| Lifestyle
Factors |
Goal(s) |
Screening |
Recommendations |
| Cigarette
smoking |
1.
Complete cessation.
2. Avoid passive cigarette smoke. |
1.
Ask about current smoking status and exposure to others' cigarette
smoke as part of routine evaluation.
2. Assess total exposure to cigarette smoke (pack-years) and
prior attempts at quitting.
3. Evaluate readiness to stop smoking. |
1.
At each visit, strongly encourage patient and family to stop
smoking. If complete cessation is not achievable, a reduction
in intake is beneficial as a step toward cessation.
2. Reinforce nonsmoking status.
3. Provide counseling, nicotine replacement, and other pharmacotherapy
as indicated in conjunction with behavioral therapy or a formal
cessation program. |
| Physical
activity |
1. Accumulate >30 min of moderate-intensity physical activity on most, and preferably all, days of the week.
2. For weight loss or sustained weight loss, accumulate 60–90 minutes of moderate-intensity physical activity on most, and preferably all, days of the week.
3.
Women with a recent acute coronary syndrome or coronary intervention or with new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease, or current/prior heart failure and an LVEF <40% should participate in a comprehensive risk-reduction regimen, such as cardiac rehabilitation or a physician-guided home or community-based program. |
1.
Ask about physical activity (household work as well as occupational
and leisure-time physical activity) as part of routine evaluation.
2. In women with symptoms that suggest CVD or in previously
sedentary women >50 y old with >2 risk factors for
CVD, consider a stress test†
to establish safety of exercise and to guide the exercise prescription. |
1.
Encourage a minimum of 30 min of moderate-intensity dynamic
exercise (eg, brisk walking) daily. This may be performed in
intermittent or shorter bouts (>10 min) of activity
throughout the day.
2. Women who already meet minimum standards may be encouraged
to become more physically active or to include more vigorous
activities.
3. Incorporate physical activity in daily activities (eg, using
stairs).
4. Muscle strengthening and stretching exercises should be recommended
as part of an overall activity program.
5. Recommend medically supervised programs for women who have
had a recent MI or revascularization procedure. |
| Nutrition |
1. AHA Step I Diet in healthy women (<30% fat, 7%–10% saturated fat, <300 mg/d cholesterol).
2. AHA Step II Diet in women with CVD or if further cholesterol
reduction is needed (<30% fat, <7% saturated fat,
and <200 mg/d cholesterol).
3. Intake of trans fatty acids (eg, hydrogenated
or partially-hydrogenated food products) should be as low as possible (<1% of energy).
4. Limit sodium chloride (salt) intake to <2.3 g/d (approximately 1 tsp). Women with high blood pressure may require further restriction.
5. Total dietary fiber intake of 25–30 g/d from foods.
6. Consume >5 servings of fruits and vegetables per
day.
7. Limit alcohol intake to <1 glass of alcohol per day
(1 glass = 4 oz wine, 12 oz beer, or 1½ oz 80-proof spirits).
Pregnant women should abstain from drinking alcohol. |
1.
Assess nutritional habits as part of a routine evaluation in
all women.
2. Consider formal dietary assessment in women with hyperlipidemia,
diabetes, obesity, and hypertension. |
1.
Consistently encourage an overall healthy eating pattern that includes intake of a variety of fruits, vegetables, whole grains, high-fiber foods, low-fat or non-fat and dairy products (skim milk); consume fish, especially oily fish, at least twice a week, legumes, and sources of protein low in saturated fat (eg, poultry, lean meats, plant sources).
2. Diets rich in antioxidant nutrients (eg, vitamins C and E, and
beta-carotene) and folate are preferred over nutritional supplements.
Note: daily supplements of 0.4 mg of folic acid are recommended
for women of child-bearing age to help prevent neural tube defects.
As an adjunct to diet, folic-acid supplementation may be considered
in high-risk women (except after revascularization procedure)
if a higher-than-normal level of homocysteine has been detected. Antioxidant vitamin supplements should not be used to prevent
CVD pending the results of ongoing trials.
3.
Omega-3 fatty acid capsules may be considered in women with CHD (850–
1000 mg EPA and DHA ) and those with high triglyceride levels (2–4 mg). |
| Weight
management |
1. Maintain or lose weight through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to achieve ideal BMI .
2. Target BMI (weight in kilograms divided by height in meters
squared) between 18.5 and 24.9 kg/m2 (BMI of
25 kg/m2 = 110% of
desirable
body weight).
3. Desirable waist circumference <88 cm (<35 inches) in women
with a BMI of 25–34.9 kg/m2. |
Measure
patient's weight and height, calculate BMI, and measure waist
circumference as part of a periodic evaluation.
Note: BMI and waist circumference are used for diagnosis, and
measurement of height and weight are used for follow-up. |
1.
Encourage gradual and sustained weight loss in persons whose
weight exceeds the ideal weight for their height.
2. Formal nutritional counseling is encouraged for women with
hypertension, hyperlipidemia, or elevated glucose levels associated
with overweight.
