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SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDITORIAL
VOLUME 8 NUMBER 2 • JUNE 2011
53
stratification of women. There is a general underestimation of CHD
risk, which has focused on short-term (10-year) risk and on MI and
CHD death. Women with a high prevalence of subclinical disease
are scored as low risk.
6,14
In non-Caucasian populations there are
problems of risk estimation, and in the elderly there is also an
underestimation of risk. A woman aged 75 years with several risk
factors will score below a 10% 10-year predicted risk for CHD.
15,16
Few women qualify for lipid-lowering therapy for prevention of
CHD.
In the most recent updated 2011 guidelines, these anomalies
have been addressed.
17
The focus is now on long-term risk for CVD
rather than solely on 10-year risk for CHD. The new cut-off point
for defining ‘high risk’ is a risk of 10% or more of death from
any cardiovascular event in the next 10 years (previously it was
20% or more). Other modifications include the use of new risk-
stratification scores (the updated Framingham CVD risk profiles and
the Reynolds risk score for women).
18,19
New major risk categories
are patients with systemic autoimmune collagen vascular disease
(such as systemic lupus erythematosus and rheumatoid arthritis)
as these disorders are known to be associated with a significantly
increased relative risk for CVD.
20
Women with a history of pre-
eclampsia, gestational DM or pregnancy-induced hypertension are
also deemed to be at major risk.
21,22
When assessing risk, it is advised that the use of CVD risk
biomarkers (such as ultra-sensitive C-reactive protein) and imaging
technologies (such as coronary calcium-scoring assessment and
carotid intima–media thickness) be reserved for refining risk
estimates in patients where there is uncertainty about the need to
start statin therapy.
23,24
The 2011 guidelines also focus on stroke and heart failure. As
women age, their risk for stroke and HF tends to increase in excess
of the risk for CHD.
A new concept of ‘ideal cardiovascular health’ has been proposed
and should be adhered to in all women. This is the absence of
clinical CVD and the presence of ideal levels of total cholesterol
(
<
5.2 mmol/l), untreated blood pressure less than 120/80 mmHg,
untreated fasting blood glucose less than 5.6 mmol/l, body mass
index less than 25 kg/m
2
, and a lifestyle that includes smoking
abstinence and physical activity (for adults aged 20 years or more
of at least 150 minutes per week of moderate-intensity exercise
and at least 75 minutes per week of vigorous-intensity exercise, or
a combination of both). When achieved or maintained into middle
age, the overall pattern of ideal cardiovascular health is associated
with greater longevity, reduction in risks for CVD events and greater
quality of life in older age.
25
In the new millennium, there is no longer any doubt about what
strategies and treatment are required to reduce CVD in women.
The major hurdle is to implement these guidelines early. This is
particularly so in low- and middle-income countries. If we are to
have any impact on the looming pandemic of CVD in the developing
world, such as sub-Saharan Africa, we should not hesitate to adopt
these updated guidelines.
References
1.
Gholizadeh L, Davidson P. More similarities than differences: an international
comparison of CVD mortality and risk factors in women.
Health Care Women
Int
2008;
29
: 3–22.
2.
The global burden of disease: 2004 update. Geneva, World Health Organisation,
2008.
3.
Women and Health: Today’s Evidence Tomorrow’s Agenda. Geneva, World Health
Organisation, 2009.
4.
Ford ES, Ajani UA, Croft JB,
et al
. Explaining the decrease in US deaths from
coronary disease, 1980–2000.
N Engl J Med
2007;
356
: 2388–2398.
5.
World health survey. Geneva, World Health Organisation (http://www.who.int/
healthinfo/survey/en/).
6.
Roger VL, Go AS, Lloyd-Jones DM,
et al
. American Heart Association Statistics
Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics
– 2011 update: a report from the American Heart Association.
Circulation
2011;
123
: e18–e209.
7.
Preis SR, Hwang SJ, Coady S,
et al
. Trends in all-cause and cardiovascular disease
mortality among women and men with and without diabetes mellitus in the
Framingham Heart Study, 1950 to 2005.
Circulation
2009;
119
: 1728–1735.
