Dallas, TX - Updated prevention guidelines for women from the American Heart Association (AHA) outline a bold prescription for the prevention of CVD that urges women to adopt a healthy lifestyle early and sets new target goals for risk assessment [1].

The guidelines, appearing in the February 20, 2007 online issue of Circulation, were presented by lead author Dr Lori Mosca (New York-Presbyterian Hospital, New York) at an AHA media briefing.

The focus is on prevention, with the goal to widen the window of opportunity for women to fight their number-one killer. "We want to prevent the risk factors," she stressed.

The guidelines simplify risk assessment. There are now three categories (high risk, at risk, and optimal risk) instead of the four (high, intermediate, lower, optimal) in the Framingham global risk model.

Mosca notes that limitations of Framingham are overcome by the new model, which better accounts for "lifetime risk, diversity, and stroke risk."

Most clinical data for the new evidence-based guidelines categorized women with CVD as high risk and apparently healthy women as a spectrum of risk, "so we were able to allow the current scheme to align with the evidence."

"Physicians should look at this as an opportunity to reinforce prevention of CVD early on, so that women won't need interventions later in life," Mosca said in interview with heartwire.

As with most evidence-based guidelines, these too have four major classes: class I (intervention is useful and effective), class IIa (weight is in favor of efficacy), class IIb (less well established), and class III (intervention not useful, could be harmful).

The high-risk criteria are CHD, CVD, peripheral arterial disease, abdominal aortic aneurysm, end-stage or chronic renal disease, diabetes, and a global risk score of greater than 20%.

The at-risk criteria include one or more major CVD risk factors (smoking, poor diet, physical inactivity, obesity, family history of premature CVD, high blood pressure [BP], or dyslipidemia), subclinical disease, metabolic syndrome, and poor exercise capacity on treadmill testing.

The optimal-risk criteria are a global risk score of less than 10% and a healthy lifestyle with no risk factors.

All women 20 years and older need initial CVD risk evaluation (medical history, physical exam, fasting glucose, lipids) and Framingham risk assessment; women with CVD need depression screening.

Class I lifestyle recommendations (smoking cessation, heart-healthy eating plan, and weight management) are indicated for all women older than 20 years.

"One of the major things we changed is the recommendation for all women to exercise, such as briskly walking a minimum of 30 minutes on most days of the week. To maintain weight goals, a woman needs to accumulate 60 to 90 minutes a day, every day of the week," Mosca says.

Diet should be rich in vegetables, whole grains, and oily fish (twice a week); saturated fat intake should be less than 10% of daily calories; and cholesterol intake should be less than 300 mg/day. (A high-risk woman would need to reduce saturated fat to 7% and cholesterol to less than 200 mg/day).

Class I recommendations for high-risk women are BP control and, in select women, LDL therapy. Class II recommendations—HDL, non-HDL, and triglyceride therapy and aspirin (for older women)—should be considered

Aspirin is recommended for high-risk women and those older than 65 (class Ia recommendation) "if MI risk prevention is likely to outweigh risk of gastrointestinal bleeding," Mosca says.

If a high-risk woman is intolerant to aspirin, clopidogrel should be substituted (class Ib recommendation).

The class I recommendation for women with a recent CVD event or procedure or congestive heart failure is rehabilitation; for other high-risk women, recommendations are BP control, LDL therapy (goal of <100 mg/dL), aspirin, ACE inhibitors, beta blockers, angiotensin-receptor blockers, glycemic control in diabetics, and in select women aldosterone blockers.

Class II recommendations for very-high-risk women are LDL therapy (goal of <70 mg/dL), omega 3 fatty acids, and depression/referral treatment.

Mosca stressed that four major recommendations were class III (not useful, may cause harm).

Therapies or supplements that are not recommended for primary or secondary prevention are:

• Hormone therapy or estrogen modulators.
• Antioxidant vitamin supplements (vitamins E, C, and beta carotene).
• Folic acid.
• Routine use of aspirin in healthy women under age 65.

According to Dr Sidney Smith (University of North Carolina, Chapel Hill), the Framingham classification table has helped physicians understand risk estimates, but the new women's guidelines are "an attempt to make things easier."

Smith told heartwire that the guidelines fill in missing information about the prevention and treatment of CVD in women. "Most of our evidence comes from trials of 75% male Caucasians, so this guideline is some of the best information we have."

Men still develop CVD 10 years earlier, so the guidelines shouldn't take the spotlight completely off men, he notes.