reality of cardiovascular disease

PERC Show more Hello could some one please tell me what the research methods and results are in this article: PERCEPTION OF RISK does not match the reality of cardiovascular disease (CVD) for women.1 Nearly 1 in 2 women over age 40 will eventually develop CVD and more women than men currently die from complications of CVD a fact largely unrecognized by clinicians across all specialities.12 Sex-based disparities in recommendations for preventive therapy can be explained at least partially by the lower perceived risk for CVD among women by clinicians and the public despite substantial evidence that this complacency is unjustified. Given these statistical realities the public health impact of CVD in women is related not only to the mortality rate but also to CVD-related morbidity and impairment in quality of life. It is common for women to delay focus on their cardiovascular health until midlife after such priorities as child rearing and other caregiving responsibilities become less consuming. In that coronary disease becomes clinically evident in women about a decade later than in men the topic of heart disease prevention tends to get postponed until the onset of menopause. However an estimated 82% of coronary events are attributed to poor adherence to a low-risk lifestyle and most of these behaviors begin to track early in life.3 The American Heart Association (AHA) launched the Go Red for Women campaign to increase awareness of heart disease in women and to serve as a clinical call to action. Since that time guidelines have been published to provide practitioners with practical tools for risk reduction that are easily implementable in the office setting.46 Management of CVD risk and symptoms in women however still lags behind that received by men. Recent statistics show significant differences between men and women in survival after a heart attack: 42% of women who have heart attacks die within 1 year compared with 24% of men. The reasons for these differences are not well understood although older age of women at diagnosis and higher prevalence of coexisting chronic conditions such as diabetes and hypertension may be contributory. Research also suggests that women may not be treated as aggressively as men and that the diagnosis may be delayed because cardiac symptoms in women may be atypical: weakness nausea and shortness of breath are common presenting symptoms. Recent evidence-based guidelines for prevention of CVD in women aim to widely disseminate a blueprint for more effective interventions by practitioners who can play a pivotal role in achieving a reversal of these escalating medical conditions and reducing CVD risk in both women and men.46 Knowing that the onset of CVD occurs in childhood and adolescence should prompt greater efforts to initiate preventive strategies early in life.78 As well practitioners are encouraged to respond to milder symptoms by implementing the newest guidelines at earlier stages of disease.6 Recommendations from the National Institute for Health and Clinical Excellence (NICE) address the effective identification and assessment of people at risk for CVD and the modification of lipids in primary and secondary prevention ( Greater attention should be paid to delivering preventive therapy regardless of sex.10 To examine some of the most challenging aspects of CVD prevention and risk assessment in women Dr. JoAnn Manson discusses the latest research and puts the findings into a clinically relevant perspective so that the most current information can be applied to improve patient care. The lifetime risk of dying from CVD is 1 in 2.6 in U.S. women highlighting the need to redouble efforts to prevent heart disease. What is the current thinking on lifestyle modification to reduce cardiovascular risk and what strategies might clinicians use to address preventable risk factors? Assignment of risk level influences the intensity of recommendations for lifestyle and preventive pharmacotherapy but women and men tend to be treated differently.11 Women assessed at intermediate risk by the Framingham Risk Score were significantly more likely than men with identical risk profiles to be assigned to a lower-risk category by clinicians. The presence of even a single risk factor for women at 50 years of age is associated with a substantially increased lifetime absolute risk for CVD and shorter duration of survival; risk is augmented among women with multiple risk factors.6 Epidemiological data suggest that heart disease stroke and type 2 diabetes are largely preventable through improved lifestyle practices.312 In the Nurses Health Study 82% of coronary heart disease cases 74% of total CVD events and 90% of diabetes cases in women could be prevented by healthy lifestyle behaviors such as not smoking engaging in regular physical activity maintaining a healthy weight and having a diet rich in whole grains fish fruits and vegetables and low in saturated fats trans fats and refined carbohydrates.3 The AHA/ACC (American College of Cardiology) guidelines for secondary prevention recommend a target body mass index (BMI) of 18.524.9 kg/m2.13 A higher BMI and lack of physical activity are strong and independent risk factors for CVD.14 Moderate-intensity activities (such as brisk walking) and vigorous exercise are associated with similar risk reductions in postmenopausal women and the results do not vary substantially according to race age or BMI.15 A brisker walking pace and fewer hours spent sitting daily also lower risk. Addressing the role of body weight specifically as a risk factor for CVD presents several challenges. Most epidemiological studies suggest that obesity (BMI 30 kg/m2 ) remains a strong predictor of CVD in women (with a 23- fold