This month’s blog post comes from our very own Lynne T. Braun, PhD, ANP, FAHA, FAANP, FNLA, FPCNA, FAAN. She shares important updates in guidelines for women’s heart health that providers should know.
Heart disease remains the #1 killer of women. We, as providers, know the basics: Women need to be vigilant in reducing their risk for heart and blood vessel disease by practicing Life’s Simple Seven: manage blood pressure, control cholesterol, reduce blood sugar, get active, eat healthfully, lose weight, and never smoke/quit smoking. This Heart Health month, I want to go beyond the basics and talk about the specific interventions women should expect from their healthcare providers if they have a higher risk for heart disease.
I recently had the privilege of serving on the writing committee of the 2018 Multi-Society Guideline on the Management of Blood Cholesterol, which can be found here. My contribution was to synthesize the evidence and write the recommendations on Issues Specific to Women. I’d like to share some key information about women’s heart health and recommendations from the guideline.
For Women with Heart Disease
I’d like to first address women with known atherosclerotic cardiovascular disease (ASCVD). These women have had heart attacks or have evidence of plaque in their coronary arteries. They are considered high risk if measures are not taken to prevent another heart attack or a first heart attack. A key preventive intervention is “high intensity” statin therapy (atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg). Statins, although there is a great deal of misinformation on the Internet, are lifesaving medications that have been shown in every randomized clinical trial to prevent heart attacks, strokes, and deaths in men and women who take them. We know that women derive as much benefit from statins as men. For those women who have side effects from statins, a lipid specialist can help identify a statin at a dose that a woman can tolerate (there are 7 different statins), or if necessary, can recommend a different medication.
For Women with Elevated Cholesterol
Another high-risk group of women are those with severely elevated cholesterol levels. Women with LDL cholesterol of 190 mg/dL or higher, and especially if they have a family history of early ASCVD (male first degree relative before age 55 years, female first degree relative before age 65 years), this typically means an inherited form of high cholesterol called familial hypercholesterolemia. The guideline recommends “high-intensity” statin therapy to lower LDL cholesterol to less than 100 mg/dL. Sometimes additional cholesterol-lowering medications are required.
For Women with Other Traditional Risk Factors
For women who do not have known ASCVD but may have traditional risk factors (high blood pressure, high cholesterol, diabetes, cigarette smoking, obesity, physically inactive) or who desire a heart health evaluation, this is what you should expect:
- If 40 years of age or older, estimation of 10-year risk for a heart attack or stroke using a risk calculator. A percent is obtained that indicates risk in the next 10 years. For example, if after entering age, sex, blood pressure, cholesterol level, presence of diabetes, smoking status, your 10-year risk is 5%, this means that if there were 100 women who were just like (had the same risk factors), 5 of the 100 women are estimated to have a heart attack or stroke in the next 10 years. If the calculated 10-year risk is 7.5% of higher, the clinician may discuss starting statin therapy to reduce a woman’s risk.
- For younger women (ages 20-40 years), the same risk calculator is used to calculate lifetime risk for having ASCVD.
- In the guideline we added “risk enhancing factors” that are not part of the 10-year risk estimation but need to be taken into consideration to evaluate risk. In other words, calculating a woman’s 10-year risk is the starting point, and the clinician should then discuss if a woman has any risk enhancing factors that tailor her risk assessment. A woman’s 10-year risk estimation may be quite low, but if she has risk enhancing factors, her risk may be much higher. Examples of risk enhancing factors are: family history of early heart disease (male first degree relative before age 55 years, female first degree relative before age 65 years), persistently elevated LDL cholesterol of 160 mg/dL or greater, chronic kidney disease, metabolic syndrome, inflammatory diseases such as rheumatoid arthritis, certain high-risk ethnicities such as South Asian, and conditions specific to women, such as pregnancy-associated complications (preeclampsia) and premature menopause (before age 40 years). These conditions increase a woman’s risk for future ASCVD, and in fact, having preeclampsia during pregnancy carries at least twice the risk of ASCVD and stroke compared with a woman who didn’t have this complication. Therefore, although a woman’s 10-year risk is calculated as low, the presence of risk enhancing factors may cause a clinician to recommend statin treatment sooner rather than later to reduce a woman’s overall risk.
- The guideline reinforces the need for a clinician-patient discussion of risk assessment and how to best manage risk. This discussion should include the potential benefit of lifestyle therapy (heart-healthy diet, regular exercise, and weight loss if necessary), the potential benefit of statin medication and potential risks, cost of treatment, and the woman’s thoughts and preferences. Even if the 10-year estimated risk is high (7.5% or above), a prescription for a statin should not be ordered without first having a clinician-patient discussion through which a woman’s questions are thoroughly answered.
For Women Who Are Pregnant or May Become Pregnant
Guideline recommendations specific to women include:
- Clinicians should perform a risk assessment and conduct a thorough menstrual and pregnancy history. They should note that pregnancy-associated complications and premature menopause increase a woman’s risk for ASCVD and consider these in treatment recommendations.
- Clinicians should counsel all sexually active women of childbearing age who are treated with a statin to use a reliable form of contraception. Statins are contraindicated when a woman is pregnant.
- In women who are treated with statin therapy and plan to become pregnant, the statin should be stopped 1-2 months before pregnancy is attempted and restarted after breastfeeding is complete. If a woman becomes pregnant while on statin therapy, the statin medication should be stopped as soon as pregnancy is discovered. The clinician and patient should discuss other ways to manage high cholesterol during pregnancy.
A most important point to remember is that healthy lifestyle is the cornerstone of prevention of heart disease and must start early in life. Even if drug treatment is ultimately required to lower cholesterol or to reduce ASCVD risk, making healthy lifestyle changes remains critical. As my colleague tells all of his patients: Eat less, make healthy food choices, and move more.