Guide to Preventive Cardiology for Women
Lori Mosca, MD, PhD, Chair; Scott M. Grundy, MD, PhD; Debra Judelson, MD;
Kathleen King, PhD, RN; Marian Limacher, MD; Suzanne Oparil, MD; Richard Pasternak, MD;
Thomas A. Pearson, MD, PhD; Rita F. Redberg, MD; Sidney C. Smith, Jr, MD;
Mary Winston, EdD, RD; Stanley Zinberg, MD
Endorsed by American Medical Women’s Association, American College of Nurse Practitioners,
American College of Obstetricians and Gynecologists, and Canadian Cardiovascular Society
C
oronary heart disease (CHD) is the single leading cause of
death and a significant cause of morbidity among American
women (1). Risk factors for CHD in women are well documented
(2). Compelling data from epidemiological studies and randomized
clinical trials show that CHD is largely preventable. Assessment and
management of several risk factors for CHD are cost-effective (3).
Despite these facts, there are alarming trends in the prevalence and
management of risk factors in women (2). Smoking rates are
declining less for women than for men. The prevalence of obesity is
increasing, and Ϸ25% of women report no regular sustained
physical activity (4). Approximately 52% of women Ͼ45 years old
have elevated blood pressure, and Ϸ40% of women Ͼ55 years old
have elevated serum cholesterol (5). The purpose of this statement
is to highlight risk factor management strategies that are appropriate
for women with a broad range of CHD risk. A more detailed
description, including the scientific basis for these recommenda-
tions, is available in the 1997 American Heart Association scientific
statement “Cardiovascular Disease in Women” (2).
Recently, the Centers for Disease Control and Prevention Na-
tional Ambulatory Medical Care Survey (6) showed clinicians are
missing opportunities to prevent CHD. In this study of 29 273
routine office visits, women were counseled less often than men
about exercise, nutrition, and weight reduction. In the multicenter
Heart and Estrogen/progestin Replacement Study (HERS) (7), only
10% of women enrolled with documented CHD had baseline
LDL-cholesterol levels below a National Cholesterol Education
Program (NCEP) target of 100 mg/dL. A recent national survey
showed that women were significantly less likely than men to enroll
in cardiac rehabilitation after an acute myocardial infarction (MI) or
bypass surgery (8). This finding is especially important because
post-MI patients not enrolled in cardiac rehabilitation are less likely
to receive aggressive risk factor management.
Recommendations for the primary and secondary prevention of
CHD have been published (9,10). Although those recommenda-
tions apply to women, there are aspects of risk factor management
that are unique to women. Pregnancy and the preconception period
are optimal times to review a woman’s risk factor status and health
behaviors to reduce future cardiovascular disease. Pregnant women
should be strongly encouraged to discontinue smoking and not to
relapse in the postpartum period. Avoidance of excess weight gain
during pregnancy may reduce the risk of developing CHD in the
future. An emphasis on prevention of CHD in postmenopausal
women is particularly important because the incidence of CHD rises
with age. The use of estrogen replacement therapy (ERT) to prevent
CHD, osteoporosis, and possibly dementia is a difficult health
decision for postmenopausal women. The potential benefits of
therapy must be weighed against the possible risks, including breast
cancer, gallbladder disease, thromboembolic disease, and endome-
trial cancer, although the last is reduced by concomitant use of a
progestin.
The recent findings from HERS (11) have challenged previ-
ous observational data regarding the role of hormones in
preventing subsequent cardiovascular events. HERS was the
first large-scale, randomized, clinical trial in older postmeno-
pausal women with confirmed coronary disease to test the
efficacy and safety of hormone replacement therapy on clinical
cardiovascular outcome in postmenopausal women. The study
population included 2763 women (mean age 66.7 years) with
established CHD randomly assigned to 0.625 mg conjugated
equine estrogens (CEE) plus 2.5 mg of medroxyprogesterone
acetate (MPA) per day or placebo. Participants were monitored
for an average of 4.1 years for the main end point of nonfatal MI
or CHD death. At study completion, no significant differences
existed between groups for any cardiovascular end points.
Surprisingly, after 1 year, HERS showed an increase in cardio-
vascular events in the treatment arm, but in years 4 and 5, fewer
events occurred than in the placebo arm. It has been hypothesized
that possible early adverse effects of estrogen in women with CHD
may be due to a procoagulant effect that may later be offset by an
antiatherogenic benefit. MPA may also have adverse cardiovascular
effects and may mitigate some of the beneficial effects of estrogen
(2). Although these hypotheses deserve further investigation, the
overall null result from HERS does not support initiation of CEE
combined with MPA in older postmenopausal women with con-
firmed coronary disease. For women with CHD already on ERT for
Ն1 year, it may be reasonable to continue therapy while awaiting
the results of a HERS follow-up study and other ongoing trials of
ERT with clinical end points. The results of the HERS trial apply to
women with preexisting CHD and may not apply to women free of
vascular disease. Furthermore, this study does not take into consid-
“A Guide to Preventive Cardiology for Women” was approved by the
American College of Cardiology Board of Trustees on February 22,
1999, and by the American Heart Association Science Advisory and
Coordinating Committee on September 7, 1998.
This document is available on the World Wide Web sites of the
American College of Cardiology (www.acc.org) and the American Heart
Association (www.americanheart.org). Reprints of this document may be
purchased for $5.00 each by calling 1-800-253-4636 or by writing the
American College of Cardiology, 9111 Old Georgetown Road, Bethesda,
Maryland 20814-1699.
(J Am Coll Cardiol 1999;33:1751–5)
© 1999 American Heart Association, Inc. and American College of
Cardiology
PII S0735-1097(99)00190-4
1751
AHA/ACC Scientific Statement: Consensus Panel Statement