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Recent surveys of American women reveal that approximately half still do not identify heart disease as the No. 1 cause of death among women. While mortality among men from cardiovascular disease (CVD) has declined steadily as a result of increased screening and detection and effective treatment, the rate among women lags dangerously behind. Paradoxically, the standard tools for 10-year CVD risk stratification have in the past misclassified women who are at intermediate risk, leaving them vulnerable in a time when excellent preventive measures are available. 

 In this podcast, renowned preventive cardiologist and women’s heart health expert Dr. C. Noel Bairey Merz speaks directly to these and other critical issues in advancing CVD detection and prevention in women and offers concrete ideas to help primary care physicians take action in daily clinical care. 



Women and Heart Disease: Incidence, Prevalence, Progress, and the Future

Links to Resources Mentioned in this Podcast 

 Fifteen-Year Trends in Awareness of Heart Disease in Women: Results of a 2012 American  Heart Association National Survey

 Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update : A Guideline From the American Heart Association

 Framingham Risk Score Calculator SI Units 

See Practice Pearls for Primary Care on next page...

Prevention of Heart Disease in Women: Pearls for Primary Care 



 1. Although heart disease remains the leading killer of women, women themselves continue to believe that breast cancer poses the greater mortality threat. Awareness is improving, however, as 53% of women in 2012 identified heart disease as the primary threat, compared with less than 20% two decades ago.

 2. Female CV mortality has fallen along with overall mortality from heart disease. Nonetheless, there is still a gender gap as reduction in mortality from heart disease among men exceeds the rate of reduction among women. 

 3. Women face unique CV risks that primary care physicians need to account for when assessing and managing prevention of CVD in women:
     o  Risk factors unique to women: pregnancy related complication (hypertension, gestational diabetes, eclampsia/pre-eclampsia), autoimmune disease (eg, systemic lupus erythema, rheumatoid arthritis) 
     o  Risk assessment scores: Framingham and Reynolds Risk Scores incorporate gender but may still underestimate the 10-year risk in women, especially since they do not incorporate risk factors unique to women. As stated in the AHA guidelines for the prevention of CVD in women, lifetime risk is a better tool for CVD risk assessment for women 
     o  Hypertension: pregnancy-related hypertensive syndromes (as above) confer a higher CV risk to women.
     o  Every woman with known heart failure should be on optimal medication management (“Magic 4 pills”): aspirin, beta-blocker, statin, ace-inhibitor

 4. Hyperlipidemia, statins and prevention: Treatment of hyperlipidemia is inconsistent among women and primarily varies with age. Data from NHANES suggest that primary care physicians are excellent at controlling and treating elevated cholesterol in the older female population (age 65+ years). These data show, however, that middle-aged and younger women remain undertreated. This may be an artifact of an unexplained reluctance among PCPs to prescribe statins to younger women, which may perhaps be linked to concerns about statin use and pregnancy or potential pregnancy. 
      •  Primary prevention: For some time there was debate about the efficacy of statin therapy for women in primary prevention. This was largely because most statin trials were performed primarily in men and so data on women was underpowered. The 

 was the first study to provide unequivocal evidence that statins are effective in primary prevention in women and should be used.
      •    Secondary Prevention: All women who have had a previous cardiac event, or have established coronary artery disease should be treated with a statin.

 5. Statins should be avoided in women who are pregnant or planning to become pregnant.
  

Female CV mortality lags behind male mortality; lifetime risk assessment, not 10-year risk, is a better estimation tool for women

The  Mediterranean diet, supplemented with either extra virgin olive oil or tree  nuts, may have just won a secure seat at the table where cardioprotection and  prevention are discussed. The results of the recent study in the 

 compared 2 Mediterranean-style diets (olive oil or tree nuts)  with a control diet (low in saturated fat) found a reduction in major cardiovascular  events of 30% among subjects in a large primary prevention cohort over about 5  years. The primary end point was a composite of myocardial infarction, stroke,  and death from cardiovascular causes.

• Were any  other end-points (eg, HbA1C, LDL-C, hs-CRP, weight) evaluated during the study?

• What  underlying mechanism might explain the benefits of the Mediterranean regimen?

• What  populations can we extrapolate this data to?

• Why  weren’t results of the low-fat diet more robust?

• What is the best advice  for primary care physicians who field questions on the study-and on current  dietary guidelines-from their patients?

Answering these and other questions in this podcast are Cardiology

host Dr Payal Kohli and her guest Dr  Michael Blaha. Dr Kohli is a cardiology fellow at the University of California  San Francisco. Dr Blaha is assistant professor of cardiology and epidemiology,  and director of clinical research for the Johns Hopkins Ciccarone Center for  the Prevention of Heart Disease, in Baltimore.

Mediterranean Diet in Primary Cardiovascular Prevention

1.  Compared with patients eating a low-fat diet, patients consuming a  Mediterranean -style diet displayed a 30% reduction in major cardiovascular  events.

2. An  almost immediate advantage was observed among patients consuming the  Mediterranean diet compared to control diet-suggesting  that the mechanism underlying the difference is something more subtle that

weight loss and lipid control, and may  involve inflammation and plaque stabilization.

3. Although  trial patients had no known coronary disease, these results are likely  generalizable to secondary prevention as well.

4. The  control group (ie, low saturated-fat group) consumed a diet with approximately  38% of calories coming from fat (much higher than the AHA recommended low-fat  diet); and, while the Mediterranean-style dieters were afforded consistent  behavioral counseling, the control group only received the intervention after 3  years in the study. Both factors could have made the between the diets appear  larger than it actually was.

5. The  Mediterranean diet continues to be an excellent option to help reduce  cardiovascular risk, although cost and access to components of the diet may  pose significant barriers.

Estruch R,  Ros E, Salas-Salvado J, et al for the PREDIMED Study Investigators. Primary  prevention of cardiovascular disease with a Mediterranean diet. 

http://www.nejm.org/doi/full/10.1056/NEJMoa1200303

Kris-Etherton  P, Eckel RH, Howard BV, St. Jeor S, Bazzarre TL. Lyon diet heart study:  benefits of a Mediterranean-style, National Cholesterol Education  Program/American Heart Association step 1 dietary pattern on cardiovascular  disease. 

.  2001;103:1823-1825 doi: 10.1161/01.CIR.103.13.1823. Available at: 

http://circ.ahajournals.org/content/103/13/1823.full.pdf+html

Patients who consumed a Mediterranean-style diet had a 30% reduction in major cardiovascular events compared with patients who ate a diet low in saturated fat.

The Mediterranean Diet in Primary Cardiovascular Prevention

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