Study Points

Women and Heart Disease

Course #33223 - $75 • 15 Hours/Credits

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Study Points

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  1. Describe the morbidity and mortality associated with heart disease, especially in women.
  2. Describe how female cardiac anatomy and physiology differs from men's.
  3. Discuss the role that traditional risk factors play in the development of heart disease in women.
  4. List gender-specific risk factors for heart disease in women.
  5. Identify reasons heart disease is more complex to diagnose in women.
  6. Compare and contrast the efficacy of non- invasive and invasive cardiac diagnostic tests in women.
  7. Describe the basic types and variations of angina and their prevalence in women.
  8. Compare and contrast the usual clinical course of women with angina versus myocardial infarction (MI).
  9. Discuss common complications seen in women post-MI.
  10. Discuss clinical outcomes of medical treatment options in women with heart disease.
  11. Discuss the preoperative status of women undergoing coronary artery bypass surgery and the implications this status may have on postoperative outcomes.
  12. Describe the research base related to the clinical outcomes of women who participate in formal cardiac rehabilitation programs.
  13. Identify nursing diagnoses and appropriate nursing interventions that are applicable to women with heart disease during the acute phase.
  14. Discuss primary and secondary prevention strategies for women.
  15. Identify at least two reasons why women were formerly excluded from clinical trials related to the diagnosis and treatment of heart disease.
  16. Identify areas where further research is needed in relation to heart disease and women.
  1. The economic cost of heart disease for 2015 was estimated to be

    OVERVIEW OF WOMEN AND HEART DISEASE

    The elderly population is changing the demography of coronary heart disease in the United States. In 2018, 16% of the U.S. population was 65 years of age and older [5]. This number is projected to grow to 20% of the U.S. population (approximately 72 million people) by 2030 [6]. Individuals who are 85 years of age and older are the most rapidly growing subgroup of elderly. Approximately 6.3 million people in the United States are 85 years of age and older, with a projected increase to more than 19 million expected by 2060 [7,8]. These trends will clearly influence the diagnosis and treatment of heart disease in women. For the year 2015, the total economic cost of this health problem in the United States was estimated to be $351.2 billion [3]. Given the fact that the incidence of heart disease in women increases with age, coupled with the projected increase in the elderly population, this economic burden will certainly continue to grow.

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  2. Among American women, heart disease is the

    OVERVIEW OF WOMEN AND HEART DISEASE

    Heart disease is the leading cause of death in American women [9]. Although the risk of breast cancer has been the focus of intense media coverage for several years, heart disease kills more women in the United States each year than all forms of cancer, including breast cancer [9]. The rate of death from heart disease declined 30% from 1999 to 2011 and then increased 6% from 2011 to 2017 [10]. It declined 14% for non-Hispanic white women. For non-Hispanic black women, it declined 20% from 1999 to 2009 and then increased 12% from 2009 to 2017. Unlike the trends for non-Hispanic white and black women, the heart disease death rates for Hispanic women declined by 37% from 1999 to 2017 [10]. This decline is most likely due to improved medical care and increased emphasis on the reduction of cardiovascular risk factors [11,12,13].

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  3. Gender-specific anatomic differences include

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Several anatomic and physiologic differences exist in the cardiovascular system of women compared to men. Because women's bodies are generally smaller in stature, the female heart and thoracic cavity are smaller and lighter. A woman's heart weighs approximately 229 grams; a man's heart weighs about 56 grams more. The female heart also has smaller coronary arteries than a man's heart. The right coronary artery appears to be more dominant in women [1,17,18,19,20].

    In addition to anatomic differences in male and female cardiovascular systems, research indicates that women may deposit plaque differently than men. The Women's Ischemia Syndrome Evaluation (WISE) Study, supported by the National Heart, Lung, and Blood Institute, evaluated gender differences in the presentation and treatment of ischemic heart disease [21,22]. Researchers found that women's atherosclerotic plaque deposition was more diffuse than men's. This physiologic difference results in scalloping or artery irregularities, rather than the large, obstructive blockages that are commonly associated with heart disease and MI. A 2019 study also analyzed plaque characteristics in male and female patients with suspected coronary artery disease. A total of 1,050 patients were matched 1:1 for sex, age, and known coronary risk factors. All patients underwent CT angiography analysis of arteries for stenosis, plaque types (i.e., noncalcified, mixed, or calcified), and high-risk plaque features [23]. The men had significantly more plaques and a larger proportion of calcified plaques; women had more mixed and noncalcified plaques, supporting the need for a differentiated plaque analysis to improve the accuracy of risk stratification for both sexes [23].

    Microvessels and vasodilator response also appear to be impaired more frequently in the female population. These less obvious changes are more difficult to detect from a traditional angiogram and may result in different symptoms. This may partially account for the differences in presentation and subsequent treatment of heart disease in women.

    On the electrocardiogram (ECG), resting heart rate is higher, PR and QRS intervals tend to be shorter, and the amplitude of the R, S, and T waves across the precordium are smaller in women. Left ventricular end-diastolic pressure and volume are also lower in women, yet stroke volume and resting ejection fractions (EF) tend to be higher in women than in men [24]. Up to 30% of women with normal coronary arteries do not have an increase in EF with exercise, a finding that has important implications for exercise testing [1,17,19,25,26,27].

    Hematologic differences also exist between men and women. Women's hematocrit and blood volumes tend to be lower, along with their oxygen-carrying capacity. Cholesterol levels tend to rise in women around 55 years of age; however, the natural estrogens of perimenopause are believed to provide protection against heart disease by conferring beneficial effects to the lipid profile. It has also been suggested that estrogen receptors located within the walls of blood vessels may affect the proliferation of smooth muscle cells, reduce platelet aggregation, and alter the degradation of collagen and elastin [22,28,29].

    The last anatomic and physiologic difference between men and women is body fat percentage (which is higher in women) and the distribution of body fat. Women who have a large waist, also referred to as abdominal obesity or central adiposity, tend to have an increased risk of an MI at an earlier age [19,20,28]. Studies have suggested that, in particular, waist-to-hip ratio measures of abdominal adiposity may be strong indicators of mortality in women [30,31,32]. Other studies have indicated that waist-to-height ratio may be an accurate predictor of heart disease in women [33,34]. Patterns of fat distribution and associated cardiovascular health risks will be discussed in further detail in the following section on traditional coronary risk factors. Table 2 summarizes how women's physiologic profile differs from men's.

