# Presentation: 393763

## Cardiovascular Disease in Women Module VII: Evidence-Based Guidelines

## Evidence-based Guidelines for Cardiovascular Disease Prevention in Women

**Mosca L, et al. Circulation 2004; 109:672-693.**
**http://www.circ.ahajournals.org**

**Notes:**
Evidence-based guidelines for the prevention of cardiovascular disease in women were published in Circulation in 2004. The reports of the Women’s Health Initiative, which unexpectedly showed that combination hormone therapy was associated with adverse CVD effects, underscored the importance of evidence-based recommendations for chronic disease prevention. 

Over 1270 articles were screened by the panel, and 400 articles were included for evidence tables. A complete listing of references reviewed by the panel is listed at the website (1).
(1) Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Evidence Based Guidelines for CVD Prevention in Women

**Classification of Recommendations**
**Class I**: Intervention is useful and effective
**Class II a: **Weight of evidence/opinion is in favor of usefulness/efficacy
**Class II b: **Usefulness/efficacy is less well established by evidence/opinion
**Class III: **Intervention is not useful/effective and may be harmful

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Level of Evidence

**A. Sufficient evidence from multiple randomized trials**
**B. Limited evidence from single randomized trial or ****     other non randomized trials**
**C. Based on expert opinion, case studies of standard ****     of care**
_**Generalizability index:**_**	****1 = very likely**
**	****	****	****	****	****2 = somewhat likely**
**	****	****	****	****	****3 = unlikely**
**	****	****	****	****	****0 = unable to project****	**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Generalizability index refers to the likelihood that data from clinical trials with men are generalizable to women; (read rest of slide)(1).

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Clinical Recommendations

**Lifestyle Interventions**
**Major Risk Factor Interventions**
**Preventive Drug Interventions**
**Atrial Fibrillation/Stroke Prevention**
**Interventions that are not useful/effective and may be harmful**

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

The clinical recommendations are grouped under these main categories; Class III lists the items that are NOT recommended as they are not useful or effective, and may be harmful.
Over 1270 articles were screened by the panel, and 400 articles were included for the evidence tables. A complete listing of references reviewed by the panel is listed at this web site (1) 

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Cardiovascular Disease Prevention in Women: Current Guidelines

**A five-step approach**
- 	**A**ssess and stratify women into high, intermediate,     	lower 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

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

A five part approach was supported by currently available evidence.

## Risk Stratification: 

**CHD equivalent**
- Diabetes mellitus
- Established atherosclerotic disease
- Includes many patients with chronic kidney disease, especially ESRD
**Major Risk Factors:**
- Age _>_ 55 years
- Smoking
- Hypertension, whether or not treated with medication
- HDL cholesterol < 40mg/dL (HDL cholesterol ≥ 60mg/dL is a negative risk factor)
- Family history of premature CVD

**     ****Source: **Mosca  2004, ATP III 2002

**Notes:**
SLIDE INFORMATION SOURCES:  Mosca L, et al.  Evidence-based guidelines for cardiovascular disease prevention in women.  Circulation 2004; 109:672-693.; Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), NIH, NHLBI, 2002.

## Risk Stratification

**Diabetes**
- Automatically places a patient in a “High Risk” category
**Family History**
- Defined as CVD in a female first degree relative < 65 years old, or a first degree male relative < 55 years old

**     ****Source: **Mosca  2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Risk Stratification

- Calculate 10 year risk for all patients with two or more risk factors that do not already meet criteria for CHD equivalent
- Use electronic calculator for most precise estimate:  www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMSTION SOURCE:  Mosca L, et al.  Evidence-based guidelines for cardiovascular disease prevention in women.  Circulation 2004; 109:672-693.

## CHD Risk Equivalents

**High Risk > 20% 10-yr risk for CHD events**
- Established coronary artery disease
- Carotid artery stenosis
- Peripheral arterial disease
- Abdominal aortic aneurysm
- Diabetes
- Includes many patients with chronic renal disease, especially ESRD

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

High risk patients have a greater than 20% 10-year risk of CHD events based on Framingham data. Among patients with chronic renal disease, those with end stage renal disease are at particular risk (1)

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Risk Stratification

**Intermediate Risk 10-20% 10-yr risk for CHD events**
- May include women with metabolic syndrome, especially women over the age of 60 or with individual factors that are markedly elevated or severe
- Often includes women with multiple risk factors, a single markedly elevated risk factor, or a 1st degree relative with premature CVD
- May include women with subclinical cardiovascular disease (elevated coronary calcium score)- this is not included in Framingham risk calculations
**Use electronic calculator for most precise estimate: www.nhlbi.nih.gov/guidelines/cholesterol/index.htm**

