Definitions of the strengths of the recommendations (I, IIa, IIb, III) and levels of the evidence (Levels A, B, C) are presented at the end of the "Major Recommendations" field.
Lifestyle Interventions
Cigarette Smoking
Women should not smoke and should avoid environmental tobacco smoke. Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or formal smoking cessation program (Class I, Level B).
Physical Activity
Women should accumulate a minimum of 30 minutes of moderate-intensity physical activity (e.g., brisk walking) on most, and preferably all, days of the week. (Class I, Level B)
Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of moderate-intensity physical activity (e.g., brisk walking) on most, and preferably all, days of the week (Class I, Level C).
Rehabilitation
A comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program, should be recommended to women with a recent acute coronary syndrome or coronary intervention, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease (Class I, Level A), or current/prior symptoms of heart failure and a left ventricular ejection fraction (LVEF) <40% (Class I, Level B).
Dietary Intake
Women should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish,1 at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/d, alcohol intake to no more than 1 drink per day,2 and sodium intake to <2.3 g/d (approximately 1 tsp salt). Consumption of trans-fatty acids should be as low as possible (e.g., <1% of energy) (Class I, Level B).
Weight Maintenance/Reduction
Women should maintain or lose weight through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist circumference <35 in. (Class I, Level B)
Omega-3 Fatty Acids
As an adjunct to diet, omega-3 fatty-acids in capsule form (approximately 850 to 1000 mg of eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) may be considered in women with coronary heart disease (CHD), and higher doses (2 to 4 g) may be used for treatment of women with high triglyceride levels. (Class IIb, Level B)
Depression
Consider screening women with CHD for depression and refer/treat when indicated (Class IIa, Level B)
Major Risk Factor Interventions
Blood Pressure — Optimal Level and Lifestyle
Encourage an optimal blood pressure of <120/80 mm Hg through lifestyle approaches such as weight control, increased physical activity, alcohol moderation, sodium restriction, and increased consumption of fresh fruits, vegetables, and low-fat dairy products. (Class I, Level B)
Blood Pressure — Pharmacotherapy
Pharmacotherapy is indicated when blood pressure is >140/90 mm Hg or an even lower blood pressure in the setting of chronic kidney disease or diabetes (>130/80 mm Hg). Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated or if there are compelling indications for other agents in specific vascular diseases. Initial treatment of high-risk women3 should be with beta-blockers and/or angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), with addition of other drugs such as thiazides as needed to achieve goal blood pressure. (Class I, Level A)
Lipid and Lipoprotein Levels – Optimal Levels and Lifestyle
The following levels of lipids and lipoproteins in women should be encouraged through lifestyle approaches: low-density lipoprotein cholesterol (LDL-C) <100 mg/dL, high-density lipoprotein cholesterol (HDL-C) >50 mg/dL, triglycerides <150 mg/dL, and non–HDL-C (total cholesterol minus HDL cholesterol) <130 mg/dL. (Class I, Level B) If a woman is at high risk3 or has hypercholesterolemia, intake of saturated fat should be <7% and cholesterol intake <200 mg/d (Class I, Level B)
Lipids — Pharmacotherapy for LDL Lowering, High Risk Women
Utilize LDL-C–lowering drug therapy simultaneously with lifestyle therapy in women with CHD to achieve an LDL-C <100 mg/dL (Class I, Level A) and similarly in women with other atherosclerotic cardiovascular disease (CVD) or diabetes mellitus or 10-year absolute risk >20% (Class I, Level B)
A reduction to <70 mg/dL is reasonable in very-high-risk women4 with CHD and may require an LDL-lowering drug combination (Class IIa, Level B).
Lipids — Pharmacotherapy for LDL Lowering, Other At-Risk Women
Utilize LDL-C–lowering therapy if LDL-C level is >130 mg/dL with lifestyle therapy, and there are multiple risk factors and 10-year absolute risk 10% to 20%. (Class I, Level B)
Utilize LDL-C–lowering therapy if LDL-C level is >160 mg/dL with lifestyle therapy and multiple risk factors even if 10-year absolute risk is <10% (Class I, Level B).
Utilize LDL-C–lowering therapy if LDL >190 mg/dL regardless of the presence or absence of other risk factors or CVD on lifestyle therapy (Class I, Level B).
