Jane Nelson Worel, MS, RN, APN-BC, FAHA, FPCNA Nurse Practitioner, Phases Primary Care for Women, Madison, Wisconsin.
Laura L. Hayman, PhD, RN, FAAN, FAHA Associate Vice-Provost for Research and Professor of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston.
The authors have no funding or conflicts of interest to disclose.
Correspondence Jane Nelson Worel, MS, RN, APN-BC, FAHA, FPCNA, Phases Primary Care for Women, 2955 Triverton Pike Dr, Madison, WI 53711 (email@example.com).
Cardiovascular disease (CVD) causes more deaths in women than do the next 3 causes combined, including all forms of cancer.1 Stroke is the third leading cause of death among women, and 3.8 million American women are stroke survivors.1 Approximately one-half of all stroke survivors live with significant disability, including weakness and cognitive deficits, 6 months after an event.2
Recognizing the significant health threat posed by CVD, the American Heart Association (AHA) has been releasing women-specific guidelines for the prevention of heart disease regularly since 1999, including the most recent, Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update.3 The first ever Guidelines for the Prevention of Stroke in Women were released in February 2014.4 These guidelines provide gender-specific recommendations for CVD risk assessment and prevention, the highlights of which will be discussed here. Please refer to the published guidelines for details and comprehensive recommendations.3,4
The Effectiveness Based Guideline for CVD Prevention in Women provides a flow diagram for CVD preventive care in women that starts with an evaluation of CVD risk at regular intervals during routine outpatient office visits. This evaluation includes the following: (1) a medical, family, and pregnancy history; (2) symptoms of CVD; (3) depression screening; (4) physical examination including blood pressure, body mass index (BMI), and waist size; (5) fasting lipoproteins and glucose; and (6) Framingham risk assessment. All women are encouraged to develop heart-healthy lifestyles, including smoking cessation, Dietary Approaches to Stopping Hypertension–like diet, regular physical activity, and weight management.
Women are classified as having ideal cardiovascular health, at risk, or at high risk. Ideal cardiovascular health is defined as total cholesterol level less than 200 mg/dL (untreated), blood pressure less than 120/80 mm Hg (untreated), fasting blood glucose level less than 100 mg/dL (untreated), BMI less than 25 kg/m2, abstinence from smoking, regular physical activity (defined as ≥150 minutes of moderate intensity weekly or ≥75 minutes of high intensity weekly), and a healthy (Dietary Approaches to Stopping Hypertension–like) diet.
At-risk women have 1 or more major risk factors for CVD. Major risk factors are cigarette smoking, hypertension, hyperlipidemia, obesity, poor diet, physical inactivity, family history of premature CVD, metabolic syndrome, evidence of advanced subclinical atherosclerosis, poor exercise capacity, systemic autoimmune collagen vascular disease or a history of preeclampsia, gestational diabetes or pregnancy induced hypertension.
High risk is defined as those with known coronary heart disease, cerebrovascular disease, peripheral vascular disease, abdominal aortic aneurysm, end-stage or chronic renal disease, or diabetes. Atrial fibrillation is recognized as a key risk factor for ischemic stroke in the Guidelines for Prevention of CVD in Women—2011 Update.3 Specific recommendations for the prevention of CVD in women are categorized as lifestyle interventions, major risk factor interventions, and preventive drug interventions (see the Table).
The 2014 Prevention of Stroke in Women Guideline highlights gender-specific risk factors for stroke associated with the complications of pregnancy, including gestational diabetes, hypertension, and preeclampsia. Women with chronic primary or secondary hypertension or previous pregnancy-related hypertension should take low-dose aspirin from the 12th week of gestation until delivery. Calcium supplementation (>1 g/d) should be considered for women with low dietary intake of calcium (<600 mg/d) to prevent preeclampsia. Moderate and severe hypertension in pregnancy should be treated with safe and effective antihypertensive medications. After giving birth, women with chronic hypertension should be continued on their antihypertensive regimen with appropriate dose adjustments. A history of hypertension or preeclampsia during pregnancy should be documented in the medical record and considered a risk factor that increases the lifetime risk of CVD.
The Prevention of Stroke Guidelines recommends careful prescribing of hormonal contraceptives in women with CVD risk factors especially cigarette smoking and previous thromboembolic events. The guideline advises against the use of postmenopausal hormone replacement therapy as a cardiovascular preventive therapy. It goes further to outline the relationship between stroke risk factors that are more commonly found in women than in men, including migraine with aura, obesity and metabolic syndrome, atrial fibrillation, depression, and psychosocial stress. Treatments to decrease migraine frequency may be considered, but evidence is lacking that this treatment reduces the risk of incident stroke. Active screening for atrial fibrillation in primary care settings is recommended along with appropriate use of anticoagulation therapies according to the level of stroke risk.
Both prevention guidelines cite concerns related to the increased rates of obesity in American women and the associated CVD risks. Nearly 2 of every 3 adult women in the United States meet BMI criteria for overweight or obese.1 The prevalence of obesity is higher in women compared with men; in 2007–2008, the age-adjusted prevalence of obesity in the United States was 35.2% in women compared with 32.0% in men.5 Obesity is an independent risk factor for stroke, with a linear association between BMI and stroke risk.6 The rise in the obesity epidemic contributes to the increase in diabetes mellitus now seen in approximately 13 million US women.1 Diabetes mellitus is a major risk factor for CVD in women.4 These guidelines emphasize the importance of weight maintenance and reduction through appropriate balance of physical activity, caloric intake, and formal behavioral programs to achieve an appropriate body weight (BMI <25 kg/m2).3,4
In 2013, the American College of Cardiology and the AHA jointly released 4 new prevention guidelines. These guidelines provide strategies for lifestyle management to reduce cardiovascular risk, management of overweight and obesity, assessment of cardiovascular risk, and treatment of blood cholesterol to reduce atherosclerotic disease risk.7–10 The 2013 American College of Cardiology/AHA prevention guidelines reflect new evidence from recent clinical trials and systematic reviews. Clinicians should be familiar with these new guidelines together with the women-specific guidelines for the prevention of CVD and stroke. Health assessment, education, and behavioral counseling are central to the practice of cardiovascular nurses, positioning them to be leaders in the implementation of CVD prevention guidelines to reduce the major health burden associated with CVD in women.
1. As Go, Mozaffarian D, Roger VL, et al. Heart Disease and Stroke Statistics—2013 update: a report from the American Heart Association. Circulation. 2013; 127( 1): e6–e245.
2. Kelly-Hayes M, Beiser A, Kase CS, et al. The influence of gender and age on disability following ischemic stroke: the Framingham Study. J Stroke Cerebrovasc Dis. 2003; 12( 3): 119–126.
3. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update. Circulation. 2011; 123( 11): 1243–1262.
4. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women: a statement for health care professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45( 5): 1545–1588.
5. Ford ED, Li C, Zhao G, Tsai J. Trends in obesity and abdominal obesity among adults in the US 1999–2008. Int J Obes (London). 2011; 35( 5): 736–743.
6. Kurth T, Gaziano JM, Rexrode KM, et al. Prospective study of body mass index and risk of stroke in apparently healthy women. Circulation. 2005; 111( 15): 1992–1998.
7. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63( 25): 2961–2984.
8. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guidelines for the management of overweight and obesity in adults; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014; 63( 25): 2987–3023.
9. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63( 25): 2935–2959.
10. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63( 25): 2890–2932.