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EDITORIAL
SA JOURNAL OF DIABETES & VASCULAR DISEASE
52
VOLUME 8 NUMBER 2 • JUNE 2011
Taking women into the new millennium: updated guidelines
for prevention of cardiovascular disease
NAOMI RAPEPORT
A
pandemic of cardiovascular disease (CVD) is afflicting
women. Heart disease is the leading cause of death
in women in every major developed country and most
emerging economies.
1
Although it is often thought of as a disease
of affluence, CVD mortality rates in women over the age of 60
years are more than double in low- and middle-income countries
than in high-income countries.
2
Much of the burden of this disease can be attenuated by
addressing critical risk factors such as hypertension, type 2 diabetes
mellitus (DM), dyslipidaemia, physical inactivity, tobacco use,
overweight and obesity. These risk factors account for 63% of the
deaths due to CVD and DM, and over three-quarters of the deaths
from coronary heart disease (CHD).
3
Tobacco use, overweight and
obesity are currently more prevalent in middle- and high-income
countries. However this situation may change, as it is projected that
by 2030, almost 75% of tobacco-related deaths will occur in low-
and middle-income countries.
3
In high-income countries, cardiovascular mortality rates in
women have declined. This is secondary to modifications in risk
behaviour, such as reduced tobacco use and increased physical
activity, better management of hypertension and dyslipidaemia,
and improved treatment of existing cardiovascular conditions.
4
These benefits are not apparent in low- and lower middle-income
countries where only a quarter of women with chronic heart
disease receive treatment.
5
In the USA, a high-income country, these positive trends are
changing. CHD mortality rates in women aged 35 to 54 years are
increasing, attributed to the obesity epidemic.
4
Nearly two out of
every three American women over 20 years of age are overweight
or obese.
6
This rise in obesity is a major contributor to the increased
prevalence of DM, which has a direct impact on the overall risk of
myocardial infarction (MI) and stroke.
7
In some ethnic groups, there
is a higher prevalence of certain risk factors, such as hypertension
among African-American women and DM in Hispanics.
6
African-
American women have the highest CHD death rates and the
highest overall CVD morbidity and mortality.
6
In Africa, data from the Interheart Study showed that women
of African ancestry presented with their first MI at a younger age
than those from western Europe and North America (median age
of 56 vs 68 and 64 years, respectively).
8
In the Heart of Soweto
study, women presented with CVD also in their fifties, and were
slightly younger than the men (53 vs 55 years,
p
=
0·031).
9
In this
cohort, heart failure (HF) was the most common primary diagnosis.
Few had coronary artery disease, but they had a high prevalence
of cardiovascular risk factors, particularly hypertension and obesity.
While most of the morbidity and mortality from CVD occurs
at older ages, exposure to these risk factors starts earlier in life,
and therefore preventive interventions need to target younger
women. The first women-specific clinical recommendations for the
prevention of CVD were published in 1999, even though there were
little gender-specific research data.
10
Prior to this, it was advised
that women be treated the same as men despite the exclusion of
women from most clinical trials. Since the late 1990s, increasing
numbers of women have participated in CVD studies, resulting
in gender-specific analyses. Furthermore, major randomised,
controlled clinical trials in women, such as the Women’s Health
Initiative, have changed the practice of CVD prevention.
11
In 2004, the Evidence-Based Guidelines for Cardiovascular
Disease Prevention inWomen were published.
12
The 2004 guidelines
confirmed that menopausal therapy [hormone-replacement
therapy (HRT) and selective oestrogen-receptor modulators] was
not a preventive treatment modality. It was given a class III status
(i.e. not useful/effective and may cause harm) for both primary
and secondary prevention of CVD. Oestrogen HRT had previously
been advocated for all postmenopausal women with coronary and
other vascular disease. To date this recommendation has remained
unchanged. Other class III interventions that also remain unchanged
include the use of antioxidant supplements such as vitamins E, C
and beta-carotene, and folic acid with or without vitamin B6 and
B12 supplementation. The routine use of aspirin in healthy women
under 65 years of age is not recommended to prevent MI.
In 2004, the Global Risk Assessment was advocated to stratify
patients’ CHD risk. It utilises the Framingham risk score, whereby,
based on the level of risk, drug therapy for hypercholesterolaemia
is advised, according to the National Cholesterol Education Panel
Adult Treatment Panel III (NCEP ATP III) targets.
In the 2007 update of these guidelines, emphasis was placed
on pre-clinical detection of disease to identify asymptomatic
individuals at high risk who could benefit from early intervention.
13
A new algorithm for risk classification was adopted that stratified
women into three categories. Women at ‘high risk’ are those
with documented CVD (such as established CHD, cerebrovascular
disease, peripheral arterial disease or abdominal aortic aneurysm),
DM, chronic kidney disease, or a 10-year predicted risk for CHD
of 20% or more. ‘At-risk’ women have one or more major CVD
risk factors [such as cigarette smoking, poor diet, physical inactivity,
obesity – particularly central adiposity, family history of premature
CVD (male relative below 55 years or female relative below 65
years), hypertension, dyslipidaemia, evidence of subclinical vascular
disease (e.g. coronary calcification), metabolic syndrome, poor
exercise capacity on treadmill test, and abnormal heart rate recovery
after stopping exercise]. Women are regarded as ‘at optimal risk’
if they have no major CVD risk factors and engage in a healthy
lifestyle.
Despite these guidelines, there are problems with risk
Correspondence to: Naomi Rapeport
Milpark Hospital, Johannesburg
e-mail: cscham@global.co.za
S Afr J Diabetes Vasc Dis
2011;
8
: 52–53.
