AHA/ACC Scientific Statement: Consensus Panel Statement

Guide to Preventive Cardiology for Women

Lori Mosca, MD, PhD, Chair; Scott M. Grundy, MD, PhD; Debra Judelson, MD;
Kathleen King, PhD, RN; Marian Limacher, MD; Suzanne Oparil, MD; Richard Pasternak, MD;
Thomas A. Pearson, MD, PhD; Rita F. Redberg, MD; Sidney C. Smith, Jr, MD;
Mary Winston, EdD, RD; Stanley Zinberg, MD
Endorsed by American Medical Womens Association, American College of Nurse Practitioners,
American College of Obstetricians and Gynecologists, and Canadian Cardiovascular Society

C oronary heart disease (CHD) is the single leading cause of

death and a significant cause of morbidity among American
women.1 Risk factors for CHD in women are well documented.2
Recommendations for the primary and secondary prevention of
CHD have been published.9,10 Although those recommendations
apply to women, there are aspects of risk factor management that
Compelling data from epidemiological studies and randomized are unique to women. Pregnancy and the preconception period are
clinical trials show that CHD is largely preventable. Assessment and optimal times to review a womans risk factor status and health
management of several risk factors for CHD are cost-effective.3 behaviors to reduce future cardiovascular disease. Pregnant women
Despite these facts, there are alarming trends in the prevalence and should be strongly encouraged to discontinue smoking and not to
management of risk factors in women.2 Smoking rates are declining relapse in the postpartum period. Avoidance of excess weight gain
less for women than for men. The prevalence of obesity is during pregnancy may reduce the risk of developing CHD in the
increasing, and '25% of women report no regular sustained future. An emphasis on prevention of CHD in postmenopausal
physical activity.4 Approximately 52% of women .45 years old women is particularly important because the incidence of CHD rises
have elevated blood pressure, and '40% of women .55 years old with age. The use of estrogen replacement therapy (ERT) to prevent
have elevated serum cholesterol.5 The purpose of this statement is to CHD, osteoporosis, and possibly dementia is a difficult health
highlight risk factor management strategies that are appropriate for decision for postmenopausal women. The potential benefits of
women with a broad range of CHD risk. A more detailed descrip- therapy must be weighed against the possible risks, including breast
tion, including the scientific basis for these recommendations, is cancer, gallbladder disease, thromboembolic disease, and endome-
available in the 1997 American Heart Association scientific state- trial cancer, although the last is reduced by concomitant use of a
ment Cardiovascular Disease in Women.2 progestin.
Recently, the Centers for Disease Control and Prevention Na- The recent findings from HERS11 have challenged previous
tional Ambulatory Medical Care Survey6 showed clinicians are observational data regarding the role of hormones in preventing
missing opportunities to prevent CHD. In this study of 29 273 subsequent cardiovascular events. HERS was the first large-
routine office visits, women were counseled less often than men scale, randomized, clinical trial in older postmenopausal women
about exercise, nutrition, and weight reduction. In the multicenter with confirmed coronary disease to test the efficacy and safety of
Heart and Estrogen/progestin Replacement Study (HERS),7 only hormone replacement therapy on clinical cardiovascular out-
10% of women enrolled with documented CHD had baseline come in postmenopausal women. The study population included
LDL-cholesterol levels below a National Cholesterol Education 2763 women (mean age 66.7 years) with established CHD
Program (NCEP) target of 100 mg/dL. A recent national survey randomly assigned to 0.625 mg conjugated equine estrogens
showed that women were significantly less likely than men to enroll (CEE) plus 2.5 mg of medroxyprogesterone acetate (MPA) per
in cardiac rehabilitation after an acute myocardial infarction (MI) or day or placebo. Participants were monitored for an average of
bypass surgery.8 This finding is especially important because 4.1 years for the main end point of nonfatal MI or CHD death.
post-MI patients not enrolled in cardiac rehabilitation are less likely At study completion, no significant differences existed between
to receive aggressive risk factor management. groups for any cardiovascular end points.
Surprisingly, after 1 year, HERS showed an increase in cardio-
vascular events in the treatment arm, but in years 4 and 5, fewer
A Guide to Preventive Cardiology for Women was approved by the events occurred than in the placebo arm. It has been hypothesized
American College of Cardiology Board of Trustees on February 22, that possible early adverse effects of estrogen in women with CHD
1999, and by the American Heart Association Science Advisory and
Coordinating Committee on September 7, 1998. may be due to a procoagulant effect that may later be offset by an
A single reprint is available by calling 800-242-8721 (US only) or antiatherogenic benefit. MPA may also have adverse cardiovascular
writing the American Heart Association, Public Information, 7272 effects and may mitigate some of the beneficial effects of estrogen.2
Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-
0160. To purchase additional reprints: up to 999 copies, call 800-611-
Although these hypotheses deserve further investigation, the overall
6083 (US only) or fax 413-665-2671; 1000 or more copies, call null result from HERS does not support initiation of CEE combined
214-706-1466, fax 214-691-6342, or e-mail [email protected]. To with MPA in older postmenopausal women with confirmed coro-
make photocopies for personal or educational use, call the Copyright nary disease. For women with CHD already on ERT for $1 year,
Clearance Center, 978-750-8400.
(Circulation. 1999;99:2480-2484.) it may be reasonable to continue therapy while awaiting the results
1999 American Heart Association, Inc. and American College of of a HERS follow-up study and other ongoing trials of ERT with
Cardiology clinical end points. The results of the HERS trial apply to women
Circulation is available at http://www.circulationaha.org with preexisting CHD and may not apply to women free of vascular
2480
 Mosca et al May 11, 1999 2481

