The first overhaul in four years of the American Heart Association guidelines on cardiovascular disease prevention in women has lowered the threshold for who is considered “high risk,”

“There have been a couple of major changes,” she notes. “As well as the lowering of this threshold, we also focus on what can be accomplished in the ‘real world’ as opposed to what is achievable in clinical trials, and we highlight the fact that women who have had pregnancy complications are at increased risk of CVD.”

In addition, “we’ve softened the recommendations on certain advice in women,” she says, including the use of aspirin in diabetics and the stringency of diabetic control, and introduced new but “soft” guidance on statin use for primary prevention in those with normal cholesterol but raised C-reactive protein (CRP) levels.

Threshold for Treatment Lowered to >10% Risk Over 10 Years

Mosca explains that the previous threshold for what is considered “high risk” among women has been lowered, from a >20% risk of dying from a heart attack in the next 10 years to a >10% risk of dying from any cardiovascular event in the next 10 years.

Pregnancy Complications up CV Risk for Women; Real World Stressed

“Another important change in terms of risk assessment is that we’ve now categorized women who have had pregnancy complications as being ‘at risk. This represents a unique opportunity to identify women at an earlier life stage than they might normally present, so we can institute more aggressive preventive therapy and control of risk factors.

The other important change in the guidelines is this -paradigm shift from evidence-based to effectiveness-based. That the guidelines themselves are based on science, and the results that we see in clinical practice are often less impressive than what we would see in clinical trials, because women are often older and have more comorbidities, so we are asking physicians to really look at the balance of benefits and risks in the real-world setting. There are certain conditions where they might not want to be as aggressive as the guidelines suggest–for example, older frail women who are more likely to have side effects.

Thresholds Softened for Aspirin and Glycemic Control in Diabetes

The new guidance also includes the softening of a number of prior recommendations.

First, the use of aspirin in diabetics, which used to be a class I recommendation, is now a class II A.

The recommendation for glycemic control in diabetes (HbA1c <7%) is also softened.

And although there has been no change on the recommendations for the use of aspirin for primary prevention in women generally, it  is not strongly recommended for women under 65.

Another new but “fairly soft recommendation” is for the use of statins in primary prevention in women without raised cholesterol but who have an elevated CRP level.The rationale for this is that the absolute benefit is very small, even though the proportional risk reduction is very high. We want doctors to recognize that the long-term side effects and cost [of statins] might outweigh the benefits. We give it a softer recommendation than we might have because of our shift toward ‘real-world’ issues.

Ref: http://www.medscape.com/viewarticle/737486?src=mpnews&spon=34