elevated risk).1416 The relationship of overweight (BMI 25.029.9 kg/m2) and CVD remains controversial especially when mortality is assessed as the end point. This is likely due to the confounding effects of weight loss from disease that often precedes mortality. Recent findings suggest however that abdominal fat represents a stronger risk factor for CVD than overall adiposity supported by evidence that waist circumference after adjusting for age and BMI is a powerful predictor of CVD in women.1718 The often coexisting conditionsexcess body weight and physical inactivityare two independent modifiable factors that together are responsible for an enormous burden of chronic disease reduced quality of life and escalating healthcare costs.19 The risk of CVD as associated with obesity is considerably attenuated but not eliminated by increased physical activity reinforcing the importance of vigilance to both weight control and physical activity.14 Given the limitations of our overburdened healthcare system including time constraints during the typical office visit clinicians may tend to avoid discussion of these issues. By involving a healthcare team including office staff nurse and dietitian clinicians are better able to put practical tools and guidelines into practice. With the pandemics of obesity diabetes and CVD practitioners are increasingly called on to promote strategies that will have a favorable impact on public health. Most can be employed efficiently taking just a few minutes of a clinicians time if done with the support of other healthcare professionals (nurses staff and dietitians). Here is a summary of practice guidelines that can be implemented efficiently with the support of a healthcare team in an office setting.4 Measure weight circumference Measure waist circumference to assess level of abdominal fat (central adiposity) which is more strongly linked to a range of chronic diseases than BMI and presents a greater risk than peripheral adiposity.20 A value of 35 inches in women is a strong marker for elevated risk of diabetes and CVD. For women deemed at risk even a modest weight loss of 5%10% of initial body weight affords tremendous health benefits including reduction in blood pressure insulin resistance and overall CVD risk. In effect reducing weight by just 1020 pounds is feasible for most patients through small and sustained dietary changes and increased physical activity. Simple strategies to begin the weight management discussion Take a brief diet history to assess a typical eating pattern such as a recall of yesterdays meals or what was eaten on the day of the appointment. This information may reveal some areas that can be easily modified such as substituting skim milk (or 1%) for whole milk or skipping a pat of butter or replacing sugar-sweetened beverages with calorie- free drinks or water. Such changes eliminate 100200 calories per day producing a 1020 pound weight loss within a year. (Note: Many patients may benefit from referral to a dietitian.) Provide a handout that outlines the principles of a healthy diet with common dietary substitutions that can be recommended to assist with dietary choices. Review portion sizes which remain a significant challenge for many Americans who have supersized expectations of food quantities. Suggest eating out less and avoiding fast food establishments where hidden calories can add up quickly (unless low calorie options are offered). Recommend avoiding fried foods which are fat-laden and calorie-dense; instead promote whole grains fruit and vegetables.21 Promote regular physical activity Promote regular physical activity by writing an exercise prescription. For most women a minimum of 30 minutes of brisk walking or comparable moderate-intensity activity daily (or vigorous exercise for 20 minutes 34 times/week) can be recommended. Another option can be aiming for 10000 steps daily (calculated by wearing a pedometer) achieved by adding 5001000 steps weekly to the patients baseline level. Suggest including 1520 minutes of strength or resistance training 23 times/week to build muscle mass which helps boost metabolic rate as well as promotes physical function improves balance and increases bone density. These benefits can lead to reduced risk of falls and bone fractures in older women. For some keeping a physical activity journal to record pedometer readings of steps taken daily or minutes of activity clocked can be beneficial. Walkers tend to respond well to the use of a pedometer to monitor progress and provide instant and ongoing feedback on activity. Recommend smoking cessation To all patients who smoke recommend smoking cessation regardless of the number of previously unsuccessful attempts to quit. 1272 CONVERSATION ABOUT STRATEGIES FOR PREVENTION OF HEART DISEASE Review new modalities including the nicotine replacements delivered by an inhaler as well as antidepressant therapies or combination strategies.22 Acupuncture may be a viable alternative for those who are unsuccessful with the suggested approaches. The Well-Integrated Screening and Evaluation for WOMen Across the Nation program (WISEWOMAN) focused on screening for heart disease and stroke risk factors and lifestyle interventions among low-income uninsured or underinsured women aged 4064. Are there clinical considerations specific to this underserved population or screening modalities that are preferable for women? First socioeconomic status poor education and health literacy are independent risk factors for CVD yet the basis for these risks is not fully understood. In underserved populations risk factors may go untreated and CVD may be quite advanced before it is detected. Moreover interventions must be culturally appropriate to be successful. Regardless of socioeconomic