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  4. Compared with the risk level of a man the same age with comparable risk factors, a premenopausal woman's risk of a coronary event is

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Certain risk factors increase the likelihood of the development of heart disease. These are known as the traditional cardiovascular risk factors, and they are shared equally between men and women. However, the weight given to these traditional risk factors may not be the same between men and women, and the traditional diagnostic tests, which generally focus on obstructive disease, are not as effective in women as compared to men [21]. At comparable levels of cardiovascular risk factors, the risk of a cardiac event in a premenopausal woman is 50% the risk level for a man the same age. The relative protection of women from heart disease may be due to better tolerance of cardiovascular risk factors, as well as hormonal and metabolic differences [21,35].

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  5. Hyperlipidemia, hypertension, and cigarette smoking are what type of risk factors for coronary heart disease?

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Again, alterable cardiovascular risk factors require the most attention when counseling female patients. These factors include smoking, hypertension, hyperlipidemia, diabetes, obesity, metabolic syndrome, sedentary lifestyle, and a Type A behavior pattern.

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  6. Which of the following groups are at an increased risk of developing hypertension?

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Like smoking, hypertension is a powerful independent risk factor for the development of heart disease in both men and women. It is also the most modifiable risk factor [55]. Compared with men, hypertension is twice as prevalent in women with heart disease. Additionally, women with hypertension have three to four times the risk of developing heart disease than women with normal blood pressure [56]. Among non-Hispanic black women, hypertension tends to be more severe, occur at an earlier age, be treated less adequately, and result in more significant morbidity and mortality rates. More than 56% of non-Hispanic black women in the United States have hypertension, compared with 41.3% of white women [1]. In addition to black women, pregnant women and postmenopausal women older than 65 years of age are also at high risk for developing hypertension [57].

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  7. Effects of obesity on metabolic processes include

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Obesity is another traditional risk factor. In 2016, 39.8% of U.S. adults were obese, an incidence that has greatly increased in the last 20 years [74,75]. As of 2018, every state in the United States had a greater than 20% prevalence of obesity. Twenty-two states reported a 30% to 35% prevalence of obesity among their populations, and nine states had an obesity prevalence of 35% or greater [75]. Women 20 to 34 years of age have had the fastest increase in the rate of obesity and overweight. Minority women as well as low socioeconomic status individuals are disproportionately affected across all age groups, with 50% at risk of being obese. Approximately 54.8% of non-Hispanic black women and 50.6% of Mexican American women in the United States are overweight or obese [76]. If a woman is 30% overweight, she is at increased risk for developing an MI, heart failure, stroke, and even death. Mild-to-moderate obesity (i.e., 5% to 15% overweight) may also be detrimental. Women who are overweight have a two to three times greater risk of an MI compared to lean women [77]. Fluctuations in weight may also impact a women's overall risk for heart disease and metabolic syndrome [78]. Like the other cardiovascular risk factors, the risk of heart disease may increase with certain risk factor combinations, such as obesity and smoking [20,36,42,48,79]. Obesity has other unfavorable influences on metabolic processes, including elevation of triglyceride, uric acid, and blood pressure levels; reduction of HDL cholesterol; and alteration of glucose tolerance and insulin sensitivity [20].

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  8. At the time of menopause,

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    At the time of menopause, serum estrogen levels decrease. The absence of estrogen increases a postmenopausal woman's vulnerability to heart disease due to the effects on lipoprotein metabolism. These changes include a decrease in HDL levels and an increase in LDL levels. In addition, blood vessels become less flexible after menopause due to the reduction in circulating estrogen [107].

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  9. Noncoronary causes of anginal-type symptoms in women include

    CARDIAC DIAGNOSTIC TESTS

    The diagnosis of coronary heart disease is a more complex process in women for two primary reasons: age at presentation and differences in presenting symptoms. As noted, women are typically 5 to 10 years older than men when presenting with heart disease, which may be due either to a delay in diagnosis or a delay in presentation. When women do present, other conditions (e.g., osteoporosis, diabetes, hypertension) and the clinician's interpretation of the woman's chest pain may obscure the indications of disease. There is a greater prevalence of noncoronary causes of chest pain in the female population, and chest pain is frequently accompanied by abdominal pain, dyspnea, nausea, fatigue, and greater functional disability [138,139,140]. Additionally, a variety of intrathoracic and extrathoracic structures may cause symptoms, such as mitral valve prolapse, pericarditis, or gallbladder disease, that localize to the chest. Therefore, the differential diagnosis of chest pain must include a number of benign conditions in order to prevent a false-positive diagnosis of heart disease in women [140,141]. Table 5 outlines the differential diagnosis to initially rule out the most critical problems.

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  10. In the diagnosis of heart disease in women, clinical history and physical examination

    CARDIAC DIAGNOSTIC TESTS

    To further complicate the picture, the clinical history and physical exam have limited value in women, except for women older than 65 years of age with definite angina [139]. The history and physical exam do provide information on the occurrence of prior events and risk factors, such as diabetes and hypertension, and also uncover symptoms of more advanced disease, such as heart failure. However, these diagnostic clues often only partially indicate disease likelihood, which makes further diagnostic tests both important and necessary [139,145,146]. The presence of new physical assessment findings, such as dysrhythmias, mitral regurgitation, a fourth heart sound (atrial gallop), or bibasilar crackles, increases the chances of a positive diagnosis of heart disease [147]. The diagnosis is also favored by the presence of other cardiovascular risk factors or by ECG changes at rest or during anginal episodes [147].

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  11. Which of the following noninvasive tests for coronary heart disease is considered controversial in women?

