Preventing Heart Disease in Women – Updated Guidelines

Roger S. Blumenthal, M.D., Director of the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins outlines new features of the AHA’s 2007 recommendations for women.

In 1999 the American Heart Association (AHA) reacted to the mountain of research showing that cardiovascular disease may affect women somewhat differently than men by publishing the first Evidence-based Guidelines for Cardiovascular Disease Prevention in Women. Since then, the guidelines have helped physicians establish preventive strategies for their female patients. The recently updated 2007 heart health guidelines include some new information that you may want to discuss with your doctor.

Heart health guidelines published in previous years focused on strategies for preventing cardiovascular disease over the short term, <10 years. But Roger S. Blumenthal, M.D., Director of the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins, stresses that the most important new concept in the updated 2007 AHA guidelines is that they go beyond 10-year risk.

Although a woman’s 10-year risk of developing heart disease may be low, Dr. Blumenthal says, "By the time a woman turns 50, her risk of heart attack or stroke over the next 35 years is between 5-10% -- if she has no other risk factors. Unfortunately, only a small percentage of women have optimal risk factors by age 50, suggesting an even higher lifetime risk of heart disease. So, women need to make changes sooner rather than later to reduce their lifetime risk."

As part of the revised guidelines’ broader approach to prevention, more stringent dietary, exercise, and cholesterol goals have been added. And the AHA has designed a new, more encompassing lifetime risk prevention algorithm for doctors to follow as they determine a patient's risk of heart disease and her treatment options. In addition, there are new recommendations for the use of aspirin, folic acid, and other dietary supplements.

Heart disease guidelines -- what’s new?

• Heart disease risk. A family history of heart attack prior to age 60 has been added to the list of risk factors that women should be aware of.
• Heart disease and smoking cessation. The new guidelines suggest smokers try behavioral modification programs, counseling, nicotine replacement therapy, or prescription smoking-cessation medications.
• Heart disease and exercise. Thirty minutes of moderately intense activity, such as brisk walking, on most, and preferably all, days of the week is still recommended. New this year is the recommendation that to lose weight or sustain weight loss, physical activity should be increased to 60–90 minutes of moderately intense exercise on all or most days of the week.
• Heart disease and diet. The AHA reduced their recommended intake of saturated fats from 10% to 7% of total daily calories. And more specific dietary recommendations advise women to consume heart-healthy omega-3 fatty acids by eating two portions of oily fish, such as mackerel or salmon, per week.
• Heart disease and aspirin. The AHA now recommends low-dose aspirin therapy of 81 mg daily or 100 mg every other day for all women age 65 or older. The maximum dosage for high-risk women of any age has been increased from 162 mg daily to 325 mg. Studies show that aspirin will not prevent heart attacks in low-risk women under 65, but it may be considered for all women at risk for stroke -- provided there is no risk of bleeding that could potentially offset the benefits of aspirin.
Heart disease and supplements. Previous guidelines recommended folic acid supplements for high-risk women with elevated levels of homocysteine, an amino acid associated with heart attack. However, recent studies indicate that folic acid -- with or without vitamin B6 or B12 supplements -- has no benefit and should not be used. In addition, new studies confirm that supplements including vitamin E, vitamin C, and beta-carotene should not be taken to prevent the development of cardiovascular disease (CVD) in women who are healthy or to prevent heart attack or stroke in those already diagnosed with CVD.

Women with heart disease are encouraged to take 850–1,000 mg of the omega-3 fatty acid supplements eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) daily. Women with high triglyceride levels should take up to 4 g of EPA and DHA daily. Heart disease and hormone replacement therapy (HRT). Progesterone and estrogen, for example, and selective estrogen-receptor modulators (SERMs), such as raloxifene and tamoxifen, which are used to treat osteoporosis and breast cancer, respectively, should not be taken to prevent CVD or to prevent heart attack or stroke in women with CVD.

• Heart disease and low-density lipoprotein (LDL, or “bad”) cholesterol. A more aggressive LDL cholesterol target of <70 mg/dL is recommended for women at high risk for heart attack or stroke; these women should consider taking medications such as a statin to achieve this goal.