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Prevention: The Key to Reducing Cardiovascular Disease Risk in Women

Hardesty, Peggy MSN, ARNP; Trupp, Robin J. MSN, APRN, BC, CCRN, CCRC

The Journal of Cardiovascular Nursing: November-December 2005 - Volume 20 - Issue 6 - p 433-441
ARTICLES
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More than 500,000 US women die of cardiovascular disease (CVD) annually, exceeding deaths for cancer, accidents, and diabetes combined. Yet women are largely unaware of this and fear breast cancer more. One way of changing this number is to change the way we approach CVD, that is, to practice preventive healthcare. Until recently, guidelines for women with CVD were derived largely from research conducted primarily on white middle-aged men. Although evidence-based medicine is still lacking, guidelines and recommendations specifically for women are now available and include aggressive management of the risk factors of smoking, hypertension, dyslipidemia, diabetes mellitus, and obesity. Unless women are educated regarding these risk factors and are enabled to make lifestyle changes, their chances of modifying and reducing their risks are severely impaired.

Peggy Hardesty, MSN, ARNP Division of Cardiology, The University of Kentucky, Lexington, KY.

Robin J. Trupp, MSN, APRN, BC, CCRN, CCRC College of Nursing, The Ohio State University, Columbus, OH.

Corresponding author Peggy Hardesty, MSN, ARNP, Division of Cardiology, University of Kentucky, 800 Rose Street, Goode, Lexington, KY 45036-0294 (e-mail: phard0@uky.edu).

One woman dies of cardiovascular disease (CVD) every minute. Think about it. As you read this introduction, another woman will die. CVD is the leading cause of death in women in the United States and in most developed countries around the world. More than 500,000 American women die of CVD annually, exceeding deaths for cancer, accidents, and diabetes combined.1 Yet, according to a recent American Heart Association (AHA) study, only 46% of women surveyed identified heart disease as the leading cause of death for women.2 Younger women and minorities had even less knowledge about their risks.1,2 Although CVD-related mortality has been decreasing for the past 2 decades in men, women have actually experienced increases.1 In addition, little progress has been made in reducing risk factors for CVD such as smoking, physical inactivity, and hypertension control.3 Considering that nearly two-thirds of women who died suddenly had no previously recognized symptoms, prevention, early identification of CVD become critical for reducing the incidence of, and improving outcomes in, CVD.1

Despite being largely preventable, coronary heart disease (CHD) is the leading culprit behind cardiovascular disease. The mean age for experiencing a first myocardial infarction (MI) is 62 years in men and 72 years in women.4 Mortality rates for women in the year following an MI are 38% compared to 24% in men.1 However, evidence and understanding for these gender-based differences are lacking. Despite efforts since the early 1990s to increase enrollment, only 20% of subjects in cardiovascular clinical trials are women.5,6 Until recently, guidelines for women with CVD were derived largely from research conducted primarily on white middle-aged men. Data from recent studies, such as the Women's Health Initiative and the Heart and Estrogen/Progestin Replacement study (HERS), further emphasize the need for evidenced-based, gender-specific research.7,8

Healthy People 2010 was established by the US Health and Human Services Department in 2002 to focus on major public health issues and increase community awareness about the importance of health promotion and disease prevention.9 Although not gender-specific, leading health indicators targeted include: physical activity, overweight and obesity, tobacco/substance abuse, responsible sexual behavior, injury and violence, environmental quality, and mental health. Behavioral changes in diet, weight, and exercise alone could produce a significant reduction in coronary heart disease. In addition, the AHA charged an expert panel with developing guidelines for the primary and secondary prevention of heart disease in women.10 These guidelines, the AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women, published in 2004, take into account the continuum across which cardiovascular disease can present and help women develop a personal plan to address specific risks.10

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Risk Assessment

The first step in prevention is the recognition of individuals at risk. Calculating the 10-year absolute risk for developing CVD can be accomplished by using the Framingham Risk Score for Women (Table 1), which stratifies women into high, intermediate, low, or optimal risk categories. Interventions are then based on the category of risk. Lifestyle recommendations, discussed below, are appropriate for all women and should be considered integral to clinical practice as a means for primary prevention. The AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women provide other risk-reducing interventions prioritized by the strength of the recommendation, the level of scientific evidence to support it, and the generalizability of the recommendation.10 Implicit is the understanding that while certain risk factors cannot be changed, such as family history or advancing age, most are modifiable and can decrease the risk of CVD development. Because women tend to develop CVD 7 to 10 years later than men, incorporating preventive measures at earlier ages can have a positive impact on outcomes.11 The AHA recommendations are broken down into 3 major categories: lifestyle interventions, major risk factor interventions, and preventive drug interventions.10