    CARDIAC DIAGNOSTIC TESTS

    Although the exercise ECG (also referred to as the stress test or exercise treadmill test) may not be as accurate in the diagnosis of heart disease in women as in men, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have recommended the routine use of the exercise ECG (when combined with traditional analysis of ST-segment and heart rate changes) for evaluating suspected coronary artery disease in women who have a normal resting ECG and good exercise tolerance [150]. Women with nonobstructive coronary artery disease and stress test abnormalities are no longer defined as having a false-positive test. Instead, their test is classified as abnormal, and they are noted as being at an elevated risk of ischemic heart disease [150]. A test result that is clearly negative has been found to be equally reliable in both women and men [141].

    Even in women with heart disease, the accuracy of diagnosing heart disease from an exercise ECG alone is not recommended. When test results are either clearly positive or not clearly positive or negative, additional risk stratification with cardiac imaging is recommended [150]. The ACCF/AHA have recommended cardiac imaging for symptomatic women with established coronary artery disease, women who have an indeterminate or intermediate-risk exercise ECG test, and women with an intermediate-risk Duke treadmill score. Cardiac imaging has also been recommended for diabetic women, women with metabolic syndrome, and women with polycystic ovary syndrome, as these women have a significantly greater risk of cardiovascular death than women without these conditions [122,150]. Better diagnostic results are seen in women with multivessel involvement versus single vessel or no disease. With multivessel disease, an overall accuracy of 84% has been reported [150].

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  12. With nuclear medicine stress tests,

    CARDIAC DIAGNOSTIC TESTS

    The nuclear medicine stress test (myocardial perfusion scanning) is another noninvasive diagnostic test that may be used in women. At peak exercise, a small amount of radioactive tracer is injected and a series of images of myocardial blood flow are then evaluated. Normal myocardial blood flow is indicated by a homogeneous distribution of thallium throughout the myocardium, while myocardial ischemia and/or infarction is suggested by either a transient or persistent defect in tracer uptake. Compared with the exercise ECG, the nuclear medicine stress test has better accuracy [151,152]. It has also been associated with fewer false-positive tests in women, especially in those patients with multivessel disease [141,153].

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  13. Radionuclide ventriculography (RNV) and radionuclide angiography (RNA)

    CARDIAC DIAGNOSTIC TESTS

    Radionuclide ventriculography (RNV) and radionuclide angiography (RNA) are types of nuclear imaging tests in which red blood cells are labeled in vivo with technetium 99m, and gated images are recorded of blood flowing through the cardiac chambers. The tests not only assess chamber size and function, but also the response of left ventricular EF and the presence or absence of new wall motion abnormalities during exercise [154]. One of the abnormal findings of the exams is the failure of the patient to increase his/her left ventricular EF at peak exercise. The tests have been associated with increased false-positive rates because up to 30% of women do not increase their EF at peak exercise [11,19,26,141]. Attenuation of myocardial activity by overlying soft tissue (e.g., breast tissue in women) also may also cause false positives [155,156]. The tests, therefore, have reduced diagnostic value for women. Radionuclide ventriculography has been largely replaced by echocardiography, which is less expensive and does not require radiation exposure [155].

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  14. Which of the following explains why cardiac enzyme elevations may be lower in women than in men?

    CARDIAC DIAGNOSTIC TESTS

    While not a diagnostic test per se, measurement of serial cardiac enzymes is also pivotal in making an accurate diagnosis of myocardial injury and/or infarction in both men and women [166]. However, due to their smaller body size, enzyme elevations may not be as high in women as those seen in men. This information is important to know when analyzing and interpreting enzyme rises in female patients presenting with cardiac symptoms. Research studies are needed to explore cardiac enzyme activity in female cardiac patients as well [19].

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  15. Major drawbacks associated with cardiac catheterization include all of the following, EXCEPT:

    CARDIAC DIAGNOSTIC TESTS

    Cardiac catheterization is the definitive diagnostic test to detect heart disease despite major drawbacks, such as its invasive nature, cost, and potential complications [11]. While the number of catheterizations performed on women has increased, men are more likely to be referred for catheterization than women, possibly because women may be at greater risk of adverse events, including death, following catheterization [167,168,169,170]. One study found that men were 40% more likely to undergo angiography than women, despite data that indicates women have more functional impairment and unstable symptoms, as measured by angiography, than men [171,172]. However, a 2010 study found a sharp decrease in catheterization in both men and women when age-specific rates were compared [72].

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  16. In women, coronary heart disease most commonly presents as

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    After menopause, the clinical manifestations of heart disease increase in women. The most common manifestation of heart disease in both men and women is angina [178]. Approximately 8.8 million women in the United States are currently living with heart disease; 35,000 are younger than 65 years of age, and 4 million suffer from angina [1,56]. The basic forms of angina include stable angina, unstable angina, and variations of angina. In terms of incidence, stable angina occurs more frequently in women in the United States than in men, with an estimated female-to-male ratio of 1.7:1 [178,179]. Stable anginal episodes often worsen and become more severe, leading to unstable angina.

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  17. Women with what type of angina have the greatest likelihood of three-vessel or left main coronary heart disease?

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    Unstable angina is a type of chest pain that radiates more widely, may occur at rest, and is difficult to relieve. Women who suffer from unstable angina have the greatest likelihood of significant coronary artery stenosis and three-vessel or left main heart disease. Consequently, these women are at greatest risk to experience more serious cardiac events, such as an MI or sudden cardiac death [180].

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  18. Microvascular angina

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    It has been speculated that up to 80% of instances of this syndrome may be due to hypersensitivity in the nerves that lead to the heart, esophagus, and chest, making women acutely aware of sensations in their heart. Another possibility is that the syndrome is caused by a disorder of the small blood vessels that feed the heart, whereby the vessels fail to dilate in response to physical and/or emotional stress. The syndrome could also be due to a hormonal imbalance induced by a deficiency of estrogen. The exact etiologic mechanism is not known, and many women respond to beta blockers, calcium channel blockers, and nitrates. However, clinical experience has generally been that pain relief with medical therapy is not sustained over time and patients are commonly and unnecessarily prescribed a large number of drugs [184,186].

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  19. Which of the following cardiac symptoms is more common in women than in men?

