Chapter 12 Cardiovascular Disease Prevention in Women

categories, based on a panel of both traditional and
novel risk factors [9].
Limitations of this new algorithm include a lack
of information regarding young women, women at
low risk, and non-Caucasian women. Accurately
estimating lifetime CVD risk for women of all ages
and ethnicities will help guide educational programs
and medical therapies for those at elevated risk.
Although a recent survey of women’s awareness,
preventive actions and barriers to cardiovascular
health showed a doubling in awareness since 1997
[9], less than 50% of women were aware of healthy
levels of risk factors. White women were signifi -
cantly more aware compared to blacks and Hispan-
ics. Importantly, awareness was associated with
increased levels of physical activity and weight loss.
The survey also found that aware women were more
likely to reduce their personal risk factors and those
of their family members. Continuing public educa-
tion and implementation of evidence-based guide-
lines for women will be important in reducing both
death and disability from CVD in women.

Summary of key changes

As in 2004, the 2007 updated Guidelines highlight
that favorable lifestyle changes can both decrease
cardiovascular risk factors and prevent cardiovascu-
lar and coronary heart disease. They further empha-
size that the intensity of the intervention should
match the woman’s level of risk. This emphasis
spurred a new risk classifi cation for women – high
risk, at risk, or optimal risk (Table 12.1).

The rationale for this new classifi cation is that

prevention is important for all women, given their

high lifetime cardiovascular risk. One of two women

will develop cardiovascular disease in her lifetime.

The updated Guideline is aligned with the evidence

base, in that most clinical trials providing the evi-

dence involved either high-risk women (those with

known cardiovascular disease), or apparently healthy

women. It further refl ects increased appreciation of

the limitations of the Framingham Risk Score,

with its narrow focus on 10-year risk, its lack of

inclusion of family history, and an underestimation

or overestimation of risk in many non-white

populations. Further, subclinical disease has been

documented among many women who score

“low-risk” on the Framingham Risk Score. Life-

style interventions are the initial approach recom-

mended for all women including a comprehensive

risk reduction program. It also refl ects expanded

indications for rehabilitation of women with vascu-

lar diseases (Table 12.2).

A simple algorithm, based on risk status helps

guide clinical decision-making and can be shared

with women as a basis for their preventive cardio-

vascular care (see Table 12.3). The American Heart

Association’s 2007 Guidelines for Preventing Car-

diovascular Disease (CVD) in Women, challenges

all health professionals to focus on a woman’s life-

time CV risk rather than her short-term risk. This

important document compels us to begin preven-

tion early, focus on lifestyle and initiate medical

therapies as indicated. Tables 12.4–12.9 summarize

the recommendations of the 2007 guidelines.

Table 12.1 Risk Classifi cation

Risk Classifi cation Defi nition

High-Risk With CAD, CVD, PAD, AAA, CRD*; Framingham Risk Score >20% or High Risk by population-adapted based global
risk tool
At Risk >1 Major Risk Factor# for CVD; evidence of subclinical disease (eg. coronary calcifi cation); poor exercise capacity
or poor HR** recovery after exercise
Optimal Risk <10% Framingham Risk Score; healthy lifestyle; no risk factors

• CAD, coronary heart disease; CVD, cerebrovascular disease; PAD, peripheral arterial disease; AAA, abdominal aortic aneurysm; CRD, chronic renal disease.
  ** HR (heart rate).

  Cigarette smoking, poor diet, physical inactivity, obesity (especially central adiposity) family history of premature CVD, hypertension, dyslipidemia [3,10].