Curr Atheroscler Rep (2015) 17:38 DOI 10.1007/s11883-015-0518-5
WOMEN AND ISCHEMIC HEART DISEASE (M GULATI, SECTION EDITOR)
Primary and Secondary Prevention of Ischemic Heart Disease in Women Priya Kohli 1,2
# Springer Science+Business Media New York (outside the USA) 2015
Abstract Cardiovascular disease remains the number one cause of mortality among women. With increasing awareness of heart disease in women and increasing focus on including more women in trials, mortality from cardiovascular disease has fallen. Despite this, more women than men die from cardiovascular disease, and increasing cardiovascular disease is seen in young women. Preventive therapies have been the focus of recent guidelines to close this gap. In this review, data for primary and secondary prevention therapies for ischemic heart disease in women will be reviewed. Keywords Ischemic heart disease . Gender . Primary Prevention . Secondary Prevention
Introduction Cardiovascular disease is the number one cause of mortality in men and women [1]. Though mortality rates have declined in both groups, a higher absolute number of women are affected by cardiovascular disease, and it is estimated that one in two women will be affected by cardiovascular disease (CVD) in their lifetime [2]. Coronary, or ischemic, heart disease (CHD) is the largest contributor to CVD mortality in women, and This article is part of the Topical Collection on Women and Ischemic Heart Disease * Priya Kohli [email protected] 1
Division of Cardiovascular Medicine, West Roxbury Veterans’ Administration Hospital, 1400 VFW Parkway, West Roxbury, MA 02132, USA
2
Harvard Medical School, Boston, MA, USA
though mortality rates have declined in women overall, the incidence of CHD in young women is rising [3]. Reductions in CVD in the past have been attributable to both risk factor reduction and implementation of secondary preventive therapies [4]. Over the past 10 years, increasing efforts have been made to improve awareness of heart disease among patients and physicians as well as to improve understanding of CVD in women [5], including the release of the American Heart Association (AHA) Effectiveness–based Guidelines for the Prevention of Cardiovascular Disease in Women [6•]. These advances have aided the decrease in CHD mortality in women through better control of risk factors as well as implementation of secondary preventive therapies. However, women remain underrepresented in trials [7] and are often less likely to receive therapies, which may explain the persistently higher mortality rates in this population [8–10]. The purpose of this article is to review and summarize the data for primary and secondary prevention therapies for the reduction of CHD in women.
Primary and Secondary Prevention Primary prevention measures are aimed at preventing the first occurrence of ischemic heart disease in patients who are identified to be at high risk of developing disease. Several risk calculators and risk classification schemes have been developed to assess risk of CHD in women, though many may underestimate risk, especially in younger women. Trials for lifestyle interventions, therapies for known CHD risk factors and other drug therapies have included women to varying degrees. Implementing primary prevention interventions in women is of significance as women who achieve an ideal risk factor profile by middle age are likely to have better outcomes [2]. Also, as many women will not have symptoms before
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sudden death [11], primary prevention measures are important to reduce CHD prevalence in this population. Recommendations for primary prevention measures in women are summarized in Table 1. Compared to the data for primary prevention measures, the study of secondary prevention interventions, those aimed at decreasing recurrence of disease once CHD has been diagnosed, has been more robust. Guidelines and recommendations outline strategies for risk factor modification and optimal medical therapy, in addition to lifestyle changes [6•, 12]. Recommendations for secondary prevention measures in women are summarized in Table 2. Prevention measures are divided into the following: (1) lifestyle interventions, such as diet, exercise, tobacco cessation, and weight management; (2) risk factor management, such as management of hypertension, hyperlipidemia, and diabetes; and (3) other pharmacologic therapies, such as aspirin, vitamin supplements, hormone replacement therapy, betablockers, and angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers.