disease. Furthermore, this study does not take into consideration the References
other potential benefits of this therapeutic protocol, which are 1. 1998 Heart and Stroke Facts: Statistical Update. Dallas, Tex: American
beyond the scope of this statement. Heart Association; 1998.
2. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-
Data are lacking for determining the long-term cardiovascular Connor E. Cardiovascular disease in women: a statement for healthcare
effects of testosterone administered with ERT. Alternatives to professionals from the American Heart Association: writing group. Cir-
traditional hormone replacement therapy are available, including culation. 1997;96:2468 2482.
soy phytoestrogens and selective estrogen receptor modulators 3. Goldman L, Garber A, Grover S, Hlatky M (Task Force 6). 27th Bethesda
Conference: matching the intensity of risk factor management with the hazard for
(SERMs); however, a recommendation regarding their use for coronary disease events: Task Force 6: cost effectiveness of assessment and
prevention of CHD has not been made at this time because of a management of risk factors. J Am Coll Cardiol. 1996;27:10201030.
lack of sufficient data. 4. US Dept of Health and Human Services. Physical Activity and Health: A
Several other aspects of risk factor management are of Report of the Surgeon General. Atlanta, Ga: US Dept of Health and
Human Services, Centers for Disease Control and Prevention, National
heightened importance for women. Diabetes is a powerful Center for Chronic Disease Prevention and Health Promotion; 1996.
risk factor in women, increasing CHD risk 3-fold to 7-fold 5. Health United States, 1998 With Socioeconomic Status and Health
compared with a 2-fold to 3-fold increase in risk in men.12 Chartbook. Hyattsville, Md: National Center for Health Statistics; 1998.
6. Missed opportunities in preventive counseling for cardiovascular disease:
This difference may be due to a particularly deleterious effect
United States, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:9195.
of diabetes on lipids and blood pressure in women.2,12 7. Schrott HG, Bittner V, Vittinghoff E, Herrington DM, Hulley S, for the
Therefore, recommendations are provided for management of HERS Research Group. Adherence to National Cholesterol Education
diabetes with an emphasis on controlling concomitant risk Program treatment goals in postmenopausal women with heart disease:
the Heart and Estrogen/progestin Replacement Study (HERS): the HERS
factors.13 Low levels of HDL cholesterol are predictive of Research Group. JAMA. 1997;277:12811286.
CHD in women and appear to be a stronger risk factor for 8. Thomas RJ, Miller NH, Lamendola C, Berra K, Hedback B, Durstin JL,
women .65 years old than for men .65.14 Women tend to Haskell W. National survey on gender differences in cardiac rehabili-
have higher HDL-cholesterol levels than men, and triglycer- tation programs: patient characteristics and enrollment patterns. J Car-
diopulmonary Rehabil. 1996;16:402 412.
ide levels may be a significant risk factor in women, espe- 9. Grundy SM, Balady GJ, Criqui MH, Fletcher G, Greenland P, Hiratzka LF,
cially older women. The current NCEP guidelines are out- Houston-Miller N, Kris-Etherton P, Krumholz HM, LaRosa J, Ockene IS,
lined in the Table with a notation to consider more aggressive Pearson TA, Reed J, Washington R, Smith SC Jr. Guide to primary prevention
targets for HDL cholesterol and triglycerides in women.15 of cardiovascular diseases: a statement for healthcare professionals from the Task
Force on Risk Reduction. Circulation. 1997;95:23292331.
The NCEP also recommends the use of ERT before choles- 10. Smith SC Jr, Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto
terol-lowering drugs to reduce LDL cholesterol in postmeno- AM, Gould KL, Greenland P, Grundy SM, Hill M, Hlatky M, Houston-
pausal women. In this statement, the recommendation has Miller N, Krauss R, LaRosa J, Ockene I, Oparil S, Pearson T, Rapaport E,
Starke R, the Secondary Prevention Panel. Preventing heart attack and death
been modified to consider statins a first-line therapy in
