New Guidelines Tackle
Women's Heart Risks

Aim Is to Counter Perception of Coronary Problems as a 'Man's Disease'.

By Ron Winslow - Staff Reporter of The Wall Street Journal

About 40,000 women died of breast cancer in the U.S. last year. More than 10 times that number died of heart disease or strokes. Yet regular breast exams are one of th emainstays of perventive health for women, while a heart checkup is often little more than an afterthought.

Seeking to redress this imbalance, the American Heart Association issued new guidelines to help women prevent heart attacks and stokes. They urge women as young as age 20 to work with their doctors to assess their risk of cardiovascular disease, and to come up with prevention strategies tailored to their personal level of risk.

The initiative underscores a persistent concern among heart and public-health experts: that docctors and female patients alike consistently underestimate the risk women face when it comes to cardiovascular disease. Though often viewed as a "man's disease," heart disease has consistently killed more women than men over the past two decades. Moreover, while th total number of men dying from heart disease declined about 12% in that time, according to heart association data, the toll among women has, at best, remained flat.

The new guidelines also amount to a re-evaluation of the science behind heart-disease prevention in the aftermath of two recent major studies that found a widely used hormone replacement therapy not only failed to protect women's hearts, but also may have harmful consequences.

HEART ADVICE The American Heart Association recommends: Assessing heart-disease risk for all women beginning as young as age 20 Cholesterol-lowering drugs for high-risk women, even if their LDL level is under 100 Don't take hormone replacement therapy for heart-disease prevention. Blood -pressure lowering drugs when a woman's blood- pressure is 140/90 or higher Aspirin only for high and intermediate - risk women.

Until those results, many doctors believed that taking HRT to relieve symptoms of menopause essentially took care of heart risk at the same time. Numerous epidemiological studies and the fact that heart disease doesn't routinely develop in women until after menopause led to the belief that estrogen protects against heart disease. But the new guidelines specifically recommend against taking HRT to prevent cardiovascular disease.

The guidelines, available on the American Heart Associations Web site (americanheart.org), also recommend women get an evaluation of their heart health using what is called the Framingham Risk Score, a composite score derived from a person's age, total cholesterol, HDL (or good cholesterol), smoking status and systolic (the high number) blood pressure. The results predict your chance of having a heart attack or stroke in the next 10 years.

If your risk is greater than 20% (or a 2% chance per year) you're considered at high risk; between 10% and 20% is intermediate risk and below 10% is considered low risk. the higher your risk, the more aggressive the strategy called for in the guidelines.

This personalized approach will enable women at high risk -- including those who halready have had a heart attack or other symptoms of disease -- to work with their doctors to avert additional heart problems, said Nanette Wenger, a cardiologist at Emory University School of Medicine, Atlanta, and a co-author of the guidelines. Those at low risk can work to prevent development of high blood pressure, high cholesterol and other risk factors for cardiovascular disease, she said.

The recommendations for treatment generally reflect well-known prevention strategies for both men and women, with some adjustments. they advise prescribing cholesterol-lowering drugs called statins to all women at high risk, even if their LDL, or bad cholesterol is below 100. They recommend niacin-based drugs, but not niacin supplements, for high-risk women with low HDL cholesterol.

They recommend ACE inhibitors and beta-blockers, which lower blood pressure and also protect against heart failure, for high-risk women. They also recommend blood-ressure-lowering drugs whenever blood pressure is 140/90 or higher. They urge women in all risk categories to stop smoking, eat healthy foods and get regular exercise.

The guidelines recommend women at high risk take aspirin daily, but they discourage daily aspirin use for women at low risk because of concerns that any protective benefit may be outweighed by increased risk of bleeding, strokes or stomach problems. In addition to the guidance against HRT, the guidelines also discourage taking vitamin E and beta carotene supplements since they have shown no cardiovascular benefit in several large clinical trials.

Getting women and their physicians to use the guidelines -- and especailly begin to get risk assessments in early adulthood - poses a substantial challenge. The heart association, the American College of Cardiology, the National Institutes of Health and other groups have been beating the drum about heart-disease risk for women for nearly a decade and the message is only beginning to sink in.

A nuew survey of 1, 024 women released with the guidelines foudn that nearly half were aware that cardiovascular disease is the leading killer of women, but only 13% believed they were personally at risk. That disconnect, plus the fact that fewer than 30% knew their cholesterol or blood pressure, "is going to be a major impediment to reducing their risk," said Lori Mosca, director of preventive cardiology at New York - Presbyterian Hospital/Columbia University Medical Center in New York, who headed th egroup that devised the recommendations.

The heart association and other groups plan efforts to urge primary-care doctors and obstetrician/gynecologists to make heart - disease risk and important part of routine "healthy women" checkups, but that can be easier said than done.

"It's easy to get women's attention over the risk of breast cancer," said Ronald L. Young, director of obstetrics and gynecology at Baylor College of Medicine, Houston. Moreover, he said, gynecologists "focus on areas of female health care that they're trained to do. Cardiovascular measures come last.".

While the new guidelines are aimed at prevention, another hope is that women who are more knowledgeable about their risk for heart disease will be quicker to recognize symptoms when they occur. When men report to the emergency room with chest pain, they're likely to say they are having a heart attack. Women, however, says Dr. Wenger, "say 'I have indigestion.' They don't perceive that they're at risk."

Write to Ron Winslow at ron.winslow@wsj.com

© 2003 Wayne Hollopeter, M.D. All Rights Reserved
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