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    Women may complain of classic substernal pain or have variations in their chest pain syndromes for reasons that are not completely understood. Women frequently report pain centered in the chest, pain in one or both arms, pain in the neck and/or jaw, or pain centered in the back and/or shoulders. They also frequently report nausea, back pain, dizziness, generalized fatigue, shortness of breath, and palpitations [139,145,187,189,190]. Women also experience weakness and loss of appetite [191]. After controlling for age, diabetes, anxiety, depression, and functional status, women are still more likely than men to report these symptoms [191]. Recognition of these gender differences in symptom reporting may result in preventing incorrect or delayed diagnosis and treatment as well as preventable deaths.

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  20. Which of the following is a factor that places women at increased risk for silent MIs and/or sudden cardiac death?

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    Unrecognized or silent MIs are more frequent in women (54%) than men (33%) and account for more than 50% of all infarctions in women 55 years of age and older [201]. Factors that place women at increased risk include older age, hypertension, and diabetes [201]. As mentioned previously, sudden cardiac death generally occurs about 5 to 10 years later in women compared to men.

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  21. Which of the following complications occur more frequently in women post-MI than in men?

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    The incidence of supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar in women and men. However, more ventricular dysrhythmias have been reported in young women with MI who use hormonal contraceptives. Women also have a much higher risk of stroke post-MI and death from stroke compared with men [56].

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  22. Compared with other women post-MI, young women who use hormonal contraceptives are at an increased risk for

    CLINICAL MANIFESTATIONS OF CARDIAC DISEASE IN WOMEN

    The incidence of supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar in women and men. However, more ventricular dysrhythmias have been reported in young women with MI who use hormonal contraceptives. Women also have a much higher risk of stroke post-MI and death from stroke compared with men [56].

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  23. What is the treatment of choice for patients with single-vessel coronary heart disease?

    THERAPEUTIC INTERVENTIONS

    PCI is the treatment of choice for patients with single-vessel coronary heart disease [207]. An estimated 35% of PCIs in the United States are performed in women [208]. At the time that this procedure is first performed, women tend to be on average nine years older than men, with more cardiovascular risk factors and severe unstable angina [208]. However, angiographically documented coronary artery disease has not been found to be more extensive in women compared to men [209]. On a per-lesion basis, angiographic success rates have been found to be similar between men (88%) and women (89%), as were clinical success rates [209,210]. Determinants of PCI success include lesion-specific angiographic features, such as the severity of stenosis, coronary calcification, and intralesional thrombosis-factors that are not influenced by either age or gender [211]. In treating left anterior descending disease, CABG surgery is an attractive option due to the high rate of post-PCI restenosis [208].

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  24. Women are less likely to receive thrombolytic therapy in the treatment of MI due to

    THERAPEUTIC INTERVENTIONS

    Thrombolytic therapy is frequently given to patients within the first six hours of presenting with possible cardiac symptoms. It has proved beneficial in restoring vessel patency and clinical outcomes in both men and women and has resulted in a 25% to 30% reduction in short-term mortality [209,216]. However, women are less likely to receive thrombolysis to restore vessel patency in the management of acute MI for several reasons, including advanced age, delayed arrival at the hospital, and medical contraindications [216]. Even in those eligible, women are less likely to receive thrombolytic therapy [217]. The Gruppo Italiano per lo Studio della Streptochinasi nell'infarto Miocardico (GISSI-1) first validated streptokinase as an effective therapy and reported a significant reduction in the 21-day mortality in women who received IV streptokinase within six hours post-MI. Despite these promising outcomes, treated women's mortality rates remain higher than men's [217,218].

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  25. All of the following factors place female patients with heart disease at increased surgical risk compared with men, EXCEPT:

    THERAPEUTIC INTERVENTIONS

    The Coronary Artery Surgery Study (CASS) investigated 2,800 women and 5,300 men who were experiencing severe enough chest pain to warrant a cardiac catheterization. This study revealed a number of differences in the preoperative status of men and women prior to bypass procedures. As discussed earlier, women were found to be at increased surgical risk because they tend to be older, have more unstable angina, frequent cardiac enlargement on chest x-ray, severe mitral regurgitation, and more symptoms and comorbidities, such as heart failure, hypertension, and diabetes. Factors that place women at lower risk include the fact that they tend to have fewer diseased arteries and less myocardial damage. In other words, women generally have better EFs and ventricular wall motion, as well as less left main stenosis and three-vessel disease [11,19,26,27,35]. It has been suggested that these differences in preoperative status may be less related to gender than to delays in the initial diagnosis and treatment of symptomatic heart disease in women. This delay translates into an older age and more frequent comorbidity in women at surgical presentation [219,220].

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  26. Surgical intervention referral patterns in women with heart disease indicate that women are most often referred

    THERAPEUTIC INTERVENTIONS

    In relation to referral patterns, women tend to be referred for surgery much later than men. In one study, fewer women with symptoms were referred for catheterization, and men underwent CABG four times as often as women. Women were referred more for symptoms of unstable angina, heart failure, and post-MI angina, while men were referred on the basis of a positive exercise ECG [19,26]. As a result, women are more likely to have surgery on an emergency basis, with potentially fewer techniques available to the surgeon, rather than on an elective basis, as is common in men. For example, the use of left internal mammary artery (LIMA) grafts is accepted as the "criterion standard" for surgical revascularization. Many studies have demonstrated better long-term patency rates and survival in patients undergoing CABG with LIMA [223,224]. The benefit of LIMA grafts has been observed consistently regardless of age, sex, stenosis severity, or LV function. Although a number of risk factors have been identified to result in LIMA graft failure, they are less common than for other grafts [224]. Nevertheless, the risk-to-benefit question is of increasing importance as the proportion of high-risk subgroups continues to rise [223,225].

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  27. During the first four weeks of recovery post-CABG surgery, women were more likely than men to report

    THERAPEUTIC INTERVENTIONS

    An interesting study has compared the symptoms experienced by men and women during the first four weeks of recovery post-CABG surgery. Women reported numbness and discomfort in their breasts, while men reported more fatigue, incisional pain, and negative emotions. Both men and women felt their recovery emotions were related to their social roles and circumstances [225]. For instance, women were concerned and anxious about who would care for them during their home recovery, as they tended to be older and live alone. In contrast, men were more concerned first with their immediate physical recovery symptoms and secondly with return to work issues [233]. Researchers have noted that women tend to find strength for the postoperative recovery phase from their own spirituality and relationships with others, especially their families, friends, and social networks [234]. One study found that women's primary concerns shifted over the course of a year after cardiac surgery [235]. In the first postoperative month, women were most concerned with issues related to future plans, such as progress in recovery and resuming their lifestyle. By one year after surgery, women were most concerned about diet, and more than half of the women were exercising more.

