Female‐friendly focus: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Cardiovascular disease remains the leading cause of morbidity/mortality for U.S. women, with one of four U.S. women dying from cardiovascular disease. Importantly, two of three U.S. women have at least one major traditional coronary risk factor, and this percentage increases with older age. Appropriately, most recommendations from the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Primary Prevention of Cardiovascular Disease1 are not gendered, reflecting the scientific databases from which they were derived, although admittedly women were underrepresented in most studies. The basis for individual patient preventive recommendations is use of the Pooled Cohort Equations; the resultant Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score is calculated separately for women and men (Figure 1 ). New to this guideline is consideration of risk-enhancing factors, a concept that may particularly advantage women. Advocated in this listing is the consideration of features unique to or predominant in women. These include pregnancy-associated conditions such as a history of preeclampsia,2 preterm delivery,3 small for gestational age infants, chronic inflammatory diseases, such as rheumatoid arthritis,4 lupus,5 or HIV/AIDS infection6 and if measured persistently elevated inflammatory markers, A history of premature menopause is also relevant.7 The ASCVD Risk Score, for example, fails to capture that individuals of South Asian ancestry constitute a high-risk population.8 Metabolic syndrome, a not infrequent presentation for women, encompasses the risk of increased waist circumference, elevated triglycerides, elevated blood pressure, elevated glucose and low HDL-cholesterol. For women at intermediate risk (a sizeable population since only 1 in 5 U.S. women has no traditional cardiovascular risk factors), addressing risk-enhancing factors for women assumes particular importance in the clinician/patient risk discussion. A detailed pregnancy history is an integral component of risk assessment for women, in that complications of pregnancy, specifically preeclampsia, gestational diabetes, pregnancy-induced hypertension, preterm delivery, and small for gestational age infants, are early indicators of an increased cardiovascular risk. More specifically, preeclampsia and gestational diabetes impart a 3- to 6-fold increased risk for subsequent hypertension, a 2-fold increased risk of ischemic heart disease and stroke. And although many manifestations of preeclampsia subside with the delivery of the placenta, there remains residual endothelial dysfunction, and this is associated with an increase in coronary artery calcium.9 Systemic autoimmune disorders are highly prevalent in women and increase the risk of coronary heart disease and cerebrovascular accident. Indeed, coronary disease is the leading cause of morbidity and mortality in women with systemic lupus erythematosus. There is a 2- to 3-fold increase in myocardial infarction and cardiovascular mortality in women with rheumatoid arthritis, and an increased risk of cardiovascular events with psoriatic arthritis, warranting screening for traditional cardiovascular risk factors in such women.10, 11 For adults 40 to 75 years, the Guideline recommends that clinicians routinely assess cardiovascular risk factors and calculate the 10-year ASCVD risk score. At age 20 to 39 years, it is reasonable to assess traditional risk factors at least every 4 to 6 years. In this younger population, however, the pregnancy-associated risk factors may uniquely identify the younger woman at increased risk. In adults at borderline risk (5% to <7.5%) 10-year ASCVD risk, or intermediate risk (≥ 7.5% to <20%) 10-year ASCVD risk, it is reasonable to use additional risk enhancing factors to guide decisions about preventive interventions (eg, statin therapy). For adults at borderline risk and with uncertain evidence-based indications for preventive interventions, it is reasonable to measure a coronary artery calcium score to guide clinician/patient risk discussions. This may be particularly relevant for women in that in the MESA database, women in the highest quintile of coronary calcium had a low risk Framingham risk score.12 Diet should emphasize the intake of vegetables, fruits, legumes, nuts, and fish. Recommendations are that adults engage in at least 150 minutes weekly of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity. In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk profile. Obesity is identified as a body mass index (BMI) ≥ 30 kg/m2 and overweight as a BMI = 25 to 29 kg/m2. Type 2 diabetes mellitus Diabetes confers greater cardiovascular risk for women than for men, 19.1% vs 10.1%. It is associated with a 40% increased risk of incident coronary heart disease and a 25% increased risk of stroke. Importantly, in most studies diabetic women compared with diabetic men have lesser treatment and control of conventional cardiovascular risk factors.16 A tailored nutrition plan focusing on a healthy dietary pattern is recommended to improve glycemic control and achieve weight loss if needed, and physical activity guidelines are noted above. It is reasonable to initiate metformin as first line therapy at the diagnosis of diabetes. With additional ASCVD risk factors a sodium-glucose cotransporter-2 (SGLC-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) agonist is prudent to improve glycemic control and reduce CVD risk. Diabetic women have a greater burden of traditional ASCVD risk factors, and risk factor control is often suboptimal in diabetic women.17-20 High blood cholesterol Hypercholesterolemia imposes the highest population-adjusted cardiovascular risk for women, 47%, with similar statin benefit evident for women and men.13, 21 Use of blood pressure lowering medications is recommended for primary prevention with a systolic blood pressure of 130 mm Hg or higher and a diastolic pressure of 80 mm Hg or higher. Tobacco use status should be assessed at every healthcare visit, with a goal of tobacco abstinence. Low-dose aspirin may be considered for the primary prevention of ASCVD among selected adults at higher ASCVD risk, but not at increased bleeding risk. It should not be routinely used for primary prevention among adults older than age 70. Consideration of cardiovascular risk factors unique to or predominant in women as risk-enhancing features in clinician/patient preventive shared decision-making discussions will likely result in an improved spectrum of care for women.