Cardiovascular Disease in Women Module VII: Evidence-Based Guidelines

1
Cardiovascular Disease in Women Module VII
Evidence-Based Guidelines
2
Evidence-based Guidelines for Cardiovascular
Disease Prevention in Women 2007 Update

• Mosca L, et al. Circulation 2007 1151481-501.
• http//www.circ.ahajournals.org

3
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 2007
4
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
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Clinical Recommendations

• Lifestyle Interventions
• Major Risk Factor Interventions
• Preventive Drug Interventions
• Interventions that are not useful/effective and
  may be harmful

Source Mosca 2007
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Cardiovascular Disease Prevention in Women
Current Guidelines

• A five-step approach
• Assess and stratify women into high risk,
  at risk, and optimal risk categories
• Lifestyle approaches recommended for all women
• Other cardiovascular disease interventions
  treatment of HTN, DM, lipid abnormalities
• Highest priority is for interventions in high
  risk patients
• Avoid initiating therapies that have been shown
  to lack benefit, or where risks outweigh
  benefits

Sources Adapted from Mosca 2004, Mosca 2007
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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 gt 20, or high
  risk based on another population-adapted global
  risk assessment tool

Source Mosca 2007
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Risk Stratification

• At Risk
• gt 1 major risk factors for CVD, including
• Cigarette smoking
• Hypertension
• Dyslipidemia
• Family history of premature CVD (CVD at lt 55
  years in a male relative, or lt 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
9
Risk Stratification

• Optimal risk
• No risk factors
• Healthy lifestyle
• Framingham global risk lt 10

Source Mosca 2007
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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 http//www.nhlbi.nih.gov/guidelines/cho
  lesterol/index.htm

Source Mosca 2004
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Lifestyle Interventions

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

Source Mosca 2007
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Lifestyle Interventions

• Smoking cessation
• Physical activity
• Heart healthy diet
• Weight reduction/maintenance
• Cardiac rehabilitation
• Omega-3 fatty acids
• Depression

Source Mosca 2007
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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
14
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 60-90 minutes
  of moderate-intensity physical activity on most,
  and preferably all, days of the week

Source Mosca 2007
15
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 lt 10 of calories, lt 300mg
  cholesterol per day
• Limit trans fatty acid intake (main dietary
  sources are baked goods and fried foods made
  with partially hydrogenated vegetable oil)

Source Mosca 2007
16
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 lt 35 inches

Source Mosca 2007
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Depression

• Consider screening women with coronary heart
  disease for depression and refer/treat when
  indicated

Source Mosca 2007
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Omega-3 Fatty Acids

• As an adjunct to diet, omega-3 fatty acid
  supplements in capsule form (approximately
  850-1000 mg of EPA and DHA) may be considered in
  women with CHD
• Higher doses (2 to 4 g) may be used for treatment
  of women with high triglyceride levels

Source Mosca 2007
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Cardiac Rehabilitation

• A comprehensive risk reduction regimen should be
  recommended to women with recent acute coronary
  syndrome or coronary intervention, new-onset or
  chronic angina, recent cerebrovascular event,
  peripheral arterial disease, or current/prior
  symptoms of heart failure and an LVEF lt 40
• Risk reduction regimens may include
• Cardiac or stroke rehabilitation
• Physician-guided home- or community-based
  exercise training programs

Source Mosca 2007
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Major Risk Factor Interventions

• Blood Pressure
• Lipids
• Diabetes

Source Mosca 2007
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Major Risk Factor Interventions

• Blood Pressure
• Target BPlt120/80 mmHg
• Pharmacotherapy if BPgt 140/90, or gt 130/80 in
  diabetics or patients with renal disease
• Lipids
• Follow NCEP/ATP III guidelines
• Diabetes
• Target HbA1Clt7, if this can be accomplished
  without significant hypoglycemia

Source Mosca 2007
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Hypertension

• Encourage an optimal blood pressure of lt 120/80
  mm Hg through lifestyle approaches
• Pharmacologic therapy is indicated when blood
  pressure is gt 140/90 mm Hg or an even lower
  blood pressure in the setting of diabetes or
  target-organ damage (gt 130/80 mm Hg)
• Thiazide diuretics should be part of the drug
  regimenfor 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
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Lipids

• Optimal levels of lipids and lipoproteins in
  women are as follows (these should be encouraged
  in all women with lifestyle approaches)
• LDL lt 100mg/dL
• HDL gt 50m/dL
• Triglycerides lt 150mg/d
• Non-HDL (total cholesterol minus HDL) lt 130mg/d

