Chapter 12 Cardiovascular Disease Prevention in WomenEuropean Guidelines for Cardiovascular
Disease Prevention in Clinical Practice
The Fourth Joint Task Force of European Society of
Cardiology recently published new guidelines for
clinicians based on a Systematic Coronary Risk Eval-
uation (SCORE) system. SCORE estimates 10 year
risk of a fi rst fatal atherosclerotic event (including
heart attack, stroke, aneurysm of the aorta or other)
[14]. These new guidelines defi ne gender differences
in the public and professional recognition of the size
of the problem of CHD in women; in the estimation
of total risk in women versus men; and in the need
to educate clinicians and the public regarding
high absolute risk in a woman’s lifetime. Specifi c
issues addressed by the European community
include:
- CHD is slightly more common (23% vs. 21%)
while stroke is markedly more common (15% vs.
11%) in women compared to men. - CVD mortality has declined more in men com-
pared to women due in large part to an increase in
myocardial infarction in older women. - Women continue to be underrepresented in clini-
cal trials thus “hampering risk management
advice.” - Systolic hypertension is more prevalent in older
women, tobacco consumption has fallen more in
men compared to women, and smoking associated
with use of oral contraceptives increased CHD
risk. - Diabetes confers a considerably greater risk in
women compared to men (self-reported diabetes
increases the 10-year risk of a fatal heart attack by
fi ve times in women compared to three times in
men). - Obesity is more common in middle aged women
and the metabolic syndrome is more common in
women with CHD compared to men. - Low absolute risk in younger women may be
“falsely reassuring” in light of the relative risk
chart. - Hormone replacement therapy is not advised for
preventive purposes. - Atypical chest pain syndrome in women creates a
disadvantage due to lower frequency of diagnostic
testing and diffi culty in interpretation. - Women have a higher in-hospital mortality for
acute coronary syndrome [14].
Future directions
Women’s risk of death and disability from CHD is
a worldwide pandemic. Implementation of the new
guidelines for preventive CVD care for women will
require intense efforts on the part of the govern-
ment, the public and healthcare professionals.
Research efforts are needed to improve the evalu-
ation, diagnosis and treatment of women with chest
pain syndromes. Data from the WISE Study indi-
cates that some women with chest pain and without
signifi cant epicardial disease by angiography, remain
at high risk for a cardiac event. Improving the ability
to identify women at risk will require advances in
our understanding of gender based pathophysiology
of vascular disease. Gender specifi c evaluation and
treatment will follow these discoveries [15]. Along
with this must come increased efforts to understand
differences in risk and treatment of CVD in older
women, in ethnic populations.
Type 2 Diabetes confers signifi cantly worse risk
for CVD morbidity and mortality in women com-
pared to men [16,17]. Defi ning the synergy between
elevated blood glucose and other CVD risk factors
in women must be a national research priority.
This will require increased inclusion of women
in all cardiovascular clinical trials to provide a
more robust evidence base, with gender-specifi c
reporting of outcomes. Efforts to improve lifestyles
and reduce risk factors in women with diabetes and
those with risk factors for diabetes also must be
intensifi ed. Along with these efforts must come a
continuing emphasis on guideline-based interven-
tion and care.
Further research efforts in the evaluation of
depression and its relationship to CVD outcomes in
women need to be undertaken. The ENRICHD Trail
demonstrated that for women and men with heart
disease, depression confers additional mortality risk
[18].
Ongoing research to develop a CVD algorithm
that more accurately predicts lifetime risk for CVD
in women is critical in our overall ability to identify
women at high lifetime risk and target appropriate
treatments. There is convincing evidence that risk
factors for CVD are found clustered in families as a
result of both lifestyle and genetics. In addition,
there is evidence that awareness of this risk by
women increases the likelihood that family-based