The following are key points to remember from this state-of-the-art review of updated recommendations for primary prevention of cardiovascular disease (CVD) in women:

1. CVD continues to be the leading cause of morbidity and mortality among women.
2. Unique risk factors related to female sex include pregnancy-associated conditions such as hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and pregnancy loss. Intrauterine growth restriction has also been associated with increased risk for dyslipidemia, insulin resistance, and diastolic dysfunction.
3. When added to current risk prediction models, pregnancy-related conditions (such as gestational diabetes) do not increase the accuracy of such models. This may be due to the association of pregnancy-related risk factors associated with traditional risk factors, which are incorporated into current prediction models. However, identification of such pregnancy-related conditions may help identify younger women (with low risk scores) to allow for earlier monitoring of cardiometabolic factors and management as needed earlier in a woman’s life.
4. Premature menopause, defined as menopause before the age of 40 years, is associated with increased risk for CVD. In the 2018 cholesterol guidelines, premature menopause was included as a risk-enhancing factor.
5. Polycystic ovarian syndrome (POS) is associated with cardiometabolic factors, which, in turn, are associated with increased CVD risk. These POS factors include abdominal obesity, abnormal glucose control and diabetes, elevated blood pressure, and dyslipidemia.
6. Sex-related differences in traditional risk factors are prevalent. Hypertension is highly prevalent among women, in particular non-Hispanic black women, compared to other groups. Obesity is a strong risk factor for hypertension among women. Sodium restriction among postmenopausal women with hypertension may be particularly beneficial. Diabetes is also a particularly strong risk factor for CVD and heart failure among women.
7. Sex-related differences in CV medications exist. For women of childbearing years, modification of medications typically used for management of CVD and related risk factors may be needed. This includes the use of angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers or statins, which are not recommended if pregnancy is planned or occurs. For many women with CV risk factors or CVD, receipt of evidence-based medications is often less likely to occur compared to men with similar risk factors or CV conditions. Last, differences in the efficacy of medications may differ by sex.
8. Women are at greater risk for stroke in the setting of atrial fibrillation compared to men. Guidelines also recommend novel anticoagulants for women as the first choice for anticoagulation, given the evidence of lower risk of bleeding in women taking a novel agent as compared to vitamin K antagonists. The 2019 guidelines were revised to recommend anticoagulation for women with a CHA₂DS₂-VASc score of ≥3 (prior recommendations were for ≥2).
9. There are no recommendations for the use of menopausal hormonal therapy for CV prevention at this time. Long-standing evidence suggests either no benefit of increased risk for women when hormonal therapy is used. However, researchers have and continue to investigate the potential for a “timing hypothesis” where hormonal therapy may be of benefit (related to CV risk) among women closer to the time of menopausal onset. Providers are recommended to review each woman’s risk factor profile and provide a tailored and shared decision-making discussion when menopausal hormonal therapy is considered, even among younger perimenopausal women.
10. Psychosocial factors such as depression, anxiety, and acute or chronic emotional stress are often observed to be more prevalent among women compared to men. Given the association between these factors and CVD risk, providers are recommended to identify and assist in the management of such factors as part of CVD prevention.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Hypertension

Keywords: Anticoagulants, Atrial Fibrillation, Blood Glucose, Blood Pressure, Cardiovascular Diseases, Depression, Diabetes, Gestational, Fetal Growth Retardation, Hypertension, Pregnancy-Induced, Infant, Newborn, Insulin Resistance, Menopause, Premature, Metabolic Syndrome, Obesity, Polycystic Ovary Syndrome, Pregnancy, Premature Birth, Primary Prevention, Risk Factors, Stroke

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