TABLE 1

TABLE 1

In addition, the use of novel markers as predictors of CVD and outcomes is expanding. Of these, high-sensitivity C-reactive protein (hsCRP) has been consistently reliable, is inexpensive, and is widely available. The hsCRP has been shown to predict vascular risk, provide prognostic value for those with the metabolic syndrome, and forecast the onset of type 2 diabetes.12 Including hsCRP in the global risk assessment for high-risk, if not all, women appears warranted at this time.

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Lifestyle Interventions

Smoking Cessation

Despite the absence of clinical trial data, smoking cessation was given the highest priority by the AHA expert panel.10 According to Healthy People 2010, cigarette smoking is the single most preventable cause of disease and death.9 The Centers for Disease Control and Prevention (CDC) estimate the annual economic toll of smoking on direct medical costs to exceed $75 billion with another $80 billion annually due to lost productivity.13Healthy People 2010 has a goal of decreasing smoking rates from 25% of adults to 12% by 2010.14 Although smoking rates have decreased slightly to 22.5%,14 it is unlikely this federal goal will be attained. Diabetes and smoking each increase the risk of CVD 4 times in women.11 Smoking prevalence is inversely related to socioeconomic status. Highest smoking rates occur in households with incomes below the poverty level and with less than college education.3,15 Although men are still more likely to smoke than women (25% vs. 20.2%, respectively),15 cigarette smoking appears to be more hazardous to women's cardiovascular health than men.4 Among women with an MI, female smokers, on average, are 19 years younger than nonsmokers at the time of first MI.16 Compare this to men, who are 7 years younger.16 Even smoking as few as 1 to 4 cigarettes per day is associated with a doubled risk for developing CHD.17 However, as seen in the Nurse's Health Study, smoking cessation conveyed a 33% decrease in CVD risk within 2 years.18

The importance of smoking cessation counseling is well recognized, yet 2 studies have demonstrated less than half of physicians routinely give this information to appropriate patients.19,20 In the Working Well Trial, which assessed gender differences in smoking cessation among blue-collar workers, women were less likely than men to maintain long-term smoking abstinence following an unaided attempt to quit. Higher cessation rates were seen for both men and women with higher levels of education and in white-collar occupations. The women in this study were found to be less motivated to quit and reported higher levels of job stress than the men. This may reinforce the belief that women smoke to cope with stress or to reduce strain.21

Women who are trying to stop smoking are more likely to be successful if they have support. Studies of unaided attempts suggest that women are more likely to experience relapse if they have no assistance.22 Smokers using proven interventions, such as counseling and pharmacotherapy, are 2 to 3 times more successful than those who quit on their own.23 Information on support groups, referral to smoking cessation programs, and the use of pharmacotherapies, such as bupropion or nicotine patches, should be incorporated into the treatment plan to assist women in achieving this goal. In the Women's Initiative for Nonsmoking (WINS) trial, Froelicher et al24 reported a high incidence of depression among subjects trying to stop smoking, further reinforcing the recommendation of using behavioral interventions along with an antidepressants such as bupropion. In order to ensure proper delivery of nicotine, the nicotine patch was also recommended over the nicotine gum. WINS emphasized the importance of addressing smoking cessation while the patient is hospitalized and focused on their health.