Lifestyle Interventions Recommendations for lifestyle modifications, including diet changes, physical activity, tobacco use, and weight management are similar for both primary and secondary prevention. Diet Maintaining a healthy diet is a cornerstone of prevention of CHD in women. In two studies of diet in the primary prevention of CHD in women, adherence to a diet rich in leafy green vegetables and olive oil [13], and lower in trans fats, high in cereal fiber, marine n-3 fatty acids and folate [14] was associated with a low risk of developing CHD. In the recent Prevención con Dieta Mediterránea (PREDIMED) study, a trend toward reduced incidence of major cardiovascular events was seen in women randomized to a Mediterranean diet with nuts of olive oil (hazard ratio 0.73, 95 % CI 0.5– 1.07) [15]. In addition to consuming a diet rich in fruits, vegetables, whole grains and high fiber foods with limited intake of saturated and trans fats, cholesterol, sodium, and sugar, consuming two servings of fish per week is suggested for additional cardiovascular benefit. Data concerning the consumption of fish and its association with CHD is conflicting in women. Though there was a significant benefit in CHD mortality in postmenopausal women who consumed more than two servings of fish per week in the Iowa Women’s Health study, this benefit was not statistically significant after adjustment for other risk factors [16]. This result also held true for women with and without a history of CHD. In a large study of over 48,
Curr Atheroscler Rep (2015) 17:38
000 women in the Danish National Birth Cohort, women of reproductive age who had little to no fish intake had a significantly higher risk of CHD as compared to women with the highest levels of fish intake (hazard ratio 3.80, 95 % CI 1.53– 9.42) [17]. There are few studies regarding the role of diet in the secondary prevention of CHD. Women comprised 30 % of the patient population in a study by Denghan et al., which examined the incidence of new CV events among patient being treated for CHD [18]. A healthy diet included a high intake of fruits, vegetables, whole grains, nuts, and fish. An inverse association between new CVD events and adherence to a healthy diet was observed. Data specific to women was not reported.
Exercise and Cardiac Rehabilitation In observational studies, increasing levels of physical activity are inversely associated with risk of incident coronary events [19, 20]. In an analysis from the Nurses’ Health Study, women without known CHD who were in the highest quintile of walking had the lowest rate of coronary events, and the reduction in coronary risk was seen whether the physical activity was brisk walking or more vigorous activity [21]. In the same study, an increase in physical activity from sedentary to active over the follow-up period resulted in a lower risk of CHD than women who remained sedentary over the study period. The risk of CHD is attenuated by physical activity in overweight and obese women [22]. As compared to men, women may have a greater improvement in CHD risk with physical activity. In a meta-analysis of studies examining CHD risk and physical activity, risk reduction in women was 40 % in the most active women compared to the least active women, whereas in men, this risk reduction was only 30 % [23, 24]. Moderate to vigorous intensity physical activity should be counseled to all women. In women with known CHD, as part of comprehensive secondary prevention care, cardiac rehabilitation (CR) is recommended for all patients who have had an acute coronary syndrome, revascularization, or chronic angina. Exercisebased CR has been shown to reduce total and cardiovascular mortality in both men and women [25]. Although women are less often referred for CR [26], a significant mortality reduction is seen among women who do participate in these programs. In a study by Colbert et al., over 25,000 participants, including 24.6 % women, with CHD were examined for referral rates to CR and subsequent mortality [27]. In this population, women were less often referred for CR (adjusted OR 0.74, 95 % CI 0.69–0.79), but those women who completed CR had the largest reduction in mortality (HR 0.36, 95 % CI 0.28–0.45) compared to their male counterparts (HR 0.51, 95 % CI 0.46–0.56).
