This is the current release of the guideline.

This guideline updates a previous version: Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC Jr, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004 Feb 10;109(5):672-93.

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 (HbA_1C) <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

1. Sufficient evidence from multiple randomized trials
2. Limited evidence from single randomized trial or other nonrandomized studies
3. Based on expert opinion, case studies, or standard of care

A clinical algorithm is provided in the original guideline document for cardiovascular disease (CVD) preventive care in women.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2004 Feb (revised 2007 Mar 20)

American Heart Association - Professional Association

American Heart Association

Expert Panel/Writing Group for Cardiovascular Disease Prevention in Women

Expert Panel/Writing Group Members: Lori Mosca, MD, MPH, PhD, Chair; Carole L. Banka, PhD; Emelia J. Benjamin, MD; Kathy Berra, MSN, NP; Cheryl Bushnell, MD; Rowena J. Dolor, MD, MHS; Theodore G. Ganiats, MD; Antoinette S. Gomes, MD; Heather L. Gornik, MD, MHS; Clarissa Gracia, MD, MSCE; Martha Gulati, MD, MS; Constance K. Haan, MD; Debra R. Judelson, MD; Nora Keenan, PhD; Ellie Kelepouris, MD; Erin D. Michos, MD; L. Kristin Newby, MD, MHS; Suzanne Oparil, MD; Pamela Ouyang, MD; Mehmet C. Oz, MD; Diana Petitti, MD, MPH; Vivian W. Pinn, MD; Rita F. Redberg, MD, MSc; Rosalyn Scott, MD; Katherine Sherif, MD; Sidney C. Smith, Jr, MD; George Sopko, MD, MPH; Robin H. Steinhorn, MD; Neil J. Stone, MD; Kathryn A. Taubert, PhD; Barbara A. Todd, MSN, CRNP; Elaine Urbina, MD; Nanette K. Wenger, MD

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

Writing Group Disclosures

American Academy of Physician Assistants - Professional Association
American Association for Clinical Chemistry, Inc.
American Association of Cardiovascular and Pulmonary Rehabilitation - Medical Specialty Society
American College of Chest Physicians - Medical Specialty Society
American College of Emergency Physicians - Medical Specialty Society
American Diabetes Association - Professional Association
American Geriatrics Society - Medical Specialty Society
American Society for Preventive Cardiology - Medical Specialty Society
American Society of Echocardiography - Professional Association
American Society of Nuclear Cardiology - Professional Association
Association of Women's Health, Obstetric, and Neonatal Nurses - Professional Association
Global Alliance for Women's Health - Professional Association
National Black Nurses Association, Inc - Professional Association
National Black Women's Health Initiative - Professional Association
National Women's Health Resource Center - Private Nonprofit Organization
Partnership for Gender-Specific Medicine - Professional Association
Preventive Cardiovascular Nurses Association - Medical Specialty Society
Society for Vascular Medicine and Biology - Medical Specialty Society
Society for Women's Health Research - Private Nonprofit Research Organization
Society of Geriatric Cardiology - Professional Association
The Mended Hearts Inc. - Private Nonprofit Organization
The North American Menopause Society - Private Nonprofit Organization
Women in Thoracic Surgery - Medical Specialty Society
WomenHeart the National Coalition for Women with Heart Disease - Private Nonprofit Organization

This is the current release of the guideline.

This guideline updates a previous version: Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC Jr, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004 Feb 10;109(5):672-93.

None available

None available

This NGC summary was completed by ECRI on May 6, 2004. The information was verified by the guideline developer on June 4, 2004. This NGC summary was updated by ECRI Institute on June 4, 2007.