February 23, 2004

Wenger coauthors heart-smart rules for women

By Sherry Baker

Emory Heart Center cardiologist Nanette Wenger coauthored new guidelines for the prevention of cardiovascular disease (CVD) in women released recently by the American Heart Association (AHA). Published in Circulation: Journal of the American Heart Association , the recommendations call for individualized treatment linked to heart attack risk over 10 years.

Risk level is based on a standardized scoring method developed by the Framingham Heart Study. Low risk means a woman has less than a 10 percent chance of a heart attack in the next 10 years; intermediate risk is a 10 to 20 percent chance; and high risk is a 20 percent chance or greater.

"This is the first major, evidence-based approach to specific coronary prevention in women with recommendations based on an individual woman's level of risk," said Wenger, professor of medicine and chief of cardiology at Grady Hospital.

"These guidelines are different because they are based on a thorough, systematic review of the scientific data, which show sex does matter when it comes to cardiovascular disease," she continued. "They are truly a consensus of the clinical care community, created with input from representatives from 12 professional organizations and 22 cosponsors."

The new guidelines include a call for smoking cessation, regular physical activity, a heart-healthy diet and weight maintenance for all women. Aspirin, ACE inhibitors and beta-blockers are recommended for high-risk women, as is statin therapy even for individuals whose LDL ("bad") cholesterol levels are below 100 mg/dL. Niacin and fibrate therapies are given a strong recommendation for high-risk women with specific cholesterol abnormalities; some women should consider supplementation with omega-3 fatty acids and folic acid.

Blood pressure-lowering drugs are recommended when blood pressure is greater than or equal to 140/90. However, the new guidelines say blood pressure should be maintained at less than 130/80 when a woman has blood pressure-related target end-organ damage or diabetes. For stroke prevention, warfarin is recommended for women with atrial fibrillation and intermediate or high risk for embolic stroke. Individuals at risk for stroke who cannot take warfarin should be given aspirin.

The guidelines also say that women with diabetes should have their blood sugar carefully controlled, as defined by achieving near-normal glycosylated hemoglobin levels (less than 0.7 percent). Hormone therapy and antioxidant vitamin supplements are not recommended for CVD prevention for women at any level of risk. In addition, the new recommendations say women with cardiovascular disease should be evaluated for depression and treated or referred for treatment when indicated.

"Emerging data have displayed important sex-based differences in coronary heart disease (CHD)--its pathophysiology, clinical presentation, diagnostic strategies, response to therapies and adverse outcomes," Wenger wrote in the lead editorial titled, "You've Come a Long Way, Baby: Cardiovascular Health and Disease in Women, Problems and Prospects," which accompanies the new guidelines. "Exploration of sex-related differences in CHD provides a basis for clinical strategies to improve outcomes for women. The goal is the lessening of the sex-based disparities in morbidity and mortality rates for women."

Wenger said an AHA survey shows that although approximately 47 percent of women are aware of heart disease as a killer of women, only about 13 percent perceive it as a personal threat. In fact, cardiovascular disease claims more women's lives than the next seven causes of death combined--nearly 500,000 women's lives a year.

"Just as improvement is needed in the perception of women of their vulnerability to heart disease, increased attention also is needed by their treating physicians that symptoms of chest pain in women should be thoroughly evaluated," said Wenger, who was honored at the first Red Dress Awards in New York, created by Woman's Day magazine to honor leaders in the fight against heart disease.

"There are many things women and their physicians can do to reduce [CHD] risks, including lifestyle changes that can help prevent or control hypertension, high cholesterol and diabetes and, if needed, medication and other therapies," Wenger said. "The new AHA guidelines can be personalized depending on a woman's individual risk status. We believe these carefully documented guidelines can, in fact, help empower women to take control of their cardiovascular health."