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Diet and Weight Management

The National Cholesterol Education Program (NCEP) issued dietary recommendations in 1993 focused on reduced intake of saturated fatty acids and cholesterol intake.25 For those at high risk, the addition of omega-3 fatty acids and folic acid should be considered.10 Women of childbearing age should be aware of the mercury content of some fish, including shark, swordfish, king mackerel, and tilefish, when increasing dietary omega-3 fatty acids in order to lessen the potential risk of fetal neurological impairment.10 Alternate sources of omega-3 fatty acids, such as walnuts, flaxseed oil, canola oil, and soybean oil, have less evidence to support any cardiovascular benefit.10

The Dietary Guidelines for Americans recommends a healthful assortment of whole grains, fresh fruits and vegetables, protein (fish, lean meat, chicken or pork, nuts or legumes), fat-free or low-fat dairy products, as well as foods that are low in saturated fats and added sugars in combination with portion control.27 B-complex vitamins and minerals are essential to proper nutrition and cardiovascular risk reduction and should be considered as a supplement to dietary intake. In 2004, the Institute of Medicine Food and Nutrition Board released recommendations limiting sodium intake to 1,500 mg/d and chloride to 2.3 mg/d for all healthy 19- to 50-year-old adults.26 Further restrictions for older Americans and "salt-sensitive" individuals with hypertension, diabetes, or chronic kidney disease are strongly encouraged.27 Supplemental folic acid should be contemplated for high-risk women with elevated homocysteine levels.8 However, the evidence for routine use of supplemental vitamin E to prevent CVD is lacking, and therefore, cannot be recommended.28

Despite continuing recommendations for weight loss, over 60% of adult US women are overweight and, as such, have a greater risk for developing CVD, hypertension, hypercholesterolemia, and stroke, than women of average weight.9,29 Obesity is one of a constellation of traits seen in the metabolic syndrome, discussed in-depth elsewhere in this issue and associated with increased rates of CVD.30 While women tend to be "pear-shaped" and carry excess subcutaneous fat in the hips, buttocks, and thighs rather than apple-shaped individuals with central adiposity, women who have waist circumferences greater than 35 inches are at increased risk for developing CVD.31,32

Defining overweight or obesity states has evolved from the standard height and weight charts to the use of the Body Mass Index (BMI) formula. While a BMI of 18-24.9 kg/m2 denotes a normal weight, overweight is associated with a BMI of 25-29.9 kg/m2 and obesity is 30 kg/m2 or greater.10 African-American and Hispanic women have especially high rates of obesity.9 A wholesome diet and regular physical activity are requisite for maintaining/attaining a healthy weight. Due to the lack of data, aggressive medical and surgical management of obesity was not recommended in the AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.10

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Physical Activity

Regular physical activity is essential for health and psychologic well-being. However, in a report from the Surgeon General in 1996, only 28% of Americans met the recommendations for moderate-to-vigorous physical activity of at least 30 minutes most days of the week, and 29% reported no additional physical activity outside of work.33 Physical inactivity increases with age and is more prevalent in women, especially African-American and Hispanic women.9 Frequently reported barriers to exercise include lack of time, lack of access, and lack of safe environments in which to work out. Women commonly report an inability to exercise due to role conflicts associated with work, running a household and child care. Because physical activity is fundamental to health, CVD risk reduction, and weight maintenance/reduction, women must be encouraged to make time for themselves and their health. Increased awareness of the benefits of exercise combined with acceptable choices for exercise, such as walking, swimming, biking, or fitness classes, may increase activity levels. Besides offering supervised activities, an organized program for at-risk individuals may also be a source of support and social interaction for some women and thereby increase the likelihood of continuing behaviors. Many organizations have information on programs directed at encouraging physical activity, such as the AHA "Choose To Move,"34 that should be made available within the clinical environment.

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Psychosocial Factors

A strong link between CVD, depression, and poor outcomes exists.35 In a study of acute cardiovascular events, major depression was reported in 15-22% of individuals, yet less than 25% had been diagnosed as depressed and of those diagnosed, about 50% received treatment.35 While the general population risk for depression is 5-12% in men, women experience rates of 10-25%. These higher rates are consistent findings across social class, ethnicity, and cultures. Increased vulnerability for depression is also seen in thyroid dysfunction, chronic pain, and sleep disorders, including sleep disordered breathing and primary insomnia.36,37 Unlike other clinical trials in which women have been underrepresented, studies for recurrent depression have had more women than men enrolled.35 Depression may be an independent risk factor for CVD in diabetic women.38 The effects of antidepressants on this risk are unknown,38 but all women should routinely be screened for depression. Those with depressive symptoms should be referred for treatment and/or counseling.10

Because depression can negatively impact adherence to medical regimens and lifestyle modifications, establishing healthy routines that include physical activity to enhance self-esteem and well-being, taking medications as directed, and well-balanced meals can help individuals regain a sense of control and provide pleasure for life.39 Support groups may be helpful to validate feelings and reduce isolation, too.