in patients with coronary disease. Circulation. 1995;92:24.
postmenopausal women on the basis of recent data that 11. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B,
suggest women may have at least as much benefit from Vittinghoff E, for the Heart and Estrogen/progestin Replacement Study
LDL-cholesterol reduction with statins as men.16 (HERS) Research Group. Randomized trial of estrogen plus progestin for
secondary prevention of coronary heart disease in postmenopausal
Recommendations for aggressive risk factor management women. JAMA. 1998;280:605 613.
are based on the future probability of a cardiovascular event. 12. Manson JE, Spelsberg A. Risk modification in the diabetic patient. In: Manson
This strategy allows high-risk patients who have not yet had JE, Ridker PM, Gaziano JM, Hennekens CH, eds. Prevention of Myocardial
an event to be considered for more intensive treatment.17 It Infarction. New York, NY: Oxford University Press; 1996:241273.
13. The American Diabetes Association. Clinical practice recommendations
also recognizes that CHD is not a categorical event but rather 1998. Diabetes Care. 1998;21(suppl 1):S23S32.
a continuum of a progressive disease process. As the avail- 14. Manolio TA, Pearson TA, Wenger NK, Barrett-Connor E, Payne GH,
ability and use of noninvasive tools to detect asymptomatic Harlan WR. Cholesterol and heart disease in older persons and women:
CHD increase, the line between primary and secondary review of an NHLBI workshop. Ann Epidemiol. 1992;2:161176.
15. National Cholesterol Education Program Expert Panel. Second report of
prevention may become less distinct. Substantial data support the National Cholesterol Education Program Expert Panel on Detection,
aggressive risk factor management in the setting of secondary Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
prevention. However, because first cardiovascular events are Treatment Panel). Circulation. 1994;89:13331445.
16. Gotto AM Jr. Cholesterol management in theory and practice. Circu-
often fatal in women, careful consideration should be given to
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individual risk factor management before onset of clinical 17. Califf RM, Armstrong PW, Carver JR, DAgostino RB, Strauss WE (Task
CHD in women. The current recommendations are developed Force 5). 27th Bethesda Conference: matching the intensity of risk factor
from previous guidelines and consensus panel statements management with the hazard for coronary disease events: stratification of
patients into high, medium and low risk subgroups for purposes of risk factor
along with newer gender-specific data when avail- management. J Am Coll Cardiol. 1996;27:10071019.
able.2,9,10,13,15,18 23 The recommendations can serve as a guide 18. Physical activity and cardiovascular health. NIH Consensus Development Panel
to risk factor management but cannot replace clinical judg- on Physical Activity and Cardiovascular Health. JAMA. 1996;276:241246.
ment. As new knowledge is acquired, revised strategies for 19. Krauss RM, Deckelbaum RJ, Ernst N, Fisher E, Howard BV, Knopp RH,
Kotchen T, Lichtenstein AH, McGill HC, Pearson TA, Prewitt TE, Stone
the prevention of CHD in women should reflect new science. NJ, Horn LV, Weinberg R. Dietary guidelines for healthy American
adults: a statement for health professionals from the Nutrition Committee,
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In addition to the American College of Cardiology and the American 20. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher
Heart Association, the following organizations assisted in the devel- VF, Mark DB, Marwick TH, McCallister BD, Thompson PD, Winters WL
opment and review of this document: American Medical Womens Jr, Yanowitz FG, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A
Association, American College of Nurse Practitioners, and American Jr, Lewis RP, ORourke RA, Ryan TJ. ACC/AHA guidelines for exercise
College of Obstetricians and Gynecologists. testing: executive summary: a report from the American College of Cardi-
2482 Preventive Cardiology for Women