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Most patients in the intermediate category of risk will have two or more risk factors (1).
Routine evaluation of coronary calcium by electron-beam computed tomography (EBCT) is not recommended (2).
Women at higher levels of intermediate risk should be treated more aggressively (3)

(1)Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002
(2)O’Rourke RA, et al. American College of Cardiology/American Heart Association expert consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. J Am Coll Cardiol, 2000;36(1):326-340.
(3)Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Risk Stratification

**Lower Risk <10% 10-yr risk for CHD events**
- May include women with one or more risk factors
- May include women with defined metabolic syndrome, if no individual factor is severe or markedly elevated
- May include women with no risk factors, but non-optimal lifestyle factors, such as lack of regular exercise or a high fat diet
**Optimal Risk <10% 10-yr risk for CHD events**
- Optimal levels of risk factors
- Heart healthy lifestyle

**     ****Source: **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Risk Stratification

**An online calculator is available at:**** **http://www.nhlbi.nih.gov/guidelines/cholesterol

**     ****Source: **NHLBI

## Lifestyle Interventions

**Smoking cessation**
**Physical activity**
**Heart healthy diet**
**Weight reduction/maintenance**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

These are the Class I lifestyle recommendations applicable to all women (1).

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Lifestyle Interventions

**Smoking **
**Physical Activity **
**Heart healthy diet**
**Weight reduction/maintenance**
**Psychosocial factors**
**Omega 3 fatty acids**
**Folic acid**
**Cardiac rehabilitation**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

The fist category in the guidelines addresses lifestyle interventions, and focuses on these categories (1).
Smoking cessation, physical activity, heart-healthy diet, and weight reduction/maintenance are Class I recommendations applicable to all women (1).
Cardiac rehabilitation is a Class I recommendation applicable to women with a history of angina, acute coronary syndrome, or coronary intervention (1).
Evaluation and treatment for depression, and use of Omega 3 fatty acids and folic acid are applicable to women with CAD or high risk women, and are Class II recommendations (1).

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## 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

**      ****Source:  **Fiore 2000

**Notes:**
SLIDE INFORMATION SOURCE:  Fiore MC, et al.  Treating tobacco use and dependence.  Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000.

## 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**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Diet

**Consistently encourage healthy eating patterns**
- Healthy food selections:
- Fruits and vegetables
- Whole grains
- Low-fat or nonfat dairy
- Legumes
- Low-fat protein
- Fish
- 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 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Trans fatty acids are found in hydrogenated vegetable oils and some animal fats(1).
Major sources are baked foods like crackers, cookies, doughnuts, breads, and food fried in hydrogenated vegetable oil, like french fires and fried chicken(1).
Based on data from randomized trials, trans fatty acids raise LDL cholesterol(1).

(1) Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002.

## Weight Maintenance/Reduction

**Consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake and formal behavioral programs**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Weight Maintenance/Reduction Goals

**BMI between 18.5 and 24.9**
**Waist circumference < 35 inches**
**Weight loss goals**
- 10% of body weight over six months or 1-2 pounds weight loss/week
- Reduce calories by 500-1,000 per day

**     ****Source: **Mosca 2004, ATP III 2002

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.;Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002

## Depression

**Women with CVD should be evaluated for depression and referred or treated when indicated. **

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

##   As an adjunct to diet, omega-3 fatty acid supplements      may be considered in high-risk women.

**Omega-3 Fatty Acids**

**     ****Source:  **Mosca  2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Omega-3 polyunsaturated fatty acids are found in certain vegetable sources, as well as in fish oils (1).
Four clinical trials incorporating increased intake of omega-3 polyunsaturated acids as fatty fish, components of a “Mediterranean” diet, or fish oil capsules suggest that omega-3 fatty acids reduce sudden death and overall death in persons with coronary artery disease (1).
The American Hear t Association currently recommends that patients with documented CHD consume 1 gram of omega-3 fatty acids daily, either through consumption of oily fish, or from omega-3 fatty acid capsules(2).
High intake of omega-3 fatty acids can cause excessive bleeding. Some types of fish can contain methylmercury, dioxin, and other environmental toxins (2).

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.
(2) Kris-Etherton PM, et al. Omega-3 fatty acids and cardiovascular disease. Aterioscler Thromb Vasc Biol 2003;23:151-152.

