I CARDIOVASCULAR DISORDERS ^226 ^484 ^669

Cardiovascular disease (CVD) is the leading cause of death in U.S. women. Cardiovascular disease often presents differently and has a higher mortal­ity rate in women than in men.

Patients should be counseled about factors that increase their risk of CVD: family history of CVD, dyslipidemia, hypertension, obesity, lack of exercise, and smoking. Individuals with polycystic ovary syndrome may be at increased risk of coronary heart disease (CHD) because of underlying chronic anovulation and hyperandrogenism (see also the “Polycystic Ovary Syndrome” section in Part 4). Other conditions unique to women that also can increase a woman’s risk of CVD include pregnancy-induced hyperten­sion, preeclampsia, and gestational diabetes. Nonmodifiable risk factors for CVD include age older than 55 years, a family history of premature CHD (defined as myocardial infarction or sudden death in a first-degree male relative before age 55 years or a first-degree female relative before age 65 years), and a personal history of peripheral arterial disease. Risk factors that can be modified include cigarette smoking; physical inactivity; obesity; a poor diet; and medical conditions such as diabetes, hypertension, and hyperlipidemia.

Patients with major medical risk factors, life habit risk factors, and emerging risk factors are characterized by a condition called metabolic syn­drome. The National Heart, Lung, and Blood Institute and the American Heart Association define metabolic syndrome in women as the presence of three or more of the following components:

• Waist circumference equal to or greater than 35 inches

• Triglyceride level 150 mg/dL or higher

• High-density lipoprotein (HDL) cholesterol less than 50 mg/dL

• Blood pressure 130/85 mm Hg or higher

• Fasting glucose level 100 mg/dL or higher

Pharmaceutical treatment for elevated triglyceride levels, reduced HDL cholesterol levels, elevated blood pressure, or elevated fasting glucose are alternative indicators for those measures.

The clinician should address the following issues with patients as indi­cated, depending on age, risk factors, and medical history:

• Educate patients regarding risk factors for, and symptoms of, CVD.

• Educate patients regarding heart attack symptoms: sudden, intense pressure or pain in the chest; shortness of breath; chest pain that spreads to the shoulders, neck, or arms; and feelings of lighthead­edness, fainting, sweating, or nausea. Although many women do experience these symptoms, women are more likely than men to have atypical symptoms, such as “heartburn,” or pain only in their shoulders, neck, or arms.

• Counsel patients regarding lifestyle modifications.

— Diet low in saturated fat, trans-fatty acids, and sodium

— Moderate exercise (see also the “Fitness” section earlier in Part 3)

— Smoking cessation

— Weight control (maintain body mass index [calculated as weight in kilograms divided by height in meters squared] between 18.5 and 24.9)

— Limiting alcohol consumption

• Counsel patients regarding safe and effective contraceptive methods.

• Screen for hypertension.

• Screen for cholesterol.

• Screen for other conditions that can affect CVD (see “Hypertension” and “Dyslipidemia” in this section and the “Diabetes Mellitus” sec­tion later in Part 3).

• Counsel patients with diabetes on the need to maintain normogly- cemia.

• Treat or refer when risk factors are identified.

• In women aged 55-79 years, the U.S. Preventive Services Task Force recommends low-dose aspirin therapy if the benefit for prevention of ischemic stroke is likely to outweigh the risk of gastrointestinal bleeding. The optimum dose of aspirin for preventing CVD events is not known, but a dosage of approximately 