ology/American Heart Association Task Force on Practice Guidelines (Com- Practice Guidelines (Committee on Management of Acute Myocardial
mittee on Exercise Testing). Circulation. 1997;96:345354. Infarction). Circulation. 1996;94:23412350.
21. The Sixth Report of the Joint National Committee on prevention, 23. National Institutes of Health, National Heart, Lung, and Blood Institute.
detection, evaluation, and treatment of high blood pressure. Arch Intern Clinical Guidelines on the Identification, Evaluation, and Treatment of
Med. 1997;157:24132446. Overweight and Obesity in Adults: The Evidence Report. Washington,
22. Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH, Califf RM, DC: US Dept of Health and Human Services; 1998.
Hillis LD, Hiratzka LF, Rapaport E, Riegel BJ, Russel RO, Smith EE III,
Weaver WD. ACC/AHA guidelines for the management of patients with
acute myocardial infarction: executive summary: a report of the American KEY WORDS: AHA Scientific Statements n prevention n women n coronary
College of Cardiology/American Heart Association Task Force on disease

Guide to Risk Reduction for Women

Lifestyle Factors Goal(s) Screening Recommendations
Cigarette smoking 1. Complete cessation. 1. Ask about current smoking status 1. At each visit, strongly encourage patient and
2. Avoid passive cigarette smoke. and exposure to others cigarette family to stop smoking. If complete cessation is
smoke as part of routine evaluation. not achievable, a reduction in intake is beneficial
2. Assess total exposure to cigarette as a step toward cessation.
smoke (pack-years) and prior 2. Reinforce nonsmoking status.
attempts at quitting. 3. Provide counseling, nicotine replacement, and
3. Evaluate readiness to stop other pharmacotherapy as indicated in
smoking. conjunction with behavioral therapy or a formal
cessation program.

Physical activity 1. Accumulate $30 min of 1. Ask about physical activity 1. Encourage a minimum of 30 min of
moderate-intensity physical activity (household work as well as moderate-intensity dynamic exercise (eg, brisk
on most, or preferably all, days of occupational and leisure-time physical walking) daily. This may be performed in
the week. activity) as part of routine evaluation. intermittent or shorter bouts ($10 min) of
2. Women who have had recent 2. In women with symptoms that activity throughout the day.
cardiovascular events or procedures suggest CVD or in previously 2. Women who already meet minimum standards
should participate in cardiac sedentary women .50 y old with $2 may be encouraged to become more physically
rehabilitation, a physician-guided risk factors for CVD, consider a stress active or to include more vigorous activities.
home exercise program, or a test* to establish safety of exercise 3. Incorporate physical activity in daily activities
comprehensive secondary prevention and to guide the exercise prescription. (eg, using stairs).
program. 4. Muscle strengthening and stretching exercises
should be recommended as part of an overall
activity program.
5. Recommend medically supervised programs
for women who have had a recent MI or
revascularization procedure.