Curr Atheroscler Rep (2015) 17:38 Table 1
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Summary of recommendations for the primary prevention of CHD in women Recommendation
Lifestyle changes Exercise
Diet Tobacco use
Weight management
Risk factor management Hypertension
Hyperlipidemia
Diabetes Other pharmacologic therapies Antiplatelet therapy
Hormone replacement therapy Supplements Omega-3 fatty acids
Two hours and 30 min per week of moderate intensity aerobic physical activity or 1 h and 15 min per week of vigorous intensity aerobic physical activity. An additional cardiovascular benefit can be gained from 300 min per week of moderate intensity exercise or 150 min per week of vigorous intensity exercise. For weight loss, a minimum of 60 to 90 min of at least moderate intensity physical activity on most, if not all, days of the week. Aerobic activity should be performed in episodes of at least 10 min, spread throughout the week. Consume a diet rich in fruits, vegetables, whole grains, and high-fiber foods. Consume oily fish twice per week. Limit intake of saturated fate, cholesterol, alcohol, sodium, and sugar. Avoid trans fatty acids. Avoid smoking and avoid all environmental tobacco smoke. Tobacco cessation methods such as counseling, nicotine replacement, and pharmacotherapy along with formal smoking cessation programs may be used. Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavior programs when indicated to maintain or achieve an appropriate body weight (body mass index
WOMEN AND ISCHEMIC HEART DISEASE (M GULATI, SECTION EDITOR)
Primary and Secondary Prevention of Ischemic Heart Disease in Women Priya Kohli 1,2
# Springer Science+Business Media New York (outside the USA) 2015
Abstract Cardiovascular disease remains the number one cause of mortality among women. With increasing awareness of heart disease in women and increasing focus on including more women in trials, mortality from cardiovascular disease has fallen. Despite this, more women than men die from cardiovascular disease, and increasing cardiovascular disease is seen in young women. Preventive therapies have been the focus of recent guidelines to close this gap. In this review, data for primary and secondary prevention therapies for ischemic heart disease in women will be reviewed. Keywords Ischemic heart disease . Gender . Primary Prevention . Secondary Prevention
Introduction Cardiovascular disease is the number one cause of mortality in men and women [1]. Though mortality rates have declined in both groups, a higher absolute number of women are affected by cardiovascular disease, and it is estimated that one in two women will be affected by cardiovascular disease (CVD) in their lifetime [2]. Coronary, or ischemic, heart disease (CHD) is the largest contributor to CVD mortality in women, and This article is part of the Topical Collection on Women and Ischemic Heart Disease * Priya Kohli [email protected] 1
Division of Cardiovascular Medicine, West Roxbury Veterans’ Administration Hospital, 1400 VFW Parkway, West Roxbury, MA 02132, USA
2
Harvard Medical School, Boston, MA, USA
though mortality rates have declined in women overall, the incidence of CHD in young women is rising [3]. Reductions in CVD in the past have been attributable to both risk factor reduction and implementation of secondary preventive therapies [4]. Over the past 10 years, increasing efforts have been made to improve awareness of heart disease among patients and physicians as well as to improve understanding of CVD in women [5], including the release of the American Heart Association (AHA) Effectiveness–based Guidelines for the Prevention of Cardiovascular Disease in Women [6•]. These advances have aided the decrease in CHD mortality in women through better control of risk factors as well as implementation of secondary preventive therapies. However, women remain underrepresented in trials [7] and are often less likely to receive therapies, which may explain the persistently higher mortality rates in this population [8–10]. The purpose of this article is to review and summarize the data for primary and secondary prevention therapies for the reduction of CHD in women.
Primary and Secondary Prevention Primary prevention measures are aimed at preventing the first occurrence of ischemic heart disease in patients who are identified to be at high risk of developing disease. Several risk calculators and risk classification schemes have been developed to assess risk of CHD in women, though many may underestimate risk, especially in younger women. Trials for lifestyle interventions, therapies for known CHD risk factors and other drug therapies have included women to varying degrees. Implementing primary prevention interventions in women is of significance as women who achieve an ideal risk factor profile by middle age are likely to have better outcomes [2]. Also, as many women will not have symptoms before
38
Page 2 of 14
sudden death [11], primary prevention measures are important to reduce CHD prevalence in this population. Recommendations for primary prevention measures in women are summarized in Table 1. Compared to the data for primary prevention measures, the study of secondary prevention interventions, those aimed at decreasing recurrence of disease once CHD has been diagnosed, has been more robust. Guidelines and recommendations outline strategies for risk factor modification and optimal medical therapy, in addition to lifestyle changes [6•, 12]. Recommendations for secondary prevention measures in women are summarized in Table 2. Prevention measures are divided into the following: (1) lifestyle interventions, such as diet, exercise, tobacco cessation, and weight management; (2) risk factor management, such as management of hypertension, hyperlipidemia, and diabetes; and (3) other pharmacologic therapies, such as aspirin, vitamin supplements, hormone replacement therapy, betablockers, and angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers.