status identifying women at higher risk for CVD remains a challenge because women are more likely than men to have atypical symptoms (i.e. chest pain when it occurs may not be the crushing substernal type of pain but rather may be diffuse or even right-sided). In addition to a strong family history some conditions that substantially increase the risk of CVD and would suggest the need for early screening in women are diabetes (either type) chronic kidney disease and autoimmune diseases (e.g. lupus). Other revelant issues are: Risk assessment As far as choice of risk prediction tools the Framingham Risk Score is still of value although some experts believe it produces an underestimation of risk for women. The recently proposed Reynolds Risk Score may have some advantages for women because in addition to the usual risk factors such as serum cholesterol blood pressure and smoking the risk algorithm adds family history of heart attack prior to age 60 blood level of C-reactive protein (CRP) and hemoglobin A1C in women with diabetes.11 These added risk factors seem to improve the accuracy of risk prediction.11 The 2007 AHA CVD guidelines offer a scheme for the female patient that classifies her as high risk at risk or at optimal risk.6 The new risk prediction algorithm reclassified 40%50% of women at intermediate (ATP-III) risk into higher-risk or lower-risk categories. Any woman who has symptoms should undergo further screening especially a woman who is categorized at elevated risk. Women who have diabetes may be asymptomatic but are strong candidates for screening. It is worth emphasizing the importance of early detection because women tend to delay seeking treatment which precludes aggressive preventive measures. Also delays may rule out the use of lifesaving treatments for acute myocardial infarction (MI) contributing to poor postevent outcomes and survival. Diagnostic screening Noninvasive diagnostic testing for CVD may be less accurate in women than in men.23 In women deemed at intermediate risk with a normal resting electrocardiogram the treadmill stress test remains a cost-effective initial method for assessing CVD. The use of echocardiography or thallium testing may have added value owing to a higher sensitivity and specificity than the ECG (electrocardiogram).23 Some concern persists that thallium testing may be less accurate in women because of artifacts from breast tissue. For high-risk symptomatic women a more aggressive approach involving coronary angiography is the preferred initial diagnostic strategy.24 Would a more aggressive approach to diabetes management in women produce better outcomes in women? What about other differences in sex-based outcomes for primary and secondary prevention of CVD? There is strong evidence that diabetes has a more adverse effect on CVD in women than in men. Diabetes is considered an AHA risk equivalent for coronary disease2526 a risk factor comparable in strength to prevalent coronary disease. The role of tight glycemic control in reducing CVD risk in diabetes remains controversial but it is clear that patients with diabetes benefit from aggressive management of traditional CVD risk factors such as hypertension and dyslipidemia. Achieving good control of blood pressure and lipids is imperative for all patients and has heightened urgency for those with diabetes or prevalent CVD. Women with CVD have a poorer quality of life than men with a comparable degree of coronary disease particularly women with comorbid diabetes.27 Thus assessing health-related quality of life may give clinicians a better understanding of the impact the disease is having on their patients lifestyle. Identifying and treating coexisting depression (which is common) and encouraging patients to cultivate a social support system may improve outcomes. Women at elevated risk of CVD are candidates for screening and preventive therapies. With few exceptions (eg the use of aspirin for primary prevention of heart disease) recommendations to prevent CVD in women are similar to those in men. Aggressive control of hypertension and dyslipidemia is critical as noted earlier. An efficient algorithm to assist healthcare providers in evaluating and prioritizing preventive interventions is available.5 Key advances in CVD management in women include aspirin hormone therapy and statins. Aspirin Women with prevalent CVD should receive regular aspirin therapy (81325 mg daily) unless there is a specific contraindication. 28 Evidence is strong that the benefits are comparable in women and men for secondary prevention of CVD or in the s
tting of an acute MI. However the indications for aspirin in primary prevention of CVD for otherwise healthy women are different.26 According to findings from the Womens Health Study (WHS) the only large-scale clinical trial of aspirin in primary prevention of CVD women aged 65 (but not younger women) appear to benefit and have a favorable benefit/risk ratio including fewer MIs strokes and total cardiovascular events.29 Women aged 65 had a reduction in coronary and total CVD events at levels comparable to those of men in the Physicians Health Study.30 However the incidence of gastrointestinal bleeds requiring transfusion was not trivial suggesting that aspirin is not free CONVERSATION ABOUT STRATEGIES FOR PREVENTION OF HEART DISEASE 1273 of risk but has an acceptable tradeoff for most older women. In contrast there was no evidence of a reduction in MI or total vascular events among women age 65 yet they had a similar rate of gastrointestinal bleeds resulting in an unfavorable benefit/risk ratio. The age-related findings may be explained by the lag of some 1015 years in onset of CVD in women so that benefits from interventions that are seen in men after age 50 