Source Mosca 2007
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Lipids

• Optimal levels of lipids and lipoproteins in
  women are as follows (these should be encouraged
  in all women with lifestyle approaches)
• LDL lt 100mg/dL
• HDL gt 50m/dL
• Triglycerides lt 150mg/d
• Non-HDL (total cholesterol minus HDL) lt 130mg/d

Source Mosca 2007
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Lipids

• In high-risk women or when LDL is elevated
• Saturated fat lt 7 of calories
• Cholesterol lt 200mg/day
• Reduce trans-fatty acids
• Major dietary sources are foods baked and fried
  with partially hydrogenated vegetable oil

Source Mosca 2007
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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
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Lipids

• Treat high risk women aggressively with
  pharmacotherapy
• LDL-lowering pharmacotherapy (preferably a
  statin) should be initiated simultaneously with
  lifestyle modification for women with LDLgt100mg/dl

Source Mosca 2007
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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 gt 200 mg/dL AND HDL lt 40 mg/dL
• LDL goal of lt 100mg/dL
• Consider statin, even if LDL lt 100mg/dL
• Optional LDL goal of lt 70mg/dL per ATP III 2004
  update

Source Grundy 2004
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High Risk Women

• gt 20 10-year risk of CHD
• CHD, large vessel atherosclerotic disease, DM
• Goal LDL lt 100mg/dL, consider statin even if
  LDLlt 100 mg/dL

Source Grundy 2004
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At-Risk Women Multiple or Severe Risk Factors,
10-20 10-Year CHD Risk

• Initiate drug therapy if LDL gt 130 mg/dL after
  lifestyle therapy
• Goal LDL lt 100 mg/dL, consider drug therapy if
  LDL 100 mg/dL

Source Grundy 2004, Mosca 2007
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At-Risk Women Multiple Risk Factors, 10-Year
CHD Risk lt 10

• Initiate drug therapy if LDL gt 160 mg/dL after
  lifestyle therapy

Source Grundy 2004, Mosca 2007
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At-Risk Women No Other Risk Factors, 10-Year
CHD Risk lt 10

• Initiate drug therapy if LDL gt 190 mg/dL after
  lifestyle therapy
• Drug therapy optional for LDL 160-189 mg/dL
  after lifestyle therapy

Source Grundy 2004, Mosca 2007
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Lipids

• High risk women
• Initiate niacin or fibrate therapy when HDL is
  low, or non-HDL is elevated after LDL goal is
  reached
• Other at-risk women
• Consider niacin or fibrate therapy when HDL is
  low, or non-HDL is elevated after LDL goal is
  reached in women with multiple risk factors and
  a 10-year CHD risk of 10-20

Source Mosca 2007
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Diabetes

• Recommendation Lifestyle and pharmacotherapy
  should be used as indicated in women with
  diabetes to achieve a HbA1C lt 7, if this can be
  accomplished without significant hypoglycemia

Source Mosca 2007
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Preventive Drug Interventions for Women with CHD

• Aspirin
• Beta-blockers
• Angiotensin converting enzyme inhibitors
• Angiotensin receptor blockers
• Aldosterone blockade

Source Mosca 2007
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Preventive Drug Interventions

• Aspirin High risk women
• 75-325 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 gt 65 years, and ischemic
  stroke prevention in women lt 65 years

Source Mosca 2007
37
Preventive Drug Interventions

• Beta-Blockers
• Should be used indefinitely in all women after
  MI, acute coronary syndrome, or left ventricular
  dysfunction with or without heart failure
  symptoms, unless contraindicated

Source Mosca 2007
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Preventive Drug Interventions

• Aldosterone blockade
• Should be used after MI in women who do not have
  significant renal dysfunction or hyperkalemia who
  are already receiving therapeutic doses of an
  angiotensin-converting enzyme inhibitor and
  beta-blocker, and have an LVEF lt 40 with
  symptomatic heart failure

Source Mosca 2007
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Preventive Drug Interventions

• Angiotensin-Converting Enzyme InhibitorsShould
  be used (unless contraindicated) after MI, and in
  those women with clinical evidence of heart
  failure or an LVEF lt 40 or diabetes mellitus
• Angiotensin-receptor blockers
• Should be used in women who cannot tolerate
  angiotensin-converting enzyme inhibitors after
  MI, and in those women with clinical evidence of
  heart failure or an LVEF lt 40 or diabetes
  mellitus, unless contraindicated

Source Mosca 2007
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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
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Interventions that are not useful/effective and
may be harmful for the prevention of heart
disease

• Antioxidant vitamin supplements (eg, vitamin E,
  C, and beta carotene) should not be used for the
  primary or secondary prevention of CVD
• Folic acid, with or without B6 and B12
  supplementation, should not be used for the
  primary or secondary prevention of CVD

Source Mosca 2007