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  28. Women are reported to drop out of formal cardiac rehabilitation programs due to

    THERAPEUTIC INTERVENTIONS

    A number of factors account for the lower program completion rates among women. These factors include family commitments, financial concerns such as insurance barriers, and lack of spousal support. Other reasons for decreased program attendance in both men and women include transportation problems, distance, cost, work conflicts, medical reasons, and having a sense of personal control over their condition [238,243]. Societal barriers, such as low education, also may impede enrollment in a rehabilitation program [244]. However, women's attendance at cardiac rehabilitation programs is more often affected by medical reasons compared to men, with complaints of increased angina and other associated symptoms, comorbidities such as arthritis and peripheral vascular disease, and/or a need for admission to transitional care postdischarge. This trend may be due to the presence of more cardiovascular risk factors and increasing cardiac symptoms in women [26,241,245]. On the other hand, men usually receive more family support and are accompanied by their spouse to cardiac rehabilitation programs more often than women, a finding that may partially explain women's higher dropout rates. Clearly, cardiac rehabilitation programs should be structured to the unique needs of women [237,246]. Home-based cardiac rehabilitation programs are another attractive option for women, especially for the elderly and homebound [19,240,247].

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  29. Assessment to determine which women are at an increased risk for not participating in cardiac rehabilitation program should include all of the following, EXCEPT:

    THERAPEUTIC INTERVENTIONS

    Nurse-led coordination of care after hospital discharge may have a role in improving rehabilitation uptake [248]. Some experts advocate giving nurses more responsibility to educate and motivate women to complete their recovery by participating in outpatient cardiac rehabilitation [249]. By assessing each woman prior to discharge, those who are at increased risk for not participating may be identified and targeted for follow-up. This assessment should include: a woman's psychologic state, namely anxiety and depression; other psychosocial factors, such as unemployment, lower educational and socioeconomic status, and lack of social support; and functional status.

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  30. Which of the following areas should be covered in patient education for women with heart disease?

    IMPLICATIONS FOR NURSING PRACTICE

    Patient education for women with heart disease should incorporate several components, including the disease process, diagnostic tests, medications, the recovery process, and risk-factor modification. In relation to the disease process, female patients should be taught symptom recognition and early treatment of complications. The positive long-term outcomes of women with angina and post-PCI and CABG surgery should be stressed when counseling patients regarding the recovery process. Medication teaching should include a description of the action and effects of the cardiac medication, along with the dosage, frequency, and possible side effects. The nurse may also act as a patient advocate with regard to diagnostic testing. Attempt to ensure that the appropriate diagnostic tests and treatment procedures are provided to the patient. Finally, risk factor modification enhances the patient's progress and quality of life [271].

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  31. As a general guideline, cholesterol screening should initially be done when a patient is

    PREVENTION STRATEGIES

    Primary prevention of cardiovascular disease begins with general screening, including a detailed history, assessment of general health, a review of cardiovascular risk factors, and measurement of weight, blood pressure, and cholesterol. With regard to total cholesterol, the initial screen should be done at 20 years of age and followed up thereafter every five years. With female patients, obstetrician/gynecologists play a key role in this screening process. If cholesterol levels are greater than 200 mg/dL, additional testing of lipoproteins, specifically HDL and LDL, and annual checks are warranted [73]. Table 6 outlines primary prevention recommendations for women, jointly developed by several organizations including the AHA, the CDC, and the NIH's Office of Research on Women's Health.

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  32. Guidelines for cardiac nutrition should emphasize that approximately what percentage of daily calories should come from saturated fat?