3. The recommended weight gain during pregnancy is 25–35
lb if the patient's pre-pregnancy weight is normal. Adjust for
multiple gestation and pre-pregnancy weight (eg, overweight women
should gain 15–25 lb, obese women, <15 lb). |
| Psychosocial
factors |
1.
Positive adaptation to stressful situations.
2. Improved quality of life.
3. Maintain or establish social connections. |
1.
Assess presence of stressful situations and response to stress
as part of a routine evaluation.
2. Evaluate for depression, especially in women with recent
cardiovascular events.
3. Assess social support system and evaluate for social isolation. |
1.
Encourage positive coping mechanisms for stress (eg, substitute
physical activity for overeating or excessive smoking in response
to stress).
2. Encourage adequate rest and relief for women who are caretakers
of others.
3. Consider treatment of depression and anxiety when appropriate.
Encourage participation in social activities or volunteer work
for socially isolated women. |
| Risk
Factors |
Goal(s) |
Screening |
Recommendations |
| Blood
pressure (BP) |
1.
Achieve and maintain BP of <120/80 mm Hg.
2. In pregnant women with hypertension, the goal of treatment
is to minimize short-term risk of elevated blood pressure in
the mother while avoiding therapy that may compromise the well-being
of the fetus. |
1.
Measure BP as part of a routine evaluation.
2. Follow-up is based on initial measurement as follows:
SBP
mm Hg |
DBP
mm Hg |
Follow-up |
| <120 |
<80 |
Recheck
in 2 y |
| 120–139 |
80–89 |
Recheck
in 1 y |
| 140–159 |
90–99 |
Confirm
in 2 mo |
| 160–179 |
100–109 |
Evaluate
in 1 mo |
| >180 |
>110 |
Evaluate
in 1 wk |
(Follow-up
screening may be modified on the basis of prior history, symptoms,
presence of other risk factors, and end organ damage.)
3. In pregnant women with hypertension, evaluate for preeclampsia. |
1.
Promote the lifestyle behaviors described previously (weight
control, physical activity, moderation in alcohol intake) and
moderate sodium restriction, and increased consumption of fresh fruits, vegetables, and low-fat dairy products to encourage an optimal BP of <120/80 mm Hg.
2. Pharmacotherapy is indicated when BP is >140/90 mm Hg or even lower in the setting of BP-related target organ damage or diabetes <130/80 mm Hg. Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated. If there are compelling indications for other agents in specific vascular diseases, or if the women are considered high risk, initial treatment should be with ß-blockers and/or ACE inhibitors/ARBs, with addition of other drugs such as thiazides as needed.
3. In pregnant women with hypertension, reduction of DBP to
90–100 mm Hg is recommended. |
| Lipids,
lipoproteins |
LDL-C <100 mg/dL
HDL-C >50 mg/dL
TG <150 mg/dL
Non–HDL-C <130 mg/dL
*LDL-C <70 mg/dL is reasonable in very-high-risk women
|
|
1.
Promote lifestyle therapy in all women to achieve lipid goals (diet, weight management, physical activity, and avoidance of tobacco). If a woman is high-risk or has hypercholesterolemia, intake of saturated fat should be <7% and TC <200 mg/dL.
2. Utilize LDL-C-lowering drug therapy simultaneously with lifestyle therapy as indicated:
| • |
High-risk (CHD, other atherosclerotic CVD, or diabetes or 10-year absolute risk >20%) achieve LDL-C <100 mg/dL |
| • |
Very-high-risk (CHD, other atherosclerotic CVD plus multiple or poorly controlled risk factors, and diabetes) LDL-C <70 mg/dL (may require combination therapy) |
| • |
Others at risk |
| |
– 10-year risk 10%–20% plus multiple risk factors if LDL-C >130 mg/dL |
| |
– <10-year risk plus multiple risk factors if LDL-C >160 mg/dL |
| |
– Regardless of the presence or absence of risk factors if the LDL-C
>190 mg/dL |
3. Pharmacotherapy for low HDL-C or elevated non–HDL-C in high-risk women:
| • |
Utilize niacin or fibrate therapy when HDL-C is low or non–HDL-C is elevated in high-risk women after LDL-C goal is reached |
4. Pharmacotherapy for low HDL-C or elevated non–HDL-C in other at risk women:
| • |
Consider niacin or fibrate therapy when HDL-C is low or non–HDL-C is elevated after LDL-C goal is reached in women with multiple risk factors and a 10-year absolute risk 10%–20%. |
|
Antioxidant supplementation
Folic acid
|
1. Antioxidant vitamin supplements (eg, vitamins E and C, and beta-carotene) will not be used for the primary or secondary prevention of CVD.
2.
Folic acid will be used as a supplement in childbearing years to prevent neural tube defects. |
|
1. Antioxidant vitamin supplements (eg, vitamins E and C, and beta-carotene) should not be used for the primary or secondary prevention of CVD .
2.
Folic acid, with or without B6 and B12 supplementation, should not be used for the primary or secondary prevention of CVD.
3.
Folic acid supplementation should be used in childbearing years to prevent neural tube defects. |
| Diabetes |
For
patients with diabetes:
1. Maintain blood glucose: Preprandial = 80–120 mg/dL;
bedtime = 100–140 mg/dL.