Education alone does not motivate changes in behavior nor will changes be made before the person is ready to make any recommended change.40,41 According to Koerbel and Korytkowski,38 and Prochaska and Velicer,42 at any point in time, 20% of individuals at-risk take steps to change a health behavior, 40% of this population have thought about making a change some time in the next 6 months, and the remaining 40% markedly deny the need for or resist change. Therein lies the challenge: teaching lifestyle interventions for healthier living to at-risk individuals who do not believe change is necessary. Some determinants of behavior and behavior change, as described by Glazer et al39 and Fishbein et al,43 include the intention to change, environmental issues (ie, barriers such as insurance or caregiver issues), capabilities for permanent change (ie, depression, elderly), emotionally invested in behavioral change, and the anticipated outcome (ie, feel bad enough to make a change). At-risk individuals must first weigh the pros and cons for changing, must have self-efficacy to make the requisite change, and must be able to resist temptation and resort to old habits.

To assist with the adoption and integration of lifestyle modifications, clinicians should incorporate explanations of CVD risks associated with current behaviors and then provide written information on the clearly-defined, behavioral changes desired. For example, identifying mutually acceptable forms of physical activity and then giving specifics on the frequency, duration, and intensity for the activity in order to achieve the desired outcomes may be helpful when initiating an exercise program. For some women, a simple written contract between the clinician and the patient about the new behavior may be effective. Discussing barriers to change and suggesting solutions, as well as establishing cues to increase positive behaviors, should be routinely integrated. However, as noted by Sneed and Paul40 and Povey et al,44 a discrepancy generally exists between the objective and subjective assessment of these goals. Therefore, the use of diaries or journals, pedometers, lists of actions that meet the criterion and those that don't, or other tools and resources may assist with assessment of the intervention on behavior. Tables 2 and 3 summarize interventions and strategies that focus on CVD prevention and are applicable to clinical practice environments.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

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Major Risk Factor Interventions

Hypertension

Major risk factors targeted for the prevention of CVD are hypertension, diabetes, and dyslipidemia. When lifestyle interventions alone are not enough to control these risks, the addition of pharmacotherapy is necessary.10 Many organizations, including the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), and the American Diabetes Association, have developed thorough guidelines for the management of these major risk factors. Paramount is the reduction of blood pressure to optimal levels, maintaining near-normal glycosolated hemoglobin (HbA1c), and achievement of targeted low density lipoprotein (LDL) and cholesterol goals. Importance of the lifestyle interventions previously discussed should be stressed and reinforced on an ongoing basis.

Optimal blood pressure is defined as 120/80 mm Hg or less. As previously discussed, diet, weight management, and routine physical activity can all play a role in blood pressure control. Medications are indicated when the BP is 140/90 or greater or 130/80 in the setting of diabetes or microalbuminuria. The AHA Evidence-Based Guidelines for Prevention of Cardiovascular Disease in Women recommends initiation of therapy when blood pressure is >140/90 or earlier in the setting of end-organ damage or diabetes.10 The use of thiazide diuretics to control blood pressure is encouraged in these practice guidelines. Other effective agents for the treatment of hypertension include angiotensin converting enzyme inhibitors (ACEI), calcium channel blockers, angiotensin receptor blockers (ARB), or beta-blockers. Because of adverse effects on a developing fetus, women of childbearing age being treated with an ACEI or ARB should be strongly counseled on the importance of contraception. If pregnancy is a possibility, these medications should be stopped immediately. Alternative antihypertensives in pregnancy include calcium channel blockers or beta-blockers.