## Folic Acid

**Folic acid supplementation may be considered in high risk women (except after revascularization procedure) if a higher-than-normal level of homocysteine has been detected**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

A randomized trial of 636 patients who had undergone successful coronary stenting were randomly assigned to receive 1 mg folic acid, 5 mg vitamin B6, and 1 mg vitamin B12 IV, followed by 1.2 mg folic acid, 48 mg vitamin B6, and 60 micrograms of vitamin B12 orally for six months, or placebo.  The restenosis rate was higher in the folate group, with a higher number of patients requiring revascularization (15.8% vs 10.6%, P=0.05).  Pending further studies, folic acid supplementation is not recommended after revascularization (1).

(1)  Lange H, et al.  Folate therapy and in-stent restenosis after coronary stenting.  N Engl J Med 2004. 350:2673-2681.

## Cardiac Rehabilitation

**Women with a recent acute coronary syndrome or coronary intervention, new onset or chronic angina should participate in a comprehensive risk reduction program, such as cardiac rehabilitation, or a ****physician-guided home or community based program**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Major Risk Factor Interventions

**Blood Pressure**
**Lipids**
**Diabetes**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## 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%

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## 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**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

These guidelines were adopted from the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure, (JNC 7), published in 2004.
Systolic BP is often more difficult to control, but is more of a CVD risk factor in those over age 50 (1).
Both systolic and diastolic BP need to be treated to goal levels (1).

(1)Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002.

## 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 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## 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 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

In all women with an elevated LDL cholesterol level, therapeutic lifestyle changes should be instituted (1)
There is no upper limit of trans fatty acids identified, as yet (2) 

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.
(2)Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002

## 2004 Update of ATP III

**5 recent clinical trials suggest added benefit of optional lowering of cholesterol more than ATP III recommended**
**Lifestyle changes remain cornerstone of treatment**** **
**Advises that intensity of LDL-lowering drug treatment in high-risk and moderately high-risk patients achieve at least 30% reduction in LDL levels**

**     ****Source: **Grundy 2004

**Notes:**
SLIDE INFORMATION SOURCE: Grundy SM, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239.

In July, 2004, some elements of the Adult Treatment Panel III were revisited, based on the completion of five clinical trials of cholesterol-lowering statin treatment that have been conducted since the release of the previous guidelines (1).
Lifestyle changes are still emphasized, including the adoption of a low saturated data and low cholesterol diet, increased physical activity and weight control (1). 
The update offers options for more intensive lowering of cholesterol levels for people at very high risk(1).

(1) Grundy SM, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239.

## 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 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Very High Risk Women

**Recent heart attack or known CAD, along with one or more of the following:**
- Multiple major risk factors, particularly in diabetics
- Severe or poorly controlled risk factors (i.e., continued smoking)
- Multiple risk factors of the metabolic syndrome, especially TG_ >_ 200 mg/dL AND HDL < 40 mg/dL
**LDL goal of < 100mg/dL**
**Consider statin, even if LDL < 100mg/dL**
**Optional LDL goal of < 70mg/dL per ATP III 2004 update**

**     ****Source:  **Grundy 2004

**Notes:**
SLIDE INFORMATION SOURCE: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239.

A new category of “very high risk” was added in the update to ATP III in 2004(1).
ATP III was updated based on the publication of five major clinical trials of statin therapy(1).
For women determined to be in a this “very-high risk” category lowering the LDL cholesterol to less than 100mg/dl, and as low as 70 mg/dl, may be considered (1)

(1) Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239.

## High Risk Women

_**>**_** 20% 10-year risk of CHD **
**CHD, large vessel atherosclerotic disease, DM**
**Goal LDL < 100mg/dL, consider statin even if ****LDL< 100 mg/dL**

**     ****Source:  **Grundy 2004, Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239; Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Intermediate Risk Women

**10-20% 10-year CHD risk**
**Multiple or severe CHD risk factors**
**Goal LDL < 100 mg/dL, consider drug therapy ****if LDL ≥ 100 mg/dL**

**     ****Source:  **Grundy 2004, Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239; Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Lower Risk Women

**Treatment goal remains LDL < 160 mg/dL, consider drug therapy if LDL ≥ 190 mg/dL, option to consider drug therapy if LDL 160-189 mg/dL**

**     ****Source:  **Grundy 2004, Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCES: Grundy SM, et al.NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004. 110:227-239; Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Lipids

**High risk women:**
- Initiate niacin or fibrate therapy when HDL is low, or non-HDL is elevated
**Intermediate and lower risk women:**
- Initiate niacin or fibrate therapy when HDL is low, or non-HDL is elevated and LDL goal is reached in intermediate and low risk women

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Low HDL is defined as ≤ 50 mg/dL. Elevated non-HDL is defined as (total cholesterol –HDL cholesterol) ≥ 130 mg/dL (1).