2. Maintain HbA1c <7%.
3. LDL-C: Many authorities believe that LDL-C should be <100
mg/dL in all patients with diabetes.
4. TG <150 mg/dL.
5. Control BP to goal of
<130/80 mm Hg. |
1.
Monitor glucose and HbA1c as part of a routine periodic evaluation in women with diabetes.
2. Screen for diabetes (fasting glucose >125 mg/dL or >200 mg/dL
2 h after 75 g glucose) as part of a periodic examination in
women with risk factors for diabetes, such as obesity. |
1.
Encourage adoption of American Diabetes Association Diet (<30%
fat, <10% saturated fat, 6%–8% polyunsaturated fat, cholesterol
<300 mg/d).
2. A low-calorie diet may be recommended for weight loss.
3. Encourage regular physical activity.
4. Pharmacotherapy with oral agents or insulin should be used
when indicated. |
Pharmacologic
Interventions |
Goal(s) |
Screening |
Recommendations |
Hormone
replacement
therapy (HRT) |
1. Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD.
2. Initiation or continuation of therapy in women for whom the potential benefits may exceed the potential risks of therapy. (Short-term therapy is indicated for treatment of menopausal symptoms.)
3.
Minimize risk of adverse side effects through careful patient selection and appropriate choice of therapy. |
1.
Review menstrual status of women >40 y old.
2. If menopausal status is unclear, measure follicle stimulating hormone level. |
1.
Counsel all women about the potential benefits and risks of
HRT, beginning at age 40, or as requested.
2. Individualize decision based on prior history and risk factors
for CVD as well as risks of thromboembolic disease, gallbladder
disease, osteoporosis, breast cancer, and other health risks.
3. Combined estrogen plus progestin hormone therapy should not
be initiated or continued to prevent CVD in postmenopausal women.
4.
Other forms of menopausal hormone therapy (eg, unopposed estrogen) should not be initiated or continued to prevent CVD in postmenopausal women. |
| Oral
contraceptives |
1.
Minimize risk of adverse cardiovascular effects while preventing
pregnancy.
2. Use the lowest effective dose of estrogen/progestin. |
Determine
contraindications and cardiovascular risk-factor status of women
who are considering using oral contraceptives. |
1.
Use of oral contraceptives is relatively contraindicated in
women >35 y old who smoke.
2. Women with a family history of premature heart disease should
have lipid analysis before taking oral contraceptives.
3. Women with significant risk factors for diabetes should have
glucose testing before taking oral contraceptives.
4. If a woman develops hypertension while using oral contraceptives,
she should be advised to stop taking them. |
| Antiplatelet
agents/anticoagulants |
Prevention
of clinical thrombotic and embolic events in women with established
CVD. |
1.
Determine if contraindications to therapy exist at the time
of the initial cardiovascular event.
2. Evaluate ongoing compliance, risk, and side effects as part
of a routine follow-up evaluation. |
1.
Routine use of aspirin in lower-risk women is not recommended
pending the results of ongoing trials.
2. If no contraindications, women with atherosclerotic CVD should
use aspirin 75–325 mg/d.
3. Clopidogrel should be used to prevent vascular events in women who cannot take aspirin.
4. Among women with chronic or paroxysmal atrial fibrillation,
warfarin should be used to maintain the INR 2.0–3.0 unless
they are considered to be at low risk for stroke (<1%/y) or
at high risk for bleeding.
5. Aspirin (325 mg) should be used in women with chronic or
paroxysmal atrial fibrillation with contraindication to warfarin
or at low risk for stroke (<1%/y). |
| ß-blockers |
Reduction
of reinfarction rate, incidence of sudden death, and overall
mortality in women after MI. |
1.
Determine if contraindications to therapy exist at the time
of the initial cardiovascular event.
2. Evaluate ongoing compliance, risk, and side effects as part
of a routine follow-up evaluation. |
Start within hours of hospitalization in women with an evolving MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, without contraindications. If not started acutely, treatment should begin within a few days of the event and continue indefinitely. Use indefinitely in all women who have had a MI, acute coronary syndrome, or other chronic ischemic syndromes with left ventricular dysfunction regardless of heart failure symptoms, unless contraindicated. |
| ACE inhibitors/ARBs
Aldosterone blockade |
To
reduce morbidity and mortality among MI survivors
and patients with left ventricular dysfunction. |
1.
Determine if contraindications to therapy exist at the time
of the initial cardiovascular event.
2. Evaluate ongoing compliance, risk, and side effects as part
of a routine follow-up evaluation. |
1.
Start early during hospitalization for myocardial infarction
unless hypotension or other contraindications exist. Continue
indefinitely for all high-risk women and those with left ventricular
dysfunction (ejection fraction <40%) or symptoms of
congestive heart failure.
2. ARBs should be used in high-risk women with clinical evidence of heart failure or an ejection fraction <40% or with diabetes who are intolerant to ACE inhibitors.
3. Discontinue ACE inhibitors if a woman becomes pregnant.
4.
Use aldosterone blockade after myocardial infarction in women who do not have significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor and ß-blocker, and have LVEF <40% with symptomatic heart failure. |