    PREVENTION STRATEGIES

    GUIDELINES FOR PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: CLINICAL RECOMMENDATIONS

    Lifestyle Interventions
    Cigarette smokingWomen 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 at least 150 minutes/week of moderate exercise, 75 minutes/week of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week (Class I, Level B).
    Women should also be advised that additional cardiovascular benefits are provided by increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5 hours/week of vigorous-intensity physical activity, or an equivalent combination of both (Class I; Level of Evidence B).
    Women should be advised to engage in muscle-strengthening activities that involve all major muscle groups performed on ≥2 days/week (Class I; Level of Evidence B).
    Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of at least moderate-intensity physical activity (e.g., brisk walking) on most, and preferably all, days of the week (Class I, Level B).
    RehabilitationA 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) <35% (Class I, Level B).
    Dietary intakeWomen should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods, consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7% of total energy intake, cholesterol to <150 mg/d, alcohol intake to no more than 1 drink per day, sodium intake to <1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty acids (Class I, Level B).
    Weight maintenance/reductionWomen 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 acidsConsumption of omega-3 fatty acids in the form of fish or in capsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered in women with hypercholesterolemia and/or hypertriglyceridemia for primary and secondary prevention. Note: Fish oil dietary supplements may have widely variable amounts of EPA and DHA (likely the only active ingredients) (Class IIb, Level B).
    Major Risk Factor Interventions
    Blood pressure—optimal level and lifestyleEncourage 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—pharmacotherapyPharmacotherapy in indicated when blood pressure is ≥140/90 mm Hg or at a lower blood pressure (≥130/80 mm Hg) in the setting of chronic kidney disease or diabetes. 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 women 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). Criteria 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%.
    Lipid and lipoprotein levels—optimal levels and lifestyleThe following levels of lipids and lipoproteins in women should be encouraged through lifestyle approaches: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I, Level B).
    Lipids—pharmacotherapy for high-risk womenUtilize LDL-lowering drug therapy simultaneously with lifestyle therapy in women with CHD to achieve an LDL <100 mg/dL (Class I, Level A) and similarly in women with other atherosclerotic CVD or diabetes or 10-year absolute risk >20% (Class I, Level B). A reduction to <70 mg/dL is reasonable in very high-risk women with CHD and may require an LDL-lowering drug combination (Class IIa, Level B). Criteria for very high-risk include established CVD plus any of the following: multiple major risk factors, severe and poorly controlled risk factors, diabetes.
    Lipids—pharmacotherapy for other at-risk womenUtilize LDL-lowering therapy if LDL 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-lowering therapy if LDL 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-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). In women >60 years of age and with an estimated CHD risk 10%, statins could be considered if hsCRP is >2 mg/dL after lifestyle modification and no acute inflammatory process is present (Class IIb, Level B).
    Lipids—pharmacotherapy for low HDL, or elevated non-HDL, high-risk womenUtilize niacin or fibrate therapy when HDL is low or non-HDL is elevated in high-risk women after LDL goal is reached (Class IIa, Level B).
    Lipids—pharmacotherapy for low HDL or elevated non-HDL, other at-risk womenConsider niacin or fibrate therapy when HDL is low (<50 mg/dL) or non-HDL is elevated (>130 mg/dL) after LDL goal is reached in women with multiple risk factors and a 10-year absolute risk 10% to 20% (Class IIb, Level B).
    DiabetesLifestyle and pharmacotherapy should be used as indicated in women with diabetes to achieve an HbA1c <7% if this can be accomplished without significant hypoglycemia (Class IIa, Level B).
    Preventive Drug Interventions
    Aspirin, high riskAspirin therapy (75–325 mg/d)a should be used in high-risk women unless contraindicated (Class I, Level A). If a high-risk woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B). Aspirin therapy (75–325 mg/d) is reasonable in women with diabetes unless contraindicated (Class IIa, Level B).
    Aspirin—other at-risk or healthy womenIn 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 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 blockersBeta blockers should be used for up to 12 months in all women after MI or acute coronary syndrome, with normal left ventricular function, unless contraindicated (Class I, Level A). Long-term beta-blocker therapy should be used indefinitely for women with left ventricular failure unless contraindications are present (Class I, Level A). Long-term beta-blocker therapy may be considered in other women with coronary or vascular disease and normal left ventricular function (Class IIb, Level C).
    Preventive Drug Interventions
    ACE inhibitors/ARBsACE 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 (Class I, Level A). In women after MI and in those with clinical evidence of heart failure or an LVEF ≤40% or with diabetes who are intolerant of ACE inhibitors, ARBs should be used instead (Class I, Level B).
    Aldosterone blockadeUse aldosterone blockade after MI in women who do not have significant hypotension, 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).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Menopausal therapyHormone therapy and selective estrogen-receptor modulators should not be used for the primary or secondary prevention of CVD (Class III, Level A).
    Antioxidant supplementsAntioxidant 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 acidFolic 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 ageRoutine use of aspirin in healthy women <65 years of age is not recommended to prevent MI (Class III, Level B).
    aAfter 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.
    Click to Review
  33. Lifestyle changes that may assist in achieving healthy blood pressure include

    PREVENTION STRATEGIES

    GUIDELINES FOR PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: CLINICAL RECOMMENDATIONS

    Lifestyle Interventions
    Cigarette smokingWomen 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 at least 150 minutes/week of moderate exercise, 75 minutes/week of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week (Class I, Level B).
    Women should also be advised that additional cardiovascular benefits are provided by increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5 hours/week of vigorous-intensity physical activity, or an equivalent combination of both (Class I; Level of Evidence B).
    Women should be advised to engage in muscle-strengthening activities that involve all major muscle groups performed on ≥2 days/week (Class I; Level of Evidence B).
    Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of at least moderate-intensity physical activity (e.g., brisk walking) on most, and preferably all, days of the week (Class I, Level B).
    RehabilitationA 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) <35% (Class I, Level B).
    Dietary intakeWomen should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods, consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7% of total energy intake, cholesterol to <150 mg/d, alcohol intake to no more than 1 drink per day, sodium intake to <1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty acids (Class I, Level B).
    Weight maintenance/reductionWomen 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 acidsConsumption of omega-3 fatty acids in the form of fish or in capsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered in women with hypercholesterolemia and/or hypertriglyceridemia for primary and secondary prevention. Note: Fish oil dietary supplements may have widely variable amounts of EPA and DHA (likely the only active ingredients) (Class IIb, Level B).
    Major Risk Factor Interventions
    Blood pressure—optimal level and lifestyleEncourage 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—pharmacotherapyPharmacotherapy in indicated when blood pressure is ≥140/90 mm Hg or at a lower blood pressure (≥130/80 mm Hg) in the setting of chronic kidney disease or diabetes. 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 women 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). Criteria 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%.
    Lipid and lipoprotein levels—optimal levels and lifestyleThe following levels of lipids and lipoproteins in women should be encouraged through lifestyle approaches: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I, Level B).
    Lipids—pharmacotherapy for high-risk womenUtilize LDL-lowering drug therapy simultaneously with lifestyle therapy in women with CHD to achieve an LDL <100 mg/dL (Class I, Level A) and similarly in women with other atherosclerotic CVD or diabetes or 10-year absolute risk >20% (Class I, Level B). A reduction to <70 mg/dL is reasonable in very high-risk women with CHD and may require an LDL-lowering drug combination (Class IIa, Level B). Criteria for very high-risk include established CVD plus any of the following: multiple major risk factors, severe and poorly controlled risk factors, diabetes.
    Lipids—pharmacotherapy for other at-risk womenUtilize LDL-lowering therapy if LDL 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-lowering therapy if LDL 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-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). In women >60 years of age and with an estimated CHD risk 10%, statins could be considered if hsCRP is >2 mg/dL after lifestyle modification and no acute inflammatory process is present (Class IIb, Level B).
    Lipids—pharmacotherapy for low HDL, or elevated non-HDL, high-risk womenUtilize niacin or fibrate therapy when HDL is low or non-HDL is elevated in high-risk women after LDL goal is reached (Class IIa, Level B).
    Lipids—pharmacotherapy for low HDL or elevated non-HDL, other at-risk womenConsider niacin or fibrate therapy when HDL is low (<50 mg/dL) or non-HDL is elevated (>130 mg/dL) after LDL goal is reached in women with multiple risk factors and a 10-year absolute risk 10% to 20% (Class IIb, Level B).
    DiabetesLifestyle and pharmacotherapy should be used as indicated in women with diabetes to achieve an HbA1c <7% if this can be accomplished without significant hypoglycemia (Class IIa, Level B).
    Preventive Drug Interventions
    Aspirin, high riskAspirin therapy (75–325 mg/d)a should be used in high-risk women unless contraindicated (Class I, Level A). If a high-risk woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B). Aspirin therapy (75–325 mg/d) is reasonable in women with diabetes unless contraindicated (Class IIa, Level B).
    Aspirin—other at-risk or healthy womenIn 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 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 blockersBeta blockers should be used for up to 12 months in all women after MI or acute coronary syndrome, with normal left ventricular function, unless contraindicated (Class I, Level A). Long-term beta-blocker therapy should be used indefinitely for women with left ventricular failure unless contraindications are present (Class I, Level A). Long-term beta-blocker therapy may be considered in other women with coronary or vascular disease and normal left ventricular function (Class IIb, Level C).
    Preventive Drug Interventions
    ACE inhibitors/ARBsACE 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 (Class I, Level A). In women after MI and in those with clinical evidence of heart failure or an LVEF ≤40% or with diabetes who are intolerant of ACE inhibitors, ARBs should be used instead (Class I, Level B).
    Aldosterone blockadeUse aldosterone blockade after MI in women who do not have significant hypotension, 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).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Menopausal therapyHormone therapy and selective estrogen-receptor modulators should not be used for the primary or secondary prevention of CVD (Class III, Level A).
    Antioxidant supplementsAntioxidant 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 acidFolic 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 ageRoutine use of aspirin in healthy women <65 years of age is not recommended to prevent MI (Class III, Level B).
    aAfter 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.
    Click to Review
  34. Which of the following is recommended for the primary or secondary prevention of cardiovascular disease?

