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New Guidelines Target Women and Heart Disease

By Sean Henahan, Access Excellence
Copyright 2004

Heart disease is the leading cause of death among American women. Yet recent surveys indicate that many women continue to underestimate the threat of heart disease, and continue to hold misconceptions regarding which lifestyle interventions are most beneficial. In part to amend this situation, the American Heart Association recently released updated guidelines for the prevention and treatment of heart disease in women. Sean Henahan talked to the director of the group that formulated the new AHA guidelines, Lori Mosca MD, MPH, PhD, about how and why they were created and what role they might play in improving public health. Dr Mosca is the Chair of Preventive Cardiology at New York Presbyterian Hospital.

Q: Would you give us some background about the new AHA guidelines for the prevention and treatment of heart disease in women? What was the rationale for preparing them?

A: Cardiovascular disease claims the lives of more than half a million women in this country every year, more than all types of cancers combined. That is one death every minute. And yet our surveys tell us that few women are aware of the degree of risk posed by heart disease.

There have been a lot of important advances in the treatment of heart disease in recent years. Previous guidelines for the prevention and treatment of cardiovascular disease have been based primarily on studies that involved men. We wanted to have a set of guidelines that we could be confident would offer the best current information on women in particular. Moreover, it has become clear from studies conducted in past five years that women are not getting the same preventive and therapeutic cardiovascular care that men are. We wanted to close that treatment gap. We wanted to make sure that we used reliable data to support preventive intervention in women.

Another rationale for creating the guidelines is exemplified in the recent Women's Health Initiative (WHI) study findings regarding hormone therapy. The study was just halted by the National Institutes of Health following the finding that hormone replacement therapy was not, as had been believed, preventing heart disease in post-menopausal women. This was a huge surprise because thousands and thousands of women had been receiving hormones to prevent heart disease, when we really didn't have quality of evidence to support that approach. This showed how some preventive interventions in women had became standard of care before we really had the scientific proof that we needed to make such strong recommendations.

Shutting down the estrogen-only arm of the WHI was the final nail in the coffin for hormone therapy. But there is good news as well. We now have a set of guidelines that are clear about what experts have documented will prevent heart disease and what will not. The guidelines assign a class III recommendations to hormone therapy, that is considered to be not useful or effective and potentially harmful.

Q: Could you tell us something about the guidelines were developed?

A: Under the auspices of the American Heart Association, we formed a team of 27 recognized authorities in different areas of heart disease. The researchers searched the world literature of the past 100 years, and systematically analysed the data from general studies, also looking at subgroup analysis of women. The team identified more than 7000 articles. They graded the articles as to quality of evidence that would used to support any subsequent recommendations. The team also developed a generalizability index, to determine likelihood that research done in men would apply to women. This formed the basis for a series of recommendation graded as Class I, Class II or Class III <see table>. The end result is hat physicians now have a tool for calculating a woman's ten-year risk of having a heart attack or stroke, along with a series of recommendations for individualized treatment.

Q: Let's talk about prevention. We are always hearing about the growing obesity epidemic in this country. Many people seem to realize the importance of losing weight, but it seems that lot more of them are going for the high protein, high fat Atkins diet approach, than the low fat heart health diet recommended by the AHA. Are you concerned by this?

A: Yes, I'm very concerned. Even though it may be associated with temporary weight loss, there is absolutely no evidence that the Atkins diet would prevent heart disease. I think a person that follows the Atkin's diet is likely to end up as a thin corpse. There is just no way that eating that amount of fat is going to be good for your coronary arteries. There will probably never be a randomised trial of the Atkins diet versus the AHA diet because it would be unethical to feed people a high fat diet. We have known for decades that societies that eat high fat die at higher rates of heart disease. We also know that following the basic guidelines of the AHA diet is a good step towards a heart healthy lifestyle.

Q: We've known since the 1960s that lowering blood pressure in hypertensive patients reduced the risk of heart attack and stroke. We've also learned that lowering cholesterol has similar effects. Are these interventions equally useful for men and women?

A: There is not a gender difference in the treatment of high blood pressure or high cholesterol. There is ample data to support treatment of both men and women. The trends we saw when we looked at the benefits of cholesterol and blood pressure lowering therapy indicated that they provided equal or potentially greater benefit in women.

