Big news this week has been the release of: "Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update. A Guideline From the American Heart Association." It is now available as a pre-publication and soon will appear ion Circulation and no doubt JACC. However the pdf is available free for downloading http://circ.ahajournals.org/cgi/reprint/CIR.0b013e31820faaf8v2 I'd be very disappointed if every Lipidaholic did not immediately go and get this. The last 2007 update was called evidence-based and the 2011 document is called effectiveness-based. Get the paper and read the gobbledygook explanation about the differences.
As with most guidelines a lot is repetitive from the 2007 update and original 2004 paper. As always guidelines are way behind what cutting edge clinicians are doing but the honest truth is that the standard of CV care for women in the US is semi-pathetic and the vast MAJORITY of clinicians counseling women do not even follow basic guidelines. How to explain 50% of women with hypertension get no treatment? Here are a few key points (positive and negative)
1) Continued emphasis on lifelong risk of CVD
2) A newer updated Framingham Risk Score (to determine ten year rsik) with the new caveat that if a woman's score puts her into the 10-20% ten year risk zone, she is now to be considered high risk (coronary heart disease risk equivalent). That is a gigantic shift in work up because previously she would have had to score > 20% which almost no woman except one who was quite elderly ever reached.
3) No routine use of aspirin unless the risk is high
4) Only recommended supplement is omega-3 FA
5) Reminder that the # 1 risk factor for premenopausal MI is smoking: surverys show very few clinicians are aware of that.
6) Reminder that > age 60 women are far more likely to die of strokes than CHD manifestations (just the opposite with men)
7) No change in LDL-C goals
8) Require non-HDL-C calculations which enter into therapeutic decisions
9) Somewhat of a move against super aggressive glycemic control
10) Reminder that black women are have horrendous risk and it is equivalent to that of a caucasian male. Also there is a "Hispanic Paradox" where even though their incidence of diabetes is high, they have the lowest CVD mortality
11) Downplaying of the role of coronary calcium and CIMT testing
12) Downplaying of CRP testing: no mention of other types of inflammation assessment
13) recognizing that making the diagnosis of metabolic syndrome matters (it is one of the criteria that puts a woman into the at-risk category
14) Alerted all that preeclamsia, eclampsia, and gestational diabetes are major risk factors for CVD later in life and a detailed pregnancy history now should be part of the medical record
15) Inflammatory collagen diseases (Lupus, RA, etc) are all major CVD risk factors and a thorough CV workup needs to be done and if positive treated in all such women.
Shortcomings:
1) Reliance on lipid goals with no serious mention of measuring atherogenic lipoproteins. There is a vague sentence that novel biomarkers (with no mention of what they consider a novel biomarker) should be reserved for better risk assessment in those with a ten year calculated risk of 10-20%. Wait a minute: as noted above any woman with a calculated risk > 10% is a high risk woman, but here they state you could use with their blessing novel biomarkers to better ascertain risk. Why do them if she is already declared high risk because of a > 10% ten year risk? This looks like the committee's right hand did not know what the left hand was doing.
In fact let me get something off my chest. There are some very prestigious people on this expert panel. They state the following: Optimal Lipid/lipoprotein concentrations: LDL-C < 100 mg/dL, HDL-C > 50 mg/dL, TG < 150 mg/dL, non-HDL-C < 130 mg/dL. CLEARLY THEY HAVE NO KNOWLEDGE that those are lipid, not lipoprotein measurements. The best any lipid measurement can be is a surrogate or proxy or estimate of what the actual lipoprotein concentration actually is. As long as experts keep disingenuously perpetuating the myth that lipid concentrations are the same as lipoprotein concentrations or worse have the same meaning the public is doomed to inferior cardiovascular care. My bet is the vast majority of those signing their names to this guideline DO HAVE THE KNOWLEDGE and have personally (and for their families) had actual lipoprotein measurements but for some reason do not like to educate providers about this crucial distinction.
Would not you think based on AMORIS, INTERHEART, Women's Health Study, Women's Health Initiative, Cardiovascular Health Study, MONET, Framingham, MESA, etc, etc, this is a topic perhaps worthy of a paragraph???
2) No lowering of desirable TG levels or even a discussion of TG issues in women.
3) A mind boggling error in which they do advocate an LDL-C goal of 70 mg/dL in very high risk women but keep the non-HDL-C goal of 130 mg/dL instead of as one would expect 100 mg/dL (as per NCEP ATP-III).
4) No serious discussion of hormonal therapies: either OC in younger women or MHT (menopausal hormone therapy) in symptomatic women with quality of life issues. A PATHETIC shortcoming. Most clinicians seeking such information have little clue the only place to obtain it is position statements from the North American Menopause society http://www.menopause.org/PSht10.pdf or ACE or the Endocrine Society J Clin Endocrinol Metab 2010 Jul;95(7 Suppl 1):s1-s66. Epub 2010 Jun 21. 5) Virtually no discussion of lipid/lipoprotein physiology and pathophysiology in women
6) Very shallow discussion of the lipid-modulating therapies that women may require.
TD