    PREVENTION STRATEGIES

    GUIDELINES FOR PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: CLINICAL RECOMMENDATIONS

    Lifestyle Interventions
    Cigarette smokingWomen 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 at least 150 minutes/week of moderate exercise, 75 minutes/week of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week (Class I, Level B).
    Women should also be advised that additional cardiovascular benefits are provided by increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5 hours/week of vigorous-intensity physical activity, or an equivalent combination of both (Class I; Level of Evidence B).
    Women should be advised to engage in muscle-strengthening activities that involve all major muscle groups performed on ≥2 days/week (Class I; Level of Evidence B).
    Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of at least moderate-intensity physical activity (e.g., brisk walking) on most, and preferably all, days of the week (Class I, Level B).
    RehabilitationA 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) <35% (Class I, Level B).
    Dietary intakeWomen should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods, consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7% of total energy intake, cholesterol to <150 mg/d, alcohol intake to no more than 1 drink per day, sodium intake to <1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty acids (Class I, Level B).
    Weight maintenance/reductionWomen 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 acidsConsumption of omega-3 fatty acids in the form of fish or in capsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered in women with hypercholesterolemia and/or hypertriglyceridemia for primary and secondary prevention. Note: Fish oil dietary supplements may have widely variable amounts of EPA and DHA (likely the only active ingredients) (Class IIb, Level B).
    Major Risk Factor Interventions
    Blood pressure—optimal level and lifestyleEncourage 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—pharmacotherapyPharmacotherapy in indicated when blood pressure is ≥140/90 mm Hg or at a lower blood pressure (≥130/80 mm Hg) in the setting of chronic kidney disease or diabetes. 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 women 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). Criteria 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%.
    Lipid and lipoprotein levels—optimal levels and lifestyleThe following levels of lipids and lipoproteins in women should be encouraged through lifestyle approaches: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I, Level B).
    Lipids—pharmacotherapy for high-risk womenUtilize LDL-lowering drug therapy simultaneously with lifestyle therapy in women with CHD to achieve an LDL <100 mg/dL (Class I, Level A) and similarly in women with other atherosclerotic CVD or diabetes or 10-year absolute risk >20% (Class I, Level B). A reduction to <70 mg/dL is reasonable in very high-risk women with CHD and may require an LDL-lowering drug combination (Class IIa, Level B). Criteria for very high-risk include established CVD plus any of the following: multiple major risk factors, severe and poorly controlled risk factors, diabetes.
    Lipids—pharmacotherapy for other at-risk womenUtilize LDL-lowering therapy if LDL 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-lowering therapy if LDL 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-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). In women >60 years of age and with an estimated CHD risk 10%, statins could be considered if hsCRP is >2 mg/dL after lifestyle modification and no acute inflammatory process is present (Class IIb, Level B).
    Lipids—pharmacotherapy for low HDL, or elevated non-HDL, high-risk womenUtilize niacin or fibrate therapy when HDL is low or non-HDL is elevated in high-risk women after LDL goal is reached (Class IIa, Level B).
    Lipids—pharmacotherapy for low HDL or elevated non-HDL, other at-risk womenConsider niacin or fibrate therapy when HDL is low (<50 mg/dL) or non-HDL is elevated (>130 mg/dL) after LDL goal is reached in women with multiple risk factors and a 10-year absolute risk 10% to 20% (Class IIb, Level B).
    DiabetesLifestyle and pharmacotherapy should be used as indicated in women with diabetes to achieve an HbA1c <7% if this can be accomplished without significant hypoglycemia (Class IIa, Level B).
    Preventive Drug Interventions
    Aspirin, high riskAspirin therapy (75–325 mg/d)a should be used in high-risk women unless contraindicated (Class I, Level A). If a high-risk woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B). Aspirin therapy (75–325 mg/d) is reasonable in women with diabetes unless contraindicated (Class IIa, Level B).
    Aspirin—other at-risk or healthy womenIn 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 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 blockersBeta blockers should be used for up to 12 months in all women after MI or acute coronary syndrome, with normal left ventricular function, unless contraindicated (Class I, Level A). Long-term beta-blocker therapy should be used indefinitely for women with left ventricular failure unless contraindications are present (Class I, Level A). Long-term beta-blocker therapy may be considered in other women with coronary or vascular disease and normal left ventricular function (Class IIb, Level C).
    Preventive Drug Interventions
    ACE inhibitors/ARBsACE 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 (Class I, Level A). In women after MI and in those with clinical evidence of heart failure or an LVEF ≤40% or with diabetes who are intolerant of ACE inhibitors, ARBs should be used instead (Class I, Level B).
    Aldosterone blockadeUse aldosterone blockade after MI in women who do not have significant hypotension, 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).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Menopausal therapyHormone therapy and selective estrogen-receptor modulators should not be used for the primary or secondary prevention of CVD (Class III, Level A).
    Antioxidant supplementsAntioxidant 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 acidFolic 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 ageRoutine use of aspirin in healthy women <65 years of age is not recommended to prevent MI (Class III, Level B).
    aAfter 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.
    Click to Review
  35. Exercise increases

