Patient Care Endocrinology & Cardiology - December 2007 - (Page 15)

Preventing CHD in women I more than 1 drink of alcohol per day has been added this year, as well as the recommendation that women avoid consuming more than 2.3 g/d (approximately 1 tsp) of salt. Because of their positive effect on lipid profiles, omega 3 fatty acids should still be considered when treating women with CHD and hypertriglyceridemia. Obesity and physical inactivity These are recognized as separate risk factors. Women who have a healthy body mass index (BMI) but who are inactive have a greater chance of developing CHD than women of similar BMI who exercise regularly. Conversely, women who are physically active and also overweight are less likely to develop CHD than overweight women who do not exercise regularly.16 Mechanisms such as endothelial cell dysfunction and increased inflammatory markers and procoagulants are coming to be understood as factors contributing to CHD. These factors are independent of obesityassociated risks such as hypertension and lowered HDL-C.17 The continued rise in the prevalence of obesity in the United States highlights the importance of the recommendation that women achieve a BMI between 18.5 and 24.9. Rehabilitation After an MI or stroke, rehabilitation with a formal program (physician-guided or community-based) is recommended. Cardiac rehab is also recommended for women with other indications such as angina, congestive heart failure (CHF), or an ejection fraction less than 40%. Unfortunately, women who are eligible to participate in such programs are half as likely to do so as men, although the participation rate for both sexes is low. This gender difference stems not only from lower compliance among women but also from the lower incidence of physician referrals given to women.18 We need to continue to encourage eligible women to participate in cardiovascular rehabilitation programs, when indicated, by providing appropriate referrals. Depression screening This intervention continues to be recommended, reflecting the importance of psychiatric health on CHD survival. Social isolation has been found to increase 6-month mortality in patients after acute MI.19 Patients who respond well to treatment with antidepressants after MI are 2.5 times less likely to die in the 6 months post-MI than are patients who do not respond to treatment.20 Risk factor intervention The benefits of optimal BP cholesterol levels, and , diabetes control on CHD risk are so well known that an in-depth review is unnecessary. The recommendation that patients with diabetes aim for a glycated hemoglobin A1c level of less than 7% is unchanged. Recommendations for BP also remain largely the same: Lifestyle changes to achieve an optimal BP of less than 120/80 mm Hg should be implemented, and pharmacotherapy should be instituted if BP exceeds 140/90 mm Hg (or 130/80 mm Hg for patients with diabetes or end-organ damage such as chronic kidney disease or CHF). In line with the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), thiazide diuretics remain first-line treatment unless there are comorbidities to guide alternative choices, such as the recommendation for using ACE inhibitors in patients with diabetes.21 The new guidelines reflect recent changes in our understanding of hypercholesterolemia. Since the ATP-III guidelines were published in 2001, ongoing research has continued to open up possibilities to improve cardiovascular risk. For example, it now appears that while levels of LDL cholesterol (LDL-C) of less than 100 mg/dL improve outcomes for highrisk patients, further benefit can be gained by achieving levels of less than 70 mg/dL.22 The current guidelines for the prevention of CVD in women restate the ATP-III guidelines for LDL-C levels, with the addition that, in high-risk women, the reduction of LDL-C to less than 70 mg/dL is now considered reasonable. LDL-C goals should be achieved through lifestyle and dietary changes as well as through pharmacotherapy, sometimes with multiple agents. Low HDL-C is also recognized as a risk factor for CHD and should be treated with niacin or fibrates when lifestyle modification is insufficient. Caution is required when combining use of a statin and a fibrate. In this setting, fenofibrate (Lofibra, TriCor) is preferred over gemfibrozil (Gemcor, Lopid). Continued on page 16 DECEMBER 2007 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY 15

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Patient Care Endocrinology & Cardiology - December 2007 Research Digest Contents Medicine in the News Options for Managing Diabetes: Three Types of Basal Insulin Therapy Using the New AHA Guidelines for Preventing Coronary Heart Disease in Women Cardiovascular and Metabolic Implications of Polycystic Ovary Syndrome Case & Comment Classified Advertising Clinical Clips

Patient Care Endocrinology & Cardiology - December 2007

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