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Diabetes

More than 9 million American women have diabetes.41,45 Once a woman is diagnosed with diabetes, her risk is equivalent to someone with established CHD, warranting aggressive medical management. The American Diabetes Association recommends that all women over 45 years have a fasting blood sugar drawn every 3 years. Earlier and more frequent screening should be performed on those at high risk, such as family history of diabetes.48 Diabetic women are not only at a greater risk for CHD, but also experience worse outcomes. Post-MI mortality rates at 28 days (22 vs. 14%) and 2 years (28.9 vs. 19.6%) are higher in diabetic women than diabetic men.38 Several interacting factors may contribute to an increased risk of CVD for diabetic women. These include the tendency for poor glycemic control, greater elevations in blood pressure and lipids, the development of central adiposity, higher rates of depression, and lower socioeconomic class.46

Lifestyle interventions and medications should be used to maintain HbA1c <7% in diabetic women. As diabetic women are more likely to have higher systolic and diastolic blood pressure than men, when combined with hyperglycemia, a predisposition for microalbuminuria and proteinuria exists that further increases the risk for vascular disorders.46 The micro-HOPE study (Heart Outcomes Prevention Evaluation) demonstrated the efficacy of ACEI in reducing the risk of MI (22%), stroke (33%), cardiovascular death (24%), and total mortality (24%).47 Thus, all women with diabetes should be treated with an ACEI.47 If the ACEI is not tolerated due to persistent cough or angioedema, an ARB is an acceptable alternate.48 Because of the effects diabetes can have on the kidneys, it is especially important to monitor renal function and electrolytes whenever initiating or increasing ACEI or ARB regimens.

Beta-blockers improve survival and decrease recurrent MI in patients with and without diabetes.49 The AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women advocates the prescription of beta-blockers indefinitely to all women with hypertension or chronic ischemia.10 While physicians have been reluctant to prescribe beta-blockers to diabetics due to concerns of masked hypoglycemia, the evidence does not support this concern and in fact suggests the benefits of beta-blockers to diabetes far outweigh this risk.50 In fact, carvedilol, a beta-blocker with alpha-1 blockade properties, has been shown to improve insulin resistance, lipoprotein/triglyceride metabolism, renal blood flow, and glomerular filtration rates, making it especially useful in diabetics and those with the metabolic syndrome.51,52

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Dyslipidemia

The NCEP ATP III modified its guidelines based on the outcomes of new clinical trial results pertaining to the benefits of lowering cholesterol. Whereas an LDL-C of ≤100 mg/dL is strongly recommended,53 an LDL-C <70 mg/dL is an optional and reasonable goal for women at high risk and very high risk (Table 1). Total lipid profile targets for these women are LDL-C <70 mg/dL, high density lipoprotein (HDL) >50 mg/dL, triglycerides <150 mg/dL, and non-HDL-C (total cholesterol minus HDL) <130 mg/dL. The lower LDL-C goal is a result of the Pravastatin or Atrovastatin Evaluation and Infection Study (Prove-IT), which demonstrated a 16% relative risk reduction for all cause mortality, MI, unstable angina, hospitalization, and interventional procedures in individuals with average LDL-C values of 62 mg/dL.54 Benefits were seen consistently across all subgroups, including men and women, diabetics and nondiabetics.54 The ATP III goals for the low-risk patient are LDL-C <100 mg/dL, total cholesterol <200 mg/dL, and HDL <40 mg/dL.55

While lipoprotein levels can be effected by diet, exercise, and weight control as previously discussed,10 Prove-IT suggests more aggressive treatment of dyslipidemias is warranted. When lifestyle approaches are not enough, pharmacotherapy is indicated. Several lipid-lowering clinical trials have demonstrated equal or improved benefits to women with CHD and diabetic women when compared to nondiabetic individuals.54 Statins are recommended to achieve the LDL-C goals and for high-risk women. The use of niacin or fibrates is suggested when LDL-C >100 mg/dL.10,55

While women should be given the opportunity to first try lifestyle interventions of diet and exercise to lower their lipids, in high-risk individuals, such as diabetics or early-onset CHD in first-generation relatives, it may be better to start medications concurrently. If given a trial intervention period, fasting lipids should be rechecked after 2-3 months to evaluate the effects. If not within target goals, therapy should be initiated. In addition, fasting lipid profiles should be drawn at least annually to detect early onset of lipid disorders and avoid sequelae.