8.
Yusuf S, Hawken S, Ôunpuu S,
et al
. Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries (the INTERHEART study):
case-control study.
Lancet
2004;
364
: 937–952.
9.
Sliwa K, Wilkinson D, Hansen C,
et al
. Spectrum of heart disease and risk factors
in a black urban population in South Africa (the Heart of Soweto Study): a cohort
study.
Lancet
2008;
371
: 915–922.
10. Mosca L, Grundy SM, Judelson D,
et al
. Guide to preventive cardiology for
women: AHA/ACC Scientific Statement Consensus panel statement.
Circulation
1999;
99
: 2480–2484.
11. Rossouw JE, Anderson GL, Prentice RL,
et al
. Risks and benefits of estrogen plus
progestin in healthy postmenopausal women: principal results from the Women’s
Health Initiative randomized controlled trial.
J Am Med Assoc
2002;
288
: 321–
333.
12. Mosca L, Appel LJ, Benjamin EJ,
et al
. Evidence-based guidelines for cardiovascular
disease prevention in women.
Circulation
2004;
109
: 672–693.
13. Mosca L, Banka CL, Benjamin EJ,
et al
. Evidence-based guidelines for cardiovascular
disease prevention in women: 2007 update.
Circulation
2007;
115
: 1481–1501.
14. Lakoski SG, Greenland P, Wong ND,
et al
. Coronary artery calcium scores and risk
for cardiovascular events in women classified as ‘low risk’ based on Framingham
risk score: the Multi-Ethnic Study of Atherosclerosis (MESA).
Arch Intern Med
2007;
167
: 2437–2442.
15. Cavanaugh-Hussey MW, Berry JD, Lloyd-Jones DM. Who exceeds TP-III risk
thresholds? Systematic examination of the effect of varying age and risk factor
levels in the ATP-III risk assessment tool.
Prev Med
2008;
47
: 619–623.
16. Vasan RS, Sullivan LM, Wilson PW,
et al
. Relative importance of borderline and
elevated levels of coronary heart disease risk factors.
Ann Intern Med
2005;
142
:
393–402.
17. Mosca L, Benjamin EJ , Berra K,
et al
. Effectiveness-based guidelines for the
prevention of cardiovascular disease in women – 2011 update: A guideline from
the American Heart Association.
Circulation
2011;
123
: 1243–1262.
18. D’Agostino RB Sr, Vasan RS, Pencina MJ,
et al
. General cardiovascular risk profile
for use in primary care: the Framingham Heart Study.
Circulation
2008;
117
:
743–753.
19. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved
algorithms for the assessment of global cardiovascular risk in women: the
Reynolds risk score.
J Am Med Assoc
2007;
297
: 611–619.
20. Salmon JE, Roman MJ. Subclinical atherosclerosis in rheumatoid arthritis and
systemic lupus erythematosus.
Am J Med
2008;
121
(suppl 1): S3–S8.
21. Bellamy L, Casas JP, Hingorani AD,
et al
. Pre-eclampsia and risk of cardiovascular
disease and cancer in later life: systematic review and meta-analysis.
Br Med J
2007;
335
: 974.
22. Garovic VD, Hayman SR. Hypertension in pregnancy: an emerging risk factor for
cardiovascular disease.
Nat Clin Pract Nephrol
2007;
3
: 613–622.
23. Hlatky MA, Greenland P, Arnett DK,
et al
. Criteria for evaluation of novel markers
of cardiovascular risk: a scientific statement from the American Heart Association.
Circulation
2009;
119
: 2408–2416.
24. Greenland P, Alpert JS, Beller GA,
et al
. 2010 ACCF/AHA guideline for assessment
of cardiovascular risk in asymptomatic adults: a report of the American College
of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines.
Circulation
2010;
122
: e584–e636.
25. Lloyd-Jones DM, Hong Y, Labarthe D,
et al
. Defining and setting national goals
for cardiovascular health promotion and disease reduction: the American Heart
Association’s Strategic Impact Goal through 2020 and beyond.
Circulation
2010;
121
: 586–613.