Q: The new guidelines do differ somewhat from the men's guidelines when it comes to the use of long-term aspirin therapy to reduce the risk of heart attack. Tell us about that.

A: Aspirin is a situation where, in some cases, aspirin therapy may be more harmful for women than for men. That may be because women are more likely to have a hemorrhagic or bleeding type of stroke. Women are also more likely to have uncontrolled hypertension, which also puts them at risk for a hemorrhagic stroke. We are more conservative in women because the risk/benefit ratio differs from what we see in men. The aspirin recommendations are the best example of how the guidelines take a more personalized approach to treatment. We recommend that women be stratified in high risk, intermediate risk, and lower risk categories. Depending on their risk level, we then make a recommendation about how aggressive to be with preventive therapy. High-risk women, all should use aspirin therapy unless otherwise contraindicated, at lowest dose possible, one 80 mg baby aspirin per day. The data are quite good for that approach. In the lower risk category, we make the opposite recommendation. We suggest that women in that group do not use aspirin therapy for prevention of heart disease, because the potential for side effects might outweigh any benefit, which is still unproven at this point. For women at intermediate risk, we suggest, the physicians individualize the treatment based on the woman's risk for heart disease and stroke, including the risk of bleeding from hemorrhagic stroke, or bleeding from the gastrointestinal tract.

Q: Your own research suggests that women continue to hold some unusual ideas about lowering their risk for heart disease, don't they?

A: We did a national survey of women's awareness of heart disease. We were happy to see that most of the women surveyed appreciated the value of exercise, weight loss and stress reduction for reducing heart disease risk. However, we also saw that many women believed that complementary and alternative medicine approaches such as antioxidant vitamin supplementation and aromatherapy could also lower risk. There are a lot of myths out there. However, our review found no evidence to support the value of antioxidant vitamin supplements, and there have been no reliable clinical trials with aromatherapy. Again, this was the rationale for creating the guidelines- we wanted to make sure that we were very clear about the available evidence to support different preventive strategies.

Q: By now most people should be at least somewhat aware that lifestyle modification, such as quitting smoking, moderating alcohol consumption and maintaining a health weight all contribute to a longer, healthier life. Yet it doesn't seem like a lot of busy doctors take the time to counsel their patients about this. What are your thoughts?

A: Lifestyle modification has been, is and always will be the primary method for prevention of heart disease. Our panel gave this a class I recommendation, our strongest recommendation. It has importance for prevention of heart disease regardless of how it affects your blood pressure or cholesterol level. There are so many good things about diet and exercise that you can't measure in terms of risk factors. If I were to write a prescription for the perfect drug, one that improves blood reactivity, lowers blood pressure, cholesterol, and heart rate, all with minimal side effects, that perfect drug would be exercise. The problem now is that less than 20% of doctors counsel women about lifestyle maneuvers in primary care practice. Women need to be proactive about their own lifestyles and they need to talk to their physicians about what the risk factors are, what their goals are and how they are going to reach those goals.

This interview was conducted on March 2nd, 2004.



Dr. Mosca

Classification and levels of evidence

Class I
Intervention is useful and effective
Class II
Weight of evidence/ opinion favors usefulness and efficacy
Class III
Intervention is not useful/effective; may be harmful

Level of Evidence

A Sufficient evidence from multiple randomized trials

B Limited evidence from single randomized trial or other nonrandomized studies

C Based on expert opinion, case studies, or standard of care

Generalizability index

1 Very likely that results generalize to women

2 Somewhat likely that results generalize to women

3 Unlikely that results generalize to women

0 Unable to project whether results generalize to women




A normally functioning heart pumps about 3 ounces of blood with each beat, or about 5 or more quarts per minute.

Source- Mayo Clinic


Primary Risk Factors for Heart Disease

1. Tobacco smoking
3. Physical Inactivity
4. High cholesterol
5. Diabetes Mellitus
6.High Blood Pressure

Source: AHA







Your heart pumps blood through a network of 60,000 miles of vessels.

Source- Mayo Clinic


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