Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review

Abstract

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted.

Keywords: adverse pregnancy outcomes; aspirin; atrial fibrillation; cardiovascular disease; gestational diabetes.

FIGURE 1. Recommendations for Cardiovascular Risk Screening After Adverse Pregnancy Outcomes

Adverse pregnancy conditions that require further cardiovascular screening within 3 months post-partum based on medical history, physical examination, and laboratory. CVD = cardiovascular disease; DM = diabetes mellitus; HELLP = hemolysis, elevated liver enzyme, low platelet count; HTN = hypertension; IUGR = intrauterine growth restriction; PMH = past medical history.

FIGURE 2. Hypertension in Women

Progression of hypertension from prevalence to prevention, screening, and therapeutic target. BMI = body mass index; BP = blood pressure.

FIGURE 3. Recommendations for Statin for ASCVD Prevention in Women

Statin therapy recommendations based on studies and guidelines. ASCVD = atherosclerotic cardiovascular disease; LDL-C = low-density lipoprotein cholesterol. * Consider sex-specific risk enhancers: premature menopause and pregnancy-associated conditions that increase ASCVD risk

FIGURE 4. Recommendation for Aspirin for ASCVD Prevention in Women

Aspirin therapy recommendation based on studies and guidelines. ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; CVD = cardiovascular disease; FHx = family history; TIA = transient ischemic attack.

CENTRAL ILLUSTRATION. Cardiovascular Disease Risk Factors in Women

The factors shown in orange are incorporated in the atherosclerotic cardiovascular disease risk calculator. However, there are unique sex-specific factors as well as psychosocial factors that contribute to CVD risk and adverse outcomes.