Patient Care Endocrinology & Cardiology - December 2007 - (Page 16)

I Preventing CHD in women Pharmacologic prevention A major change in this year’s guidelines concerns the use of aspirin for the prevention of CVD. Aspirin use continues to be recommended in women who are at high risk, with the recommended upper dosage of aspirin now being 325 mg/d versus the previous recommendation of 162 mg/d. Clopidogrel (Plavix) is now also recommended for high-risk women who cannot take aspirin, another new addition to the updated guidelines. Recommendations for at-risk and optimal-risk patients have now changed, reflecting the fact that, while low-dosage aspirin has been shown to reduce CHD primarily in older women, it reduces the risk of stoke in women of all ages.23,24 Women younger than 65 are therefore now advised to take low-dosage aspirin (81 mg/d or 100 mg every other day) when the benefits of aspirin therapy for the prevention of stroke are thought to outweigh the risks of treatment. Women 65 years or older with controlled BP are advised to take low-dosage aspirin for prevention of both CHD and stroke if the benefits outweigh the risks for hemorrhagic stroke and GI bleeding. The recommendation for the use of beta-blockers and ACE inhibitors in high-risk women are unchanged, but the indications are now explicitly outlined as follows: Beta-blockers should be used (unless contraindicated) in women who have experienced an acute coronary syndrome or have left ventricular (LV) dysfunction, regardless of the presence or absence of symptoms. Unless contraindicated, ACE inhibitors or angiotensin receptor blockers are recommended in high-risk women following MI, in women with diabetes, or those with an LV ejection fraction of 40% or less. Finally, the new recommendation for the use of aldosterone blockade is for post-MI women with an LV ejection fraction of 40% or less and continued symptomatic CHF despite treatment with an ACE inhibitor and beta-blocker. Interventions recommended against More recent evidence has shown that some interventions previously thought to help prevent CHD may not be as beneficial as once believed. Indeed, in some instances, there may be evidence of harm. A primary example of this is the use of hormone replacement therapy (HRT), once thought to be cardioprotective. As in 2004, this year’s guidelines advise against HRT, since it has not been shown to have a positive effect on CHD risk and may increase the risk of stroke.25 The current guidelines advise against the use of folic acid and vitamin B12 supplementation for the prevention of CHD—a reversal of the 2004 guidelines, which supported the use of folic acid supplementation. It had been previously proposed that folic acid treatment would reduce the risk of CHD by decreasing homocysteine levels, since elevated blood levels of homocysteine have been associated with CHD. However, studies have shown that the decrease in blood homocysteine levels from folate and vitamin B12 treatment does not decrease the incidence of CHD death in post-MI patients and may in fact increase CHD events.26 Thus, women are now advised against folic acid supplementation. Current research has not shown demonstrable benefit from antioxidant supplementation with vitamins E and C and beta carotene. In the current recommendations, women are still advised against the use of antioxidants for CHD prevention. Routine aspirin use in healthy women younger than 65 is not recommended for MI prevention. I This article was contributed by Drs Salt and DeCaro and edited by Peter D’Epiro, PhD. Drs Salt and DeCaro disclose that they have no financial relationship with any manufacturer in this area of medicine. REFERENCES 1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007; 115:e69-e171. 2. Lloyd-Jones D, Leip E, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006;113:791-798. 3. Declining prevalence of no known major risk factors for heart disease and stroke among adults: United States, 1991–2001. MMWR Morb Mortal Wkly Rep. 2004;53:4-7. 4. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol. 2007;49:1230-1250. 5. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115:1481-1501. 6. Mosca L, Appel LJ, Benjamin E, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109;672-693. Continued on page 24 16 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY www.patientcareonline.com http://www.patientcareonline.com

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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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