Guide to Preventive Cardiology for Women

C oronary heart disease (CHD) is the single leading cause of death and a significant cause of morbidity among American women. 1 Risk factors for CHD in women are well documented. 2 Compelling data from epidemiological studies and randomized clinical trials show that CHD is largely preventable.Assessment and management of several risk factors for CHD are cost-effective.3 Despite these facts, there are alarming trends in the prevalence and management of risk factors in women. 2 Smoking rates are declining less for women than for men.The prevalence of obesity is increasing, and Ϸ25% of women report no regular sustained physical activity.4 Approximately 52% of women Ͼ45 years old have elevated blood pressure, and Ϸ40% of women Ͼ55 years old have elevated serum cholesterol.5 The purpose of this statement is to highlight risk factor management strategies that are appropriate for women with a broad range of CHD risk.A more detailed description, including the scientific basis for these recommendations, is available in the 1997 American Heart Association scientific statement "Cardiovascular Disease in Women." 2 Recently, the Centers for Disease Control and Prevention National Ambulatory Medical Care Survey 6 showed clinicians are missing opportunities to prevent CHD.In this study of 29 273 routine office visits, women were counseled less often than men about exercise, nutrition, and weight reduction.In the multicenter Heart and Estrogen/progestin Replacement Study (HERS), 7 only 10% of women enrolled with documented CHD had baseline LDL-cholesterol levels below a National Cholesterol Education Program (NCEP) target of 100 mg/dL.A recent national survey showed that women were significantly less likely than men to enroll in cardiac rehabilitation after an acute myocardial infarction (MI) or bypass surgery.8 This finding is especially important because post-MI patients not enrolled in cardiac rehabilitation are less likely to receive aggressive risk factor management.Recommendations for the primary and secondary prevention of CHD have been published.9,10 Although those recommendations apply to women, there are aspects of risk factor management that are unique to women.Pregnancy and the preconception period are optimal times to review a woman's risk factor status and health behaviors to reduce future cardiovascular disease.Pregnant women should be strongly encouraged to discontinue smoking and not to relapse in the postpartum period.Avoidance of excess weight gain during pregnancy may reduce the risk of developing CHD in the future.An emphasis on prevention of CHD in postmenopausal women is particularly important because the incidence of CHD rises with age.The use of estrogen replacement therapy (ERT) to prevent CHD, osteoporosis, and possibly dementia is a difficult health decision for postmenopausal women.The potential benefits of therapy must be weighed against the possible risks, including breast cancer, gallbladder disease, thromboembolic disease, and endometrial cancer, although the last is reduced by concomitant use of a progestin.The recent findings from HERS 11 have challenged previous observational data regarding the role of hormones in preventing subsequent cardiovascular events.HERS was the first largescale, randomized, clinical trial in older postmenopausal women with confirmed coronary disease to test the efficacy and safety of hormone replacement therapy on clinical cardiovascular outcome in postmenopausal women.The study population included 2763 women (mean age 66.7 years) with established CHD randomly assigned to 0.625 mg conjugated equine estrogens (CEE) plus 2.5 mg of medroxyprogesterone acetate (MPA) per day or placebo.Participants were monitored for an average of 4.1 years for the main end point of nonfatal MI or CHD death.At study completion, no significant differences existed between groups for any cardiovascular end points.Surprisingly, after 1 year, HERS showed an increase in cardiovascular events in the treatment arm, but in years 4 and 5, fewer events occurred than in the placebo arm.It has been hypothesized that possible early adverse effects of estrogen in women with CHD may be due to a procoagulant effect that may later be offset by an antiatherogenic benefit.MPA may also have adverse cardiovascular effects and may mitigate some of the beneficial effects of estrogen.2 Although these hypotheses deserve further investigation, the overall null result from HERS does not support initiation of CEE combined with MPA in older postmenopausal women with confirmed coronary disease.For women with CHD already on ERT for Ն1 year, it may be reasonable to continue therapy while awaiting the results of a HERS follow-up study and other ongoing trials of ERT with clinical end points.The results of the HERS trial apply to women with preexisting CHD and may not apply to women free of vascular "A Guide to Preventive Cardiology for Women" was approved by the American College of Cardiology Board of Trustees on February 22, 1999, and by the American Heart Association Science Advisory and Coordinating Committee on September 7, 1998.