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Preventing, diagnosing, and treating cardiovascular disease in women

An article published in the journal Medical Clinics of North America provides recent updates on cardiovascular disease prevention, diagnosis, and treatment in women.

Cardiovascular disease (CVD) is a leading cause of death in the United States. The risk is even higher for women as they face disparities in CVD management, including delayed diagnosis and lack of guideline-directed treatment. However, prevention and risk reduction of atherosclerotic CVD are possible through proper primary care facilities

Cardiovascular disease prevention

The American Heart Association has recently expanded from “Life’s Simple 7” (a prescription for ideal cardiovascular health) to “Life’s Essential 8” with the intention of developing an outline for atherosclerotic CVD management.

“Life’s Essential 8” focuses on a healthy diet, regular physical exercise, restricting nicotine exposure, adequate sleep, and maintaining blood cholesterol, blood sugar, and blood pressure.

Mediterranean diet

The Mediterranean diet is a well-established dietary intervention to prevent cardiovascular and metabolic events. The diet is known to reduce the risk of CVD and myocardial infarction by 30%.

The Mediterranean diet includes a high amount of fresh and seasonal vegetables and fruits and minimally processed whole grains or bread. The meals can be consumed with wine. Olive oil is the primary fat source, and white meat, egg, legumes, and fish are allowed in the diet a few times per week. However, the intake of red meat and processed meat is largely prohibited. 

Weight management

Obesity accounts for 64% and 46% higher risk of CVD in women and men, respectively. In obese or overweight individuals, a weight reduction of even 5-10% can provide health benefits. A healthy diet and exercise are vital interventions for weight reduction and maintenance. A weight loss of 25-35% through surgical interventions can reduce the risk of CVD.

For the pharmacological management of obesity, the US Food and Drug Administration (FDA) has approved two medicines, liraglutide and semaglutide, which are glucagon-like peptide-1 receptor agonists (GLP1-RAs). Semaglutide has been found to reduce body weight by almost 15% in clinical trials.

Tirzepatide, an FDA-approved anti-diabetic medicine, has been found to reduce body weight by more than 20%. This medicine is a combination of glucose-dependent insulinotropic polypeptide (GIP) and GLP1-RA. However, a common trend of weight regain has been observed with the discontinuation of anti-obesity medicines.

Management of blood cholesterol   

Statin therapy is commonly used as a secondary preventive measure in individuals with atherosclerotic CVD. Based on the atherosclerotic CVD Pooled Cohort Equation (PCE), a 10-year atherosclerotic CVD risk of less than 5% and more than 20% is clinically considered to categorize low-risk and high-risk individuals aged 40 – 75 years. A coronary artery calcium (CAC) score is more potent than PCE for cholesterol risk assessment.   

Clinical cholesterol management guidelines recommend lifestyle interventions for low-risk individuals and high-intensity statin therapy for high-risk individuals aged 40 – 75. Moderate-intensity statin therapy is recommended for individuals falling between these two groups. For individuals who cannot tolerate statin therapy, other LDL-lowering medications including ezetimibe and proprotein convertase subtilisin/kexin type-9 inhibitors are recommended.  

Management of blood sugar

Accurate management of type 2 diabetes is vital for CVD risk reduction. While statin therapy is recommended for diabetic patients aged 40 – 75 years, metformin and lifestyle interventions are advised to initially manage diabetes.

The American Diabetes Association recommends GLP1-RA or sodium-glucose cotransport-2 (SGLT2) inhibitor medicines for diabetes management of patients at high risk for or with clinically-diagnosed cardiovascular or kidney disease. These medicines are also effective for CVD management in patients without diabetes.

According to the experts’ opinion, women with a history of gestational diabetes, preeclampsia, polycystic ovarian syndrome, or obesity should be screened for diabetes detection and treated with GLP1-RAs and SGLT2 inhibitors for cardiovascular benefits.   

Management of blood pressure

Annual monitoring of normal blood pressure (<120/80 mm Hg) is recommended for cardiometabolic risk management. Lifestyle modifications are recommended for elevated blood pressure (120 to 129/<80 mm Hg). Anti-hypertensive medication is needed for stage 1 (130 to 139/80 to 89 mm Hg) and stage 2 (BP 140/90 mm Hg) hypertension.

Women face inequalities in diagnosing and managing hypertension, despite menopause being an added risk factor. For women of reproductive age, calcium channel blockers (specifically nifedipine), beta-blockers, and diuretics are advised for blood pressure management.   

Prevention of CVD with aspirin

Low-dose aspirin is a well-established intervention for the secondary prevention of CVD. However, the intervention is not recommended for primary prevention, given the risk of bleeding. Primary prevention with low-dose aspirin is particularly not recommended for patients aged over 60 years.

Diagnosis and treatment of CVD

Including acute coronary syndrome (ACS) in the differential diagnosis is a significant criterion for evaluating CVD. If ACS is suspected, an immediate interpretation using an electrocardiogram is advised. Women are at higher risk of ACS than men.

Cardiac troponin I or T and high-sensitivity troponin are the main biomarkers for the detection of myocardial injury. For low-risk patients, exercise stress testing is advised for coronary disease detection. For patients with intermediate-risk, various cardiac imaging techniques are effective for disease diagnosis.

For pregnant and breastfeeding women, cardiac testing with minimal radiation risk is recommended. However, testing procedures with iodinated contrast and gadolinium are not recommended in these patients.    

Long-term management of CVD is worse in women because of delayed clinic visits or delayed diagnosis due to highly variable symptom presentation. Women are also less likely than men to receive guideline-directed therapies.

Among various CVD, cases of spontaneous coronary artery dissection and microvascular disease have been increasing in recent years. Therefore, lipid-lowering medicines, beta-blockers, or antiplatelet therapy are recommended to manage spontaneous coronary artery dissection.  

Targeted therapies with beta-blockers or calcium channel blockers and long-acting nitrates are recommended for managing microvascular disease.

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