Guideline Update on Primary Cardiovascular Prevention in Women Takes on Conventional and Sex-Specific Risks

Hypertensive disorders of pregnancy and gestational diabetes mellitus (DM) put women at elevated risk for cardiovascular disease (CVD) later in life, and early primary prevention to address these and other conditions unique to women can improve eventual outcomes. So contends a new Journal of the American College of Cardiology (JACC) State-of-the-Art Review (2020;75[20]:2602-2618) summarizing updated recommendations for the primary prevention of CVD in women.

The document, developed by the ACC’s Cardiovascular Disease in Women Committee, is an update to a 2011 guideline update on the topic from the American Heart Association (AHA), which covered only conventional CVD risk factors.

“A plethora of evidence pertaining to women’s cardiovascular risk has emerged in the past decade, enabling JACC to issue the first comprehensive guideline detailing women’s unique risk factors with recommendations for primary prevention,” says lead and corresponding author Leslie Cho, MD, Director of the Women’s Cardiovascular Center and Co-Section Head of Preventive Cardiology and Rehabilitation at Cleveland Clinic.

In addition to covering risks specific to women, the new update discusses traditional CVD risk factors, with an emphasis on distinct manifestations and treatment responses in women. Multiple tables and figures concisely summarize key points and management strategies.

Risk factors particular to women

The review discusses — and provides treatment recommendations for — the following disorders that are unique to or likelier to occur in women:

• Pregnancy-related disorders. Hypertensive disorders of pregnancy, gestational DM, preterm birth, pregnancy loss and having a baby with low birthweight for gestational age are associated with developing later CVD. This is especially significant when such complications occur in younger pregnant women, at an age before conventional CVD risk factors usually manifest. “At Cleveland Clinic, pregnant women who have preeclampsia or diabetes in pregnancy are automatically flagged for follow-up in the electronic medical record,” says Dr. Cho. “This provides the opportunity to conduct a thorough risk assessment and counsel women on lifestyle choices.”
• Polycystic ovarian syndrome. Women with this condition are prone to developing metabolic syndrome, which contributes to endothelial dysfunction and subclinical atherosclerosis. Menstrual irregularities should be treated, and metformin is recommended for insulin resistance. Women should be monitored every six to 12 months for weight changes, blood pressure, and fasting lipid and blood sugar levels.
• Autoimmune and inflammatory conditions. Women are more likely to have diseases such as systemic lupus erythematosus and rheumatoid arthritis, which are associated with accelerated atherosclerosis and coronary vascular dysfunction. “Eighty percent of patients who have autoimmune disease are women, and they need aggressive risk factor modifications,” notes Dr. Cho.

“Many of the conditions unique to women arise decades before cardiovascular disease manifests itself,” she adds. “This creates a huge window of opportunity to take proactive measures that can make a real difference in outcomes.”

Traditional risks: How women differ

The updated guideline also examines how the following traditional CVD risk factors affect women in different ways than men:

• Obesity is the most significant risk factor for developing hypertension among women. Dr. Cho notes that thiazide diuretics may be an ideal antihypertensive medication choice for women with osteoporosis because these drugs reduce calcium excretion and thereby lower osteoporotic fracture risk.
• Blood cholesterol. No sex-specific guidelines exist for managing hyperlipidemia with statins, but its role for women has been controversial, and women are less likely to receive guideline-recommended therapy. Since the 2011 AHA guideline update, two large meta-analyses that included over 40,000 women demonstrated that statin therapy offers similar benefit to men and women for both primary and secondary prevention, and for all levels of risk in primary prevention. The new JACC review includes tables on statin recommendations for women for primary and secondary prevention and during pregnancy.
• Diabetes mellitus. Whereas rates of type 2 DM are higher in girls than in boys, once midlife arrives, incidence rates in men exceed those in women. Incidences are similar between the sexes in later life. “Diabetes nearly cancels the gender gap between men and women in development of cardiovascular disease,” says Dr. Cho. “Especially for women who develop the disease early, there is longer exposure to insulin resistance and its attendant harms.” She emphasizes that the increased CVD risk associated with DM requires aggressive risk factor reduction, but studies consistently show DM to be underdiagnosed and undertreated in women, resulting in poorer control of traditional risk factors. The review provides a table of DM risk management and treatment goals, and notes two gender differences in responses to medications: (1) Glucagon-like peptide-1 receptor agonists provide better glycemic control in men, but women tend to benefit with greater weight loss. (2) Thiazolidinediones control blood sugar better in obese women.

Personalized treatment for better outcomes

The new guideline update also covers anticoagulation therapy for atrial fibrillation, aspirin therapy, perimenopausal hormone therapy and psychosocial issues.

“Cardiovascular disease is preventable in 90% of cases,” concludes Dr. Cho. “Tailoring management with a knowledge of important gender differences helps providers optimize patient care.”