Juggling Multiple Guidelines: A Woman's Heart in the Balance

In 2011, the American Heart Association (AHA) issued the pivotal "Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women-2011 Update." In the interim, multiple guidelines have dramatically altered recommendations for preventive cardiovascular care. This article addresses how I juggle these multiple guidelines in my clinical practice. In brief, my approach to risk stratification is to use the Pooled Cohort Equations, but I also routinely assess the risk factors unique to or predominant in women such as pregnancy complications and systemic autoimmune collagen vascular diseases. I follow the 2013 AHA/American College of Cardiology (ACC) Guidelines on Lifestyle Management to Reduce Cardiovascular Risk, but find value in the detailed aspects of physical activity recommendation in the 2011 Women's Guideline, including those for weight loss or weight loss maintenance. Based solely on epidemiological data, I consider a blood pressure (BP) of 120//80 mmHg ideal in women who remain asymptomatic at that level. I typically titrate BP therapy to 120-130/80-90 mmHg as tolerated. I endorse the current ACC/AHA recommendations for cholesterol management, but for my women patients older than age 75 who previously tolerated a high-intensity statin, I continue that medication or whatever statin they tolerated through age 75. For women older than age 75 with a recent acute atherosclerotic cardiovascular disease (ASCVD) event, a high-risk population, I follow the guideline for younger patients. As ASCVD events are becoming more common before 40 years of age, I screen younger women earlier when risk factors unique to or predominant in women are present. I incorporate sex-specific risk factors for stroke in the risk ascertainment component of women's medical records. With regard to depression, at minimum I perform screening for all women with coronary heart disease with a 2-item Patient Health Questionnaire (PHQ-2). For women with suspected ischemic heart disease, I adhere to the recommendations of the 2014 Consensus Statement of the AHA, "The Role of Noninvasive Testing in the Evaluation of Women with Suspected Ischemic Heart Disease." An unmet need remains an updated guideline on Prevention of Cardiovascular Disease in Women.