(1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Diabetes

**Recommendation: Lifestyle and pharmacotherapy should be used to achieve near normal HbA1C (<7%) in women with diabetes**

**     ****Source:  **Grundy 2004

**Notes:**
SLIDE INFORMATION SOURCE: Grundy SM, et al. NECP Report: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227-239.

## Preventive Drug Interventions for Women with CHD

**Aspirin**
**Beta-blockers**
**Angiotensin converting enzyme inhibitors**
**Angiotensin receptor blockers**

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Preventive Drug Interventions

**Aspirin – High risk women**
- 75-162 mg, or clopidogrel if patient intolerant to aspirin; should be used in high-risk women unless contraindicated
**Aspirin-Intermediate risk women**
- Consider aspirin therapy (75-162 mg) in intermediate-risk women as long as blood pressure is controlled and benefit is likely to outweigh risk of GI side effects

**     ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Preventive Drug Interventions

**Aspirin – Lower risk women**
- Many women, especially those age 65 and older, may benefit from taking low-dose aspirin every other day to prevent stroke
- Women over age 65 may benefit from taking low-dose aspirin to reduce major cardiovascular events
- The use of low dose aspirin in lower risk women should be balanced against the risk of increased internal bleeding

**     ****Source:  **NHLBI

## Preventive Drug Interventions

**Beta-Blockers **
- 	Should be used indefinitely in all women who have had a myocardial infarction or who have had chronic ischemic syndromes (unless contraindicated)
**Angiotensin-Converting Enzyme Inhibitors**Should be used (unless contraindicated) in high-risk women
**Angiotensin-receptor blockers**Should be used in high-risk women with clinical evidence of heart failure or an ejection fraction of <40% who are intolerant of ACE inhibitors

**      ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Atrial Fibrillation/Stroke Prevention

**Warfarin: Among women with chronic or paroxysmal atrial fibrillation, warfarin should be used to maintain the INR at 2.0-3.0 unless they are considered to be at low risk of stroke ( <1%/year).**
**Aspirin: 325 mg should be used in women with chronic or paroxysmal atrial fibrillation with a contraindication to warfarin or a low risk for stroke (<1%/year).**

**     ****Source:  **Mosca  2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

## Interventions that are not useful/effective and may be harmful for the prevention of heart disease

**Hormone Therapy**
- Combined estrogen and progesterone hormone therapy should not be initiated or continued to prevent CVD in post-menopausal women. Alternative forms of HT should not be used to prevent CVD, pending results of ongoing trials

**      ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

Both the American College of Obstetricians and Gynecologists (ACOG) and the United States Food and Drug Administration (FDA) have concluded that hormone therapy should not be initiated or continued to prevent CVD in post-menopausal women(1,2).

(1) American College of Obstetricians and Gynecologists Task Force for Hormone Therapy. Executive summary. Obstet Gynecol 2004;104 (4Suppl):IS-4S.
(2) FDA approves new labels for estrogen and estrogen plus progestin therapies for postmenopausal women following review of Women’s Health Initiative data. Rockville, Md:Food and Drug Administration, January 8,2003.

## Interventions that are not useful/effective and may be harmful for the prevention of heart disease

**Antioxidant supplements**
- No cardiovascular benefit in randomized trials of primary and secondary prevention

**      ****Source:  **Mosca 2004

**Notes:**
SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.

The Women’s Health Study, a 10-year randomized double-blind, placebo controlled trial of nearly 40,000 healthy women aged 45 years and older showed no cardiovascular benefit or risk  to vitamin E supplementation (600 IU every other day)(1). 
The HOPE and HOPE-TOO trials randomized over 9000 patients with vascular disease or diabetes mellitus aged 55 years or older to Vitamin E 400 IU daily or placebo.  Mean duration of follow-up was seven years.  Long term vitamin E supplementation did not prevent major cardiovascular events, and was associated with a higher risk of heart failure (RR=1.21, P=.045), and hospitalization for heart failure(2).

(1)Lee IM, et al.  Vitamin E in the primary prevention of cardiovascular disease and cancer. JAMA 2005; 294:56-65.
(2) Lonn E, et al.  Effects of long-term vitamin E supplementation on cardiovascular events and cancer.  JAMA 2005;293:1338-1347.

## Reproductive Age Women and CHD

**Over 10,000 reproductive age women suffer MI 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 2004, Pregler 2005

- Final May 2006

**Notes:**
SLIDE INFORMATION SOURCES:  Heart Disease and Stroke Statistics- 2004 Update, American Heart Association; Janet Pregler, M.D., personal communication, March, 2005.