary sources are baked goods and fried foods made with partially hydrogenated vegetable oil) Source: Mosca 2007

29 Major Risk Factor Interventions  Blood Pressure  Target BP<120/80 mmHg  Pharmacotherapy if BP> 140/90, or > 130/80 in diabetics or patients with renal disease  Lipids  Follow NCEP/ATP III guidelines  Diabetes  Target HbA1C<7%, if this can be accomplished without significant hypoglycemia Source: Mosca 2007

30 Hypertension  Encourage an optimal blood pressure of < 120/80 mm Hg through lifestyle approaches  Pharmacologic therapy is indicated when blood pressure is > 140/90 mm Hg or an even lower blood pressure in the setting of diabetes or target-organ damage (> 130/80 mm Hg)  Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated, or unless compelling indications exist for other agents  For high risk women, initial treatment should be with a beta- blocker or angiotensin converting enzyme inhibitor or angiotensin receptor blocker Source: Mosca 2007

31 Lifestyle Approaches to Hypertension in Women Source: JNC VII 2004, Sacks 2001, Mosca 2007  Maintain ideal body weight  Weight loss of as little as 10 lbs reduces blood pressure   DASH eating plan  Even without weight loss, a diet rich in fruits, vegetables, and low fat dairy products can reduce blood pressure   Sodium restriction to 2300 mg/d  Further restriction to 1500 mg/d may be beneficial, especially in African American patients   Increase physical activity   Limit alcohol to one drink per day  Alcohol raises blood pressure  One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor

32 DASH Eating Plan  7–8 servings of grains, grain products daily  4–5 servings of vegetables daily  4–5 servings of fruits daily  2–3 servings of low-fat or nonfat dairy foods daily  ≤ 2 servings of meats, poultry, fish daily  4–5 servings of nuts, seeds, legumes weekly  Limited intake of fats, sweets Source: NHLBI 1998

33 DASH Diet with Low Sodium Intake in Hypertensive Individuals Compared to Control Diet with Average U.S. Sodium Intake African American Non-African American * P<.001 from baseline * Source: Sacks 2001 *

34 Lipids  Optimal levels of lipids and lipoproteins in women are as follows (these should be encouraged in all women with lifestyle approaches):  LDL < 100mg/dL  HDL > 50m/dL  Triglycerides < 150mg/d  Non-HDL (total cholesterol minus HDL) < 130mg/d Source: Mosca 2007

35 Lipids  In high-risk women or when LDL is elevated:  Saturated fat < 7% of calories  Cholesterol < 200mg/day  Reduce trans-fatty acids  Major dietary sources are foods baked and fried with partially hydrogenated vegetable oil Source: Mosca 2007

36 Approximate and Cumulative LDL Cholesterol Reduction Achievable By Dietary Modification Dietary Component Dietary Change Approximate LDL Reduction Major Saturated fat<7% of calories8-10% Dietary cholesterol<200 mg/day3-5% Weight reductionLose 10 lbs5-8% Other LDL-lowering options Viscous fiber5-10 g/day3-5% Plant/sterol2g/day6-15% stanol esters Cumulative estimate20-30% Source: Adapted from ATP III 2002

37 Lipids  Treat high risk women aggressively with pharmacotherapy  LDL-lowering pharmacotherapy (preferably a statin) should be initiated simultaneously with lifestyle modification for women with LDL>100mg/dl Source: Mosca 2007

38 Coronary Disease Mortality and Diabetes in Women Source: Krolewski 1991

39 Race/Ethnicity and Diabetes  At high risk:  Latinas  American Indians  African Americans  Asian Americans  Pacific Islanders Source: American Diabetes Association 2001

40 Preventive Drug Interventions  Aspirin – High risk women  mg/day, or clopidogrel if patient intolerant to aspirin, should be used in high-risk women unless contraindicated  Aspirin- Other at-risk or healthy women  Consider aspirin therapy (81 mg/day or 100 mg every other day) if blood pressure is controlled and benefit is likely to outweigh risk of GI side effects and hemorrhagic stroke  Benefits include ischemic stroke and MI prevention in women aged > 65 years, and ischemic stroke prevention in women < 65 years Source: Mosca 2007

41 Women’s Health Initiative Estrogen and Progestin Arm: Absolute Excess Risk  Excess CHD events: 7/10,000 woman-years  Excess stroke events : 8/10,000 woman-years  Excess pulmonary emboli: 8/10,000 woman-years  Excess invasive breast cancer: 8/10,000 woman-years Source: Writing Group for the WHI Investigators 2002

42 Women’s Health Initiative Estrogen and Progestin Arm: Absolute Benefits  Fewer colorectal cancers: 6/10,000 woman-years  Fewer hip fractures: 5/10,000 woman-years Source: Writing Group for the WHI Investigators 2002

43 Women’s Health Initiative: Estrogen Alone in Postmenopausal Women Compared to Placebo: Major Clinical Outcomes * * P <.05 * Favors Treatment Favors Placebo Source: Adapted from WHI Steering Committee 2004

44 Menopausal Hormone Therapy, SERMs and CVD: Summary of Major Randomized Trials  Use of estrogen plus progestin associated with a small but significant risk of CHD and stroke  Use of estrogen without progestin associated with a small but significant risk of stroke  Use of all hormone preparations should be limited to short term menopausal symptom relief  Use of a selective estrogen receptor modulator (raloxifene) does not affect risk of CHD or stroke, but is associated with an increased risk of fatal stroke Source: Hulley 1998, Rossouw 2002, Anderson 2004, Barrett-Connor 2006

45 Interventions that are not useful/effective and may be harmful for the prevention of heart disease  Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD Source: Mosca 2007

46 Interventions that are not useful/effective and may be harmful for the prevention of heart disease  Antioxidant supplements and folic acid supplements  No cardiovascular benefit in randomized trials of primary and secondary prevention Source: Mosca 2007

47 The NORVIT Trial: Homocysteine Lowering Did Not Reduce Cardiovascular Events in Women with Prior MI Relative Risk of CVD Event *Compared to B12 alone Source: Bonaa 2006 * ** **Compared to placebo

48 Reproductive Age Women and CHD  Over 10,000 reproductive age women suffer MI or fatal CHD each year  All women of reproductive age prescribed drug therapy should be counseled about preconception planning, as many recommended drugs are contraindicated during pregnancy  Reproductive age women with CHD who are pregnant or planning pregnancy should be cared for by health care providers with expertise in both cardiovascular disease and obstetrics (team approach) Source: American Heart Association 2008, Pregler 2005

49 The Heart Truth Professional Education Campaign Website

50 Conclusions  Gender differences exist in diagnosis, treatment, and prognosis of CHD  Knowledge of gender differences is essential for appropriate therapy  Evidence-based guidelines provide a framework for prevention and treatment of cardiovascular disease in women


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