E-01 : primitive hypertension
E- 01 : hypertension with renal disease
B-CRF : cardiovascular complications
Prevention of Cardiovascular Disease in Women: Highlights for the
Clinician of the 2011 American Heart Association Guidelines
Nanette K. Wenger
Advances in Chronic Kidney Disease. Volume 20, Issue 5 , Pages 419-422, September
2013
Emory University School of Medicine, Emory Heart and Vascular Center, Atlanta, GA
ABSTRACT
The 2011 Update to the American Heart Association Effectiveness-Based Guidelines for the
Prevention of Cardiovascular Disease in Women is designed to assist women and health
professionals in understanding the cardiovascular disease risk for women and undertaking
the most effective preventive interventions. Although coronary heart disease remains the
leading cause of mortality for women in the United States, cardiovascular mortality among
U.S. women has decreased dramatically each year since 2000, with the decline in mortality
being steeper for women than for men. Nonetheless, since 1984, more women than men
continue to die annually from cardiovascular disease. Half of the decrement in cardiovascular
mortality for women since 2000 reflects the improved management of their established
cardiovascular disease; the other half is attributable to reductions in their major coronary risk
factors, hence the importance of this prevention guideline.
Key Words: Prevention, Cardiovascular disease, Women, AHA guidelines
COMMENTS
Use of the traditional Framingham Risk Score is acknowledged to underestimate
cardiovascular risk in women, likely because of its focus on 10-year risk, in that women
develop cardiovascular disease later in life. This likely underlies the problem that physicians
and other healthcare providers characteristically underestimate the cardiovascular risk for
women, leading to underprescription and underutilization of preventive therapies.
The 2007 American Heart Association prevention guideline promulgated an algorithm
designed to reflect women's increased lifetime risk for cardiovascular disease; This simplified
approach to cardiovascular risk assessment in women classifies them as “high risk,” “at risk,”
and as at “ideal cardiovascular health.”
Characteristics of high-risk status include
•Clinically manifest coronary heart disease
•Clinically manifest cerebrovascular disease
•Clinically manifest peripheral arterial disease
•Abdominal aortic aneurysm
•End-stage kidney disease or CKD
•Diabetes mellitus
•10-year predicted cardiovascular risk ≥ 10%
At-risk women are characterized by having at least 1 of the following major risk factors:
•Cigarette smoking
•Systolic blood pressure of 120 mmHg or greater, diastolic blood pressure of 80 mmHg or
greater, or being treated for hypertension
•Total cholesterol of 200 mg/dL or greater, high-density lipoprotein cholesterol (HDL-C) less
than 50 mg/dL, or being treated for dyslipidemia
•Obesity, particularly central obesity
•Poor diet
•Physical inactivity
•Family history of premature cardiovascular disease occurring in first-degree relatives in men
younger than 55 years of age or in women younger than 65 years of age
•Metabolic syndrome
•Evidence of advanced subclinical atherosclerosis (eg, coronary calcification, carotid plaque,
or increased intima-media thickness)
•Poor exercise capacity on treadmill test and/or abnormal heart rate recovery after stopping
exercise
•Systemic autoimmune collagen-vascular disease (eg, lupus or rheumatoid arthritis)
•History of preeclampsia, gestational diabetes, or pregnancy-induced hypertension
Ideal cardiovascular health is characterized by all of the following:
•Total cholesterol less than 200 mg/dL (untreated)
•Systolic blood pressure less than 120 mmHg/diastolic blood pressure less than 80 mmHg
(untreated)
•Fasting blood glucose less than 100 mg/dL (untreated)
•Body mass index (BMI) less than 25 kg/m2
•Abstinence from smoking
•Physical activity at goal for adults older than 20 years of age: 150 minutes/week or more of
moderate intensity, 75 minutes/week or more of vigorous intensity, or a combination
•Healthy (Dietary Approaches to Stop Hypertension (DASH)-like) diet
Newly added to the at-risk characteristics since 2007 is the evidence of systemic
autoimmune collagen vascular disease, particularly lupus or rheumatoid arthritis; because of
the increased relative risk for cardiovascular disease in these women, they should be
screened for cardiovascular risk factors.
Also newly added are complications of pregnancy, which appear to be early indicators of
cardiovascular risk, mandating the appropriate referral of women with these pregnancy
complications for cardiovascular risk assessment and surveillance. Highlighted is that a
detailed history of pregnancy complications should be part of the routine cardiovascular risk
assessment for all women.
Thus, the recommended evaluation for cardiovascular risk in women encompasses a
medical history that includes a family history and a history of pregnancy complications,
assessment of symptoms of cardiovascular disease, and depression screening for women
documented to have cardiovascular disease. Physical examination for risk assessment
should include measurements of blood pressure, BMI, and waist circumference; laboratory
tests should include fasting lipoprotein and glucose levels; and a Framingham Risk
assessment should be performed if there is no evidence for cardiovascular disease, CKD, or
diabetes mellitus.
Pr. Jacques CHANARD
Professor of Nephrology