may become evident in women only after age 65. Hormone therapy (HT) HT is no longer recommended for CVD prevention in women at any age in either primary or secondary prevention settings. HT should not be started or continued for the express purpose of preventing CVD. Increased coronary risk with HT is observed mostly in women distant from the onset of menopause; menopausal women who experience moderate to severe symptoms may still be appropriate candidates for HT. Women in the menopausal transition who are symptomatic and considered at low risk for CVD are candidates for short-term HT (recommended duration is generally 5 years). Recent evidence suggests that HT initiated soon after the onset of menopause may have a more favorable benefit/ risk ratio than when started more than a decade after menopause providing some reassurance to younger women who are considering HT for symptom relief.3132 Statins HMG CoA reductase inhibitors (statins) have been demonstrated to be of benefit in secondary prevention of CVD in women with results comparable to those in men. Statin therapy has been associated with 20%35% reductions in CVD and total mortality among women in secondary prevention settings. In such high-risk women with a baseline low-density lipoprotein cholesterol (LDL-C) of 130 mg/dL and for whom lifestyle intervention fails to achieve the desired goal of 100 mg/dL cholesterol-lowering therapy should be considered.33 When drug therapy is initiated it should be done concomitantly with lifestyle changes. Few large-scale trials of statins in the primary prevention of CVD in women have been conducted so relevant data are limited. ATP-III guidelines for the use of cholesterol-lowering medications in the primary prevention of CVD can be applied. 3334 Although aspirin and statins are established interventions the promise of omega 3 fatty acids and vitamin D recently garnered significant attention. Is there sufficient evidence for the efficacy of either of these therapies? Both omega 3 fatty acids and vitamin D have major potential benefits in the prevention of CVD but their efficacy for primary prevention has not been conclusively demonstrated. We believe that further study including large-scale randomized clinical trials of these agents in the primary prevention of CVD are needed before a broad public health endorsement can be made. Such trials are particularly important because other nutritional supplements such as vitamin E beta-carotene and folic acid/B vitamins offered promise for CVD prevention and then were proved ineffective once submitted to rigorous testing in randomized clinical trials. A summary of what is known to date follows. Omega 3 fatty acids (n-3 FAs) The clinical uses of the marine n-3 fatty acids (FAs) [eicosapentgenoic acid (EPA) and ducosahexgenoic acid (DHA)] include treatment of moderate to severe hypertriglyceridemia and a promising role in the secondary prevention of cardiovascular events. As an adjunct to diet n-3 FAs in capsule form (approximately 8501000 mg of EPA and DHA) may be considered in women with CVD and higher doses (24 g) may be used for treatment of women with high triglyceride levels.6 More research including a large-scale clinical trial is needed to evaluate its possible use in primary prevention of MI stroke and other CVD events.33 Vitamin D and calcium Calcium supplementation is generally considered necessary to promote both bone and heart health but one recent study suggested that calcium may raise the risk of CVD in healthy postmenopausal women.35 This finding is in contrast to the much larger Womens Health Initiative (WHI) in which a combination of calcium and vitamin D (400 IU/day) did not raise CVD risk and had a neutral effect on MI stroke and total CVD outcomes.36 An evaluation of higher doses of vitamin D (1000 IU daily) in randomized clinical trials is needed to determine efficacy in counteracting the widespread vitamin D deficiency evident in the population. Subgroups likely to have an elevated risk of vitamin D deficiency are the elderly (because of reduced absorption and synthesis) the obese (vitamin D is a fat-soluble vitamin that may be stored in fat cells thereby reducing its bioavailability) and African Americans and other groups with darker skin pigmentation (melanin blocks the effect of UV light on vitamin D synthesis in the skin). There is mounting evidence that vitamin D may have a role in reducing CVD risk. In particular a higher risk of cardiovascular events has been found in people with low levels of 25-hydroxyvitamin D (25-OH D).3738 Vitamin D plays an important role in several essential pathways and mechanisms that may impact coronary risk including decreasing the inflammatory response improving glucose tolerance lowering blood pressure and decreasing smooth muscle cell proliferation. Moreover low levels of 25-OH D are associated with vascular risk factors which may be responsible at least in part for its association with increased CVD risk.39 An improved understanding of the effect of vitamin D on the risk of CVD cancer fractures and a host of other outcomes is needed; such advances in knowledge will require large-scale randomized trials. At present the likely benefits of vitamin D on bone and the potential reduction in risk of certain cancers and autoimmune diseases support supplementation at levels of 8001000 IU daily. In summary a broad array of strategies is available to reduce the risk of CVD in women including the powerful role of lifestyle modifications aggressive management of traditional CVD risk factors and use of aspirin and other pharmacological agents when appropriate. Other interventions including increased intake of the marine omega 3 fatty acids Show less

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