Risk Identification and Reduction of CVD in Women

Brown HL, Warner JJ, Gianos E, et al.
Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists: A Presidential Advisory From the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation 2018;May 10:[Epub ahead of print].

The American Heart Association and the American College of Obstetricians and Gynecologists have issued a Presidential Advisory to raise awareness of cardiovascular disease (CVD) risk factors among women. The majority of women consider their obstetrician/gynecologist to be their primary physician during the childbearing years, which is an important time period for atherosclerotic CVD (ASCVD) risk assessment and primary prevention. Additionally, cardiologists need to be aware of sex-specific CVD risk factors. The following are key points to remember from this joint statement about CV risk in women:

  1. The population-adjusted risk of CV mortality is higher for women (21%) than men (15%).
  2. Traditional ASCVD risk factors may affect women differently than men:
    • Women over 65 years of age are more likely to be hypertensive than men and less likely to be adequately treated.
    • Diabetes mellitus, obesity, psychosocial factors, and smoking increase the risk of ASCVD more in women than in men.
    • Physical inactivity is the most prevalent risk factor for women. Women are 55% less likely than men to participate in cardiac rehabilitation.
  3. Female predominant risk factors include autoimmune disorders such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma. Breast cancer and its treatment also increase the risk for ASCVD.
  4. Sex-specific ASCVD risk factors are related to pregnancy and hormonal influences, such as polycystic ovarian syndrome, functional hypothalamic amenorrhea, unsuccessful fertility therapy, menopausal status, and hormone use.
  5. Pregnancy complications associated with increased future risk of ASCVD include preeclampsia, gestational diabetes mellitus, gestational hypertension, preterm delivery, and low-for-estimated-gestational age birth weight. Even when these conditions resolve, women remain at increased risk for ASCVD. For example, preeclampsia and gestational hypertension are associated with a three- to six-fold increased risk of later developing hypertension and a two-fold risk for ischemic heart disease and stroke.
  6. Oral contraceptives do not increase ASCVD risk in women without traditional risk factors. Smokers on oral contraceptives have a seven-fold increase in CVD risk. Hypertension can worsen in association with oral contraceptivess.
  7. Postpartum follow-up visits and well-woman visits should be an opportunity for ASCVD risk assessment, counseling, and risk reduction. Among pregnant women, 30-40% have one risk factor that can lead to long-term health problems, and 20-30% carry a predictor of ASCVD risk.
  8. Women with hyperlipidemia should be counseled to lower saturated fats and increase dietary fiber by following a DASH, Mediterranean, or plant-based whole food diet. Guidelines recommend against the use of statins during pregnancy, although data about safety are mixed. Pregnant women with triglycerides >1000 mg/dl may benefit from fenofibrates, particularly if they also have hypertension or diabetes mellitus.
  9. Physical activity (moderate-intensity) is supported during pregnancy (if not contraindicated) and may reduce the risk of preeclampsia and gestational diabetes.
  10. Patients need to be asked about sex-specific risk factors, despite these risk factors not being included in traditional risk assessment tools. The use of electronic health record templates could be useful.
  11. Traditional risk factors should be addressed, including metabolic syndrome, diabetes, hypertension, dyslipidemia, optimal weight/weight loss and dietary concerns, physical inactivity, smoking, and mental health and stress.
  12. Several educational resources for physicians and patients are listed at the end of this statement.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Diet, Exercise, Hypertension, Smoking

Keywords: Amenorrhea, Arthritis, Rheumatoid, Breast Neoplasms, Cardiac Rehabilitation, Cardiovascular Diseases, Contraceptives, Oral, Coronary Artery Disease, Diabetes, Gestational, Diet, Dietary Fiber, Electronic Health Records, Exercise, Fenofibrate, Fertility, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipidemias, Hypertension, Pregnancy-Induced, Lupus Erythematosus, Systemic, Menopause, Metabolic Syndrome X, Obesity, Polycystic Ovary Syndrome, Postpartum Period, Pre-Eclampsia, Pregnancy, Primary Prevention, Risk Assessment, Risk Factors, Risk Reduction Behavior, Smoking, Stroke, Triglycerides, Weight Loss, Women

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