Beside the major risk factors targeted for prevention identified above, the AHA Evidence-Based Guidelines for Prevention of Cardiovascular Disease in Women recommend the routine use of aspirin (75 to 162 mg daily) in high-risk women unless contraindicated, warfarin in women with chronic or paroxysmal atrial fibrillation to decrease the incidence of stroke (target International Normalized Ratio [INR] of 2.0-3.0), and if deemed at high risk for bleeding, aspirin 325 mg daily as an alternative to warfarin.10 For diabetic women with a contraindication to aspirin therapy, clopidogrel should be considered as anti-platelet therapy.48

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Interventions to Avoid

As important as knowing what to do is knowing what not to do. The AHA Guidelines for Cardiovascular Disease Prevention in Women has classified certain interventions as Class III recommendations that should not be used to prevent CVD due to unproven benefits and possible harmful effects. Category III recommendations include the use of hormone therapy in postmenopausal women, antioxidant supplements, and aspirin in low-risk patients.

The Class III recommendations on hormone therapy were based on the results of the HERS clinical trial8 and the subsequent Women's Health Initiative hormone program trials using estrogen plus progestin and estrogen alone.57 Conjugated estrogen therapy alone did not decrease CHD incidence in postmenopausal women.56

These major trials led the Food Drug Administration to recommend that HRT only for the treatment of menopausal symptoms at the lowest effective dose for the shortest time possible. Women must be made aware that HRT does not offer any protection against the development of CVD.

There have been many trials in the past several years that have examined the effects of antioxidant vitamin and mineral supplements on CVD risk. For the most part, these studies were conducted on post-MI subjects or those at risk for CVD, but some did study healthy subjects. The AHA has determined that the clinical trials have failed to demonstrate a beneficial effect on CVD using antioxidant supplements.58 Vivekananthan et al performed a meta-analysis of 15 studies to analyze the effects of antioxidant vitamins on cardiovascular morbidity and mortality demonstrating a consistent lack of efficacy for different doses of various antioxidants in diverse patient populations. Beta-carotene was actually associated with an increase in cardiovascular mortality, and vitamin E had no effect on cardiac death or event rates. The authors report that although these compounds are known as antioxidant vitamins, they probably do not have great antioxidant effects in the setting of coronary disease and that other compounds with known antioxidant actions in this area should be investigated.59

Current data do not support additional benefits associated with the use of antioxidants at levels exceeding those provided by a diet adhering to AHA dietary guidelines. As previously stated, these recommendations include a diet high in food sources of antioxidants and other cardioprotective nutrients such as whole grains, nuts, fruits, and vegetables.60

The routine use of aspirin in women who are considered low risk (10-year absolute CHD risk of less than 10%) is not recommended. The combination of uncontrolled hypertension and aspirin use could increase the risk for hemorrhagic stroke. Weighing the risks of gastrointestinal bleeding, aspirin allergy, and other side effects is important before deciding to use aspirin to prevent CVD. The United States Preventive Services Task Force recently performed a systematic overview of 5 primary prevention trials of aspirin and examined the different levels of CHD risk for which aspirin may have a net beneficial effect. The 5 randomized trials had a total of more than 50,000 participants.61 Low-dose aspirin (<162 mg/d) was used in 4 of the 5 trials, and treatment duration ranged from 3 to 7 years. Most participants were middle-aged men, and only 2 trials (Hypertension Optimal Treatment and Primary Prevention Project) included women. Results showed patients at low risk for CHD probably do not benefit from, and may even be harmed by, aspirin because the risk for adverse events may exceed the benefits.61

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Conclusion

Women and their healthcare providers need to work together to reduce CVD risks. We can accomplish this by educating our patients, family, and friends about lifestyle modifications that can decrease CVD risk factors and the development of CVD. We must be proactive and focus on prevention. While most women in a recent study felt comfortable discussing prevention with their healthcare provider, only 38% of the women reported their providers ever discussed heart disease with them.2 Establishment of goals for blood pressure, cholesterol, weight, and physical activity, along with recommendations on the best way to reach them, is essential. Special attention is needed for 25- to 34-year-old women who typically do not understand or appreciate their risk, yet are prime targets for the development of early CVD. Healthcare providers must incorporate discussions of CVD and associated risk factors as part of routine assessment and whenever the opportunity presents. Empowering women to recognize their CVD risks, providing the knowledge to modify those risks, and recognizing and praising their efforts are fundamental first steps for preventing heart disease in women.

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Keywords:

cardiovascular disease in women; primary prevention in women; risk reduction for cardiovascular disease

© 2005 Lippincott Williams & Wilkins, Inc.