Lipids — Pharmacotherapy for Low HDL or Elevated Non-HDL, High-Risk Women
Utilize niacin5 or fibrate therapy when HDL-C is low or non–HDL-C is elevated in high-risk women5 after LDL-C goal is reached (Class IIa, Level B).
Lipids — Pharmacotherapy for Low HDL or Elevated Non-HDL, Other At-Risk Women
Consider niacin5 or fibrate therapy when HDL-C is low or non–HDL-C is elevated after LDL-C goal is reached in women with multiple risk factors and a 10-year absolute risk 10% to 20% (Class IIb, Level B).
Diabetes Mellitus
Lifestyle and pharmacotherapy should be used as indicated in women with diabetes (Class I, Level B) to achieve glycosylated hemoglobin (HbA1C) <7% if this can be accomplished without significant hypoglycemia (Class I, Level C).
Preventive Drug Interventions
Aspirin — High Risk
Aspirin therapy (75 to 325 mg/d)6 should be used in high-risk3 women unless contraindicated. (Class I, Level A)
If a high-risk3 woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B).
Aspirin — Other At-Risk or Healthy Women
In women >65 years of age, consider aspirin therapy (81 mg daily or 100 mg every other day) if blood pressure is controlled and benefit for ischemic stroke and myocardial infarction (MI) prevention is likely to outweigh risk of gastrointestinal bleeding and hemorrhagic stroke (Class IIa, Level B) and in women <65 years of age when benefit for ischemic stroke prevention is likely to outweigh adverse effects of therapy (Class IIb, Level B).
Beta-Blockers
Beta-blockers should be used indefinitely in all women after MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated. (Class I, Level A)
ACE inhibitors/ARBs
ACE inhibitors should be used (unless contraindicated) in women after MI and in those with clinical evidence of heart failure or an LVEF <40% or with diabetes mellitus (Class I, Level A). In women after MI and in those with clinical evidence of heart failure or an LVEF <40% or with diabetes mellitus who are intolerant of ACE inhibitors, ARBs should be used instead. (Class I, Level B)
Aldosterone Blockade
Use aldosterone blockade after MI in women who do not have significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor and beta-blocker, and have LVEF <40% with symptomatic heart failure (Class I, Level B).
1Pregnant and lactating women should avoid eating fish potentially high in methylmercury (e.g., shark, swordfish, king mackerel, or tile fish) and should eat up to 12 oz/wk of a variety of fish and shellfish low in mercury and check the Environmental Protection Agency and the US Food and Drug Administration's Web sites for updates and local advisories about safety of local catch.
2A drink equivalent is equal to a 12-oz bottle of beer, a 5-oz glass of wine, or a 1.5-oz shot of 80-proof spirit.
3Criteria for high risk include established CHD, cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm, end-stage or chronic renal disease, diabetes mellitus, and 10-year Framingham risk >20%.
4Criteria for very high risk include established CVD plus any of the following: multiple major risk factors, severe and poorly controlled risk factors, diabetes mellitus.
5Dietary supplement niacin should not be used as a substitute for prescription niacin.
6After percutaneous intervention with stent placement or coronary artery bypass grafting within previous year and in women with noncoronary forms of CVD, use current guidelines for aspirin and clopidogrel.
Class III Interventions (Not Useful/Effective and May Be Harmful) for CVD or MI Prevention in Women
Menopausal Therapy
Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD (Class III, Level A).
Antioxidant Supplements
Antioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should not be used for the primary or secondary prevention of CVD (Class III, Level A)
Folic Acid1
Folic acid, with or without B6 and B12 supplementation, should not be used for the primary or secondary prevention of CVD (Class III, Level A).
Aspirin — for MI in Women <65 Years of Age2
Routine use of aspirin in healthy women <65 years of age is not recommended to prevent MI (Class III, Level B).
1Folic acid supplementation should be used in the childbearing years to prevent neural tube defects.
2For recommendation for aspirin to prevent CVD in women >65 years of age or stroke in women <65 years of age, please see Preventive Drug Interventions section above.
Definitions:
Strength of Recommendations
Classification:
Class I: Intervention is useful and effective.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Intervention is not useful/effective and may be harmful.
Level of Evidence
- Sufficient evidence from multiple randomized trials
- Limited evidence from single randomized trial or other nonrandomized studies
- Based on expert opinion, case studies, or standard of care