Lifestyle Interventions Recommendations for lifestyle modifications, including diet changes, physical activity, tobacco use, and weight management are similar for both primary and secondary prevention. Diet Maintaining a healthy diet is a cornerstone of prevention of CHD in women. In two studies of diet in the primary prevention of CHD in women, adherence to a diet rich in leafy green vegetables and olive oil [13], and lower in trans fats, high in cereal fiber, marine n-3 fatty acids and folate [14] was associated with a low risk of developing CHD. In the recent Prevención con Dieta Mediterránea (PREDIMED) study, a trend toward reduced incidence of major cardiovascular events was seen in women randomized to a Mediterranean diet with nuts of olive oil (hazard ratio 0.73, 95 % CI 0.5– 1.07) [15]. In addition to consuming a diet rich in fruits, vegetables, whole grains and high fiber foods with limited intake of saturated and trans fats, cholesterol, sodium, and sugar, consuming two servings of fish per week is suggested for additional cardiovascular benefit. Data concerning the consumption of fish and its association with CHD is conflicting in women. Though there was a significant benefit in CHD mortality in postmenopausal women who consumed more than two servings of fish per week in the Iowa Women’s Health study, this benefit was not statistically significant after adjustment for other risk factors [16]. This result also held true for women with and without a history of CHD. In a large study of over 48,
Curr Atheroscler Rep (2015) 17:38
000 women in the Danish National Birth Cohort, women of reproductive age who had little to no fish intake had a significantly higher risk of CHD as compared to women with the highest levels of fish intake (hazard ratio 3.80, 95 % CI 1.53– 9.42) [17]. There are few studies regarding the role of diet in the secondary prevention of CHD. Women comprised 30 % of the patient population in a study by Denghan et al., which examined the incidence of new CV events among patient being treated for CHD [18]. A healthy diet included a high intake of fruits, vegetables, whole grains, nuts, and fish. An inverse association between new CVD events and adherence to a healthy diet was observed. Data specific to women was not reported.
Exercise and Cardiac Rehabilitation In observational studies, increasing levels of physical activity are inversely associated with risk of incident coronary events [19, 20]. In an analysis from the Nurses’ Health Study, women without known CHD who were in the highest quintile of walking had the lowest rate of coronary events, and the reduction in coronary risk was seen whether the physical activity was brisk walking or more vigorous activity [21]. In the same study, an increase in physical activity from sedentary to active over the follow-up period resulted in a lower risk of CHD than women who remained sedentary over the study period. The risk of CHD is attenuated by physical activity in overweight and obese women [22]. As compared to men, women may have a greater improvement in CHD risk with physical activity. In a meta-analysis of studies examining CHD risk and physical activity, risk reduction in women was 40 % in the most active women compared to the least active women, whereas in men, this risk reduction was only 30 % [23, 24]. Moderate to vigorous intensity physical activity should be counseled to all women. In women with known CHD, as part of comprehensive secondary prevention care, cardiac rehabilitation (CR) is recommended for all patients who have had an acute coronary syndrome, revascularization, or chronic angina. Exercisebased CR has been shown to reduce total and cardiovascular mortality in both men and women [25]. Although women are less often referred for CR [26], a significant mortality reduction is seen among women who do participate in these programs. In a study by Colbert et al., over 25,000 participants, including 24.6 % women, with CHD were examined for referral rates to CR and subsequent mortality [27]. In this population, women were less often referred for CR (adjusted OR 0.74, 95 % CI 0.69–0.79), but those women who completed CR had the largest reduction in mortality (HR 0.36, 95 % CI 0.28–0.45) compared to their male counterparts (HR 0.51, 95 % CI 0.46–0.56).
Curr Atheroscler Rep (2015) 17:38 Table 1
Page 3 of 14 38
Summary of recommendations for the primary prevention of CHD in women Recommendation
Lifestyle changes Exercise
Diet Tobacco use
Weight management
Risk factor management Hypertension
Hyperlipidemia
Diabetes Other pharmacologic therapies Antiplatelet therapy
Hormone replacement therapy Supplements Omega-3 fatty acids
Two hours and 30 min per week of moderate intensity aerobic physical activity or 1 h and 15 min per week of vigorous intensity aerobic physical activity. An additional cardiovascular benefit can be gained from 300 min per week of moderate intensity exercise or 150 min per week of vigorous intensity exercise. For weight loss, a minimum of 60 to 90 min of at least moderate intensity physical activity on most, if not all, days of the week. Aerobic activity should be performed in episodes of at least 10 min, spread throughout the week. Consume a diet rich in fruits, vegetables, whole grains, and high-fiber foods. Consume oily fish twice per week. Limit intake of saturated fate, cholesterol, alcohol, sodium, and sugar. Avoid trans fatty acids. Avoid smoking and avoid all environmental tobacco smoke. Tobacco cessation methods such as counseling, nicotine replacement, and pharmacotherapy along with formal smoking cessation programs may be used. Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavior programs when indicated to maintain or achieve an appropriate body weight (body mass index