    PREVENTION STRATEGIES

    Reports on physical activity and coronary heart disease in women have been conflicting. While some studies have found no reduction in heart disease risk, many other studies have demonstrated lower all-cause mortality in women and men with higher levels of fitness. A study published in 2001 reported that even light-to-moderate amounts of exercise (i.e., at least one hour of walking a week) were associated with a lowered risk of coronary heart disease in women [297]. This correlation extended to women with heightened risk for heart disease, including those who were overweight, who had high cholesterol, and who smoked. Exercise may favorably modify other cardiovascular risk factors by increasing HDL, decreasing total cholesterol levels, augmenting fibrinolytic activity to decrease the risk of thromboembolism, and improving insulin resistance, especially in obese women. Additional benefits associated with exercise include weight and blood pressure control, as well as promoting a general sense of well-being [298].

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  36. The Nurse's Health Study demonstrated that low-dose aspirin is associated with a reduction in heart attack risk among women of

    PREVENTION STRATEGIES

    As with men, low-dose aspirin therapy may play a role in the primary prevention of heart disease in women. The NHS demonstrated a 32% reduction in risk of first MI in women who took low-dose aspirin (i.e., one to six aspirin per week) [303]. While low-dose aspirin may be associated with a somewhat lower cardiovascular and total mortality rate in women, its cardioprotective role is not without limitations. Routine use of aspirin for the primary prevention of MI in healthy women younger than 65 years of age is not recommended unless the benefit outweighs the risk of adverse effects [281]. The optimum dose of aspirin as a primary preventive measure has not been established. Also, the benefit of such therapy should be weighed against the risk of stroke and gastrointestinal bleeding [304].

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  37. Women have formerly been excluded from large-scale clinical trials related to heart disease due to

    IMPLICATIONS FOR FURTHER RESEARCH

    In the past, a paucity of research existed regarding women and heart disease. Women have been excluded from studies for a number of reasons. Women of reproductive age have been excluded due to the possible risks to the fetus, while older women have not been studied because they often have multiple health problems, which may create health risks or confuse the research findings. As a result, women have had restrictions in clinical care, such as the underutilization of thrombolytic therapy for the management of evolving MIs. Age-based exclusions of women from clinical trials on invasive diagnostic or therapeutic techniques have also limited the participation of women [7,325,326].

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  38. Difficulties regarding the current base of research related to women and heart disease include

    IMPLICATIONS FOR FURTHER RESEARCH

    Additionally, sample sizes of existing studies have traditionally been too small to either evaluate effects or draw conclusions. As a result, the findings of studies conducted with men, as well as with younger populations, have been used to diagnose and treat women and the elderly. In other words, studies done on men were driving clinical practice with female cardiac patients. Yet, research indicates that differences exist in disease presentation, cardiovascular risk factors, and the diagnosis and response of women to various treatments for heart disease [122,327].

    At the federal level, two major initiatives have been instituted to expand the base of research related to women-specific health issues. The NIH has mandated that investigators include women and minorities in clinical research populations for health-related studies. At the very least, the investigator must adequately justify any decisions to exclude potential subjects from these studies [328]. A second factor that has influenced the research base related to women's health is the development of the NIH Interdisciplinary Women's Health Research Center, formed to encourage studies related to issues affecting women's health [329].

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  39. The Women's Health Initiative addresses all of the following major health issues of women, EXCEPT:

    IMPLICATIONS FOR FURTHER RESEARCH

    The Women's Health Initiative (WHI), a 15-year study of 160,000 women, was undertaken as the largest NIH clinical trial to answer questions regarding postmenopausal women's health. The WHI specifically addressed the major health problems of menopausal women, including heart disease, cancer, and osteoporosis [330]. In relation to heart disease, the WHI studied the effects of low-fat diets in preventing coronary disease and the risks and benefits of HRT [330]. As discussed earlier, the WHI trials investigated both combination (estrogen plus progestin) and unopposed estrogen hormone therapy. Both trials were cut short prior to the projected completion dates. In July 2002, the WHI halted the combination therapy trials due to a significantly increased incidence of breast cancer. In February 2004, the unopposed estrogen study was stopped when researchers determined that the heightened risk of stroke was unacceptable to continue the trial. In the case of the combination hormone study, researchers found an increased risk for MI, stroke, and venous thromboembolism. The estrogen-only study resulted in increased risk of stroke and venous thromboembolism, but no difference in the risk of MI [316,317]. Again, there is some controversy regarding the trials' designs and whether the findings are universally applicable [331,332]. However, the U.S. Food and Drug Administration continues to recommend against the routine use of HRT as preventive treatment for heart disease in postmenopausal women [333].

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  40. Further research studies are needed on

    IMPLICATIONS FOR FURTHER RESEARCH

    Beyond the large NIH trials that have been initiated, other research by various disciplines is desperately needed related to women and heart disease. This research involves asking questions, such as those listed in Table 7, related to cardiovascular risk factors, the impact of heart disease on the patient and family, the clinical course of women with heart disease, and intervention studies. For instance, why do women fail to receive diagnostic studies or therapeutic interventions to the same extent that men do? Many studies have shown less active or aggressive diagnosis and management of heart disease in women. Fewer women with positive noninvasive cardiac tests are catheterized and fewer women have revascularization by either PCI or CABG surgery compared to men [122,205,225,334]. The question remains: Are men overtreated, or are women undertreated?

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