Nutrition 1. AHA Step I Diet in healthy women 1. Assess nutritional habits as part of 1. Encourage a well-balanced and diversified diet
(#30% fat, 810% saturated fat, a routine evaluation in all women. that is low in saturated fat and high in fiber.
and ,300 mg/d cholesterol). 2. Consider formal dietary assessment 2. Use skim milk instead of milk with a higher
2. AHA Step II Diet in women with in women with hyperlipidemia, fat content.
CVD or if a further reduction in diabetes, obesity, and hypertension. 3. Diets rich in antioxidant nutrients (eg, vitamin
cholesterol is needed (#30% fat, C, E, and beta-carotene) and folate are preferred
,7% saturated fat, and ,200 mg/d over nutritional supplements. Note: Daily
cholesterol). supplements of 0.4 mg of folic acid are
3. Limit sodium chloride (salt) intake recommended for women of child-bearing age to
to 6 g/d. Women with high blood help prevent neural tube defects.
pressure may require further 4. Limit alcohol intake to #1 glass of alcohol per
restriction. day. (1 glass54 oz wine, 12 oz beer, or 112 oz
4. Total dietary fiber intake of 80-proof spirits.) Pregnant women should abstain
2530 g/d from foods. from drinking alcohol.
5. Consume $5 servings of fruits
and vegetables per day.

Weight management 1. Achieve and maintain desirable Measure patients weight and height, 1. Encourage gradual and sustained weight loss
weight. calculate BMI, and measure waist in persons whose weight exceeds the ideal
2. Target BMI (weight in kilograms circumference as part of a periodic weight for their height.
divided by height in meters squared) evaluation. 2. Formal nutritional counseling is encouraged for
between 18.5 and 24.9 kg/m2 (BMI Note: BMI and waist circumference women with hypertension, hyperlipidemia, or
of 25 kg/m25110% of desirable are used for diagnosis, and elevated glucose levels associated with overweight.
body weight). measurement of height and weight 3. The recommended weight gain during pregnancy
3. Desirable waist circumference are used for follow-up. is 2535 lb if the patients prepregnancy weight is
,88 cm (,35 inches) in women normal. Adjust for multiple gestation and
with a BMI of 2534.9 kg/m2. prepregnancy weight (eg, overweight women should
gain 1525 lb, obese women, ,15 lb).
 Mosca et al May 11, 1999 2483

Continued
Lifestyle Factors (continued) Goal(s) Screening Recommendations
Psychosocial factors 1. Positive adaptation to stressful 1. Assess presence of stressful 1. Encourage positive coping mechanisms for stress
situations. situations and response to stress as (eg, substitute physical activity for overeating or
2. Improved quality of life. part of a routine evaluation. excessive smoking in response to stress).
3. Maintain or establish social 2. Evaluate for depression, especially 2. Encourage adequate rest and relief for women who
connections. in women with recent cardiovascular are caretakers of others.
events. 3. Consider treatment of depression and anxiety when
3. Assess social support system and appropriate.
evaluate for social isolation. 4. Encourage participation in social activities or
volunteer work for socially isolated women.
Risk Factors Goals Screening Recommendations
Blood pressure 1. Achieve and maintain blood 1. Measure blood pressure as part of 1. Promote the lifestyle behaviors described above
pressure ,140/90 mm Hg and lower a routine evaluation. (weight control, physical activity, moderation in
if tolerated (optimal ,120/80). 2. Follow-up is based on initial alcohol intake) and moderate sodium restriction.
2. In pregnant women with measurement as follows: 2. If blood pressure remains $140/90 mm Hg after
hypertension, the goal of treatment is SBP, DBP, 3 months of lifestyle modification or if initial level
to minimize short-term risk of mm Hg mm Hg Follow-up is .160 mm Hg systolic or 100 mm Hg diastolic,
elevated blood pressure in the ,130 ,85 Recheck in 2 y then initiate and individualize pharmacotherapy
mother while avoiding therapy that 130139 8589 Recheck in 1 y based on the patients characteristics.
may compromise the well-being of 140159 9099 Confirm in 2 mo 3. In pregnant women with hypertension, reduction
the fetus. 160179 100109 Evaluate in 1 mo of diastolic blood pressure to 90100 mm Hg is
$180 $110 Evaluate in 1 wk recommended.
(Follow-up screening may be modified
on the basis of prior history,
symptoms, presence of other risk
factors, and end organ damage.)
3. In pregnant women with
hypertension, evaluate for
preeclampsia.

Lipids, lipoproteins Primary goal: Women without CVD 1. Promote lifestyle approach in all women (diet,
Women without CVD Measure nonfasting total and HDL weight management, smoking avoidance, and
Lower risk (,2 risk factors) cholesterol and assess nonlipid risk exercise as described above). Rule out other
LDL goal ,160 mg/dL (optimal factors. Follow-up is based on the secondary causes of dyslipidemia.
,130 mg/dL) following initial measurements: 2. Suggested drug therapy for high LDL levels
Higher risk ($2 risk factors) TC ,200, HDL $45, follow-up in 5 (defined as [a] $220 mg/dL in low-risk,
LDL goal ,130 mg/dL years; TC ,200, HDL ,45, follow-up premenopausal women, [b] $190 mg/dL in
with fasting lipoprotein analysis. TC postmenopausal women with ,2 risk factors, and
Women with CVD 200239, HDL $45, and ,2 risk [c] $160 mg/dL with $2 risk factors) is based on
LDL #100 mg/dL factors, follow-up in 12 years. TC triglyceride level as follows:
200239, HDL ,45 or $2 risk TG ,200 mg/dL
Secondary goals: factors, follow-up with fasting Statin, Resin, Niacin
HDL .35 mg/dL lipoprotein analysis. TC $240, Note: ERT is an option for postmenopausal women,
Triglycerides ,200 mg/dL follow-up with fasting lipoprotein but treatment should be individualized and
analysis. (All cholesterol values in considered with other health risks.
Note: In women, the optimal level of mg/dL.) TG 200400 mg/dL
triglycerides may be lower (#150 Statin, Niacin
mg/dL) and the HDL higher ($45 Women with CVD TG .400 mg/dL
mg/dL). Fasting lipoprotein analysis (may take Consider monotherapy with statin, niacin, fibrate,
46 wk to stabilize after or a combination of the above.
cardiovascular event or bypass
surgery).

Diabetes For patients with diabetes: 1. Monitor glucose and hemoglobin 1. Encourage adoption of American Diabetes
1. Maintain blood glucose: A1c as part of a routine periodic Association Diet (,30% fat, ,10% saturated fat,
preprandial580120 mg/dL evaluation in women with diabetes. 68% polyunsatured fat, cholesterol ,300 mg/d).
bedtime5100140 mg/dL. 2. Screen for diabetes (fasting glucose 2. A low-calorie diet may be recommended for
2. Maintain Hb A1c ,7%. .125 mg/dL or .200 mg/dL 2 h weight loss.
3. LDL ,130 mg/dL (,100 mg/dL if after 75 g glucose) as part of a 3. Encourage regular physical activity.
established CVD). Note: Many periodic examination in women with 4. Pharmacotherapy with oral agents or insulin
authorities believe that LDL should be risk factors for diabetes, such as should be used when indicated.
,100 mg/dL in all patients with obesity.
diabetes.
4. Triglycerides ,150 mg/dL.
5. Control blood pressure.
2484 Preventive Cardiology for Women

Continued
Pharmacological
Interventions Goal(s) Screening Recommendations
Hormone replacement 1. Initiation or continuation of therapy 1. Review menstrual status of women 1. Counsel all women about the potential
therapy in women for whom the potential .40 y old. benefits and risks of HRT, beginning at age 40 or
benefits may exceed the potential 2. If menopausal status is unclear, as requested.
risks of therapy. (Short-term therapy measure FSH level. 2. Individualize decision based on prior history and
is indicated for treatment of risk factors for CVD as well as risks of
menopausal symptoms.) thromboembolic disease, gallbladder disease,
osteoporosis, breast cancer, and other health risks.
2. Minimize risk of adverse side 3. Combination therapy with a progestin is
effects through careful patient usually indicated to prevent endometrial
selection and appropriate choice of hyperplasia in a woman with an intact uterus
therapy. and prescribed estrogen. The choice of agent
should be made on an individual basis.

Oral contraceptives 1. Minimize risk of adverse Determine contraindications and 1. Use of oral contraceptives is relatively
cardiovascular effects while cardiovascular risk factor status of contraindicated in women $35 y old who
preventing pregnancy. women who are considering using smoke.
2. Use the lowest effective dose of oral contraceptives. 2. Women with a family history of premature
estrogen/progestin. heart disease should have lipid analysis before
taking oral contraceptives.
3. Women with significant risk factors for
diabetes should have glucose testing before
taking oral contraceptives.
4. If a woman develops hypertension while using
oral contraceptives, she should be advised to
stop taking them.

Antiplatelet Prevention of clinical thrombotic and 1. Determine if contraindications to 1. If no contraindications, women with
agents/anticoagulants embolic events in women with therapy exist at the time of the initial atherosclerotic CVD should use aspirin
established CVD. cardiovascular event. 80325 mg/d.
2. Evaluate ongoing compliance, risk, 2. Other antiplatelet agents, such as newer
and side effects as part of a routine thiopyridine derivatives, may be used to prevent
follow-up evaluation. vascular events in women who cannot take
aspirin.

b-blockers To reduce the reinfarction rate, 1. Determine if contraindications to Start within hours of hospitalization in women
incidence of sudden death, and therapy exist at the time of the initial with an evolving MI without contraindications. If
overall mortality in women after MI. cardiovascular event. not started acutely, treatment should begin
2. Evaluate ongoing compliance, risk, within a few days of the event and continue
and side effects as part of a routine indefinitely.
follow-up evaluation.

ACE inhibitors To reduce morbidity and mortality 1. Determine if contraindications to 1. Start early during hospitalization for MI unless
among MI survivors and patients therapy exist at the time of the initial hypotension or other contraindications exist.
with LV dysfunction. cardiovascular event. Continue indefinitely for all with LV dysfunction
2. Evaluate ongoing compliance, risk, (ejection fraction #40%) or symptoms of
and side effects as part of a routine congestive heart failure; otherwise, ACE inhibitors
follow-up evaluation. may be stopped at 6 wk.
2. Discontinue ACE inhibitors if a woman
becomes pregnant.
CVD indicates cardiovascular disease; BMI, body mass index; SBP, systolic blood prssure; DBP, diastolic blood pressure; TC, total cholesterol; TG, triglycerides;
HRT, hormone replacement therapy; and FSH, follicle-stimulating hormone.
*The choice of test modality should be based on the resting ECG, physical ability to exercise, and local expertise and technologies.
The ACC and the AHA recommend cholesterol screening guidelines as outlined by the National Cholesterol Education Panel (measure total and HDL cholesterol
at least once every 5 years in all adults $20 y old. The consensus panel recognizes that some organizations use other guidelines, such as the US Preventive Services
Task Force, which recommends that cholesterol screening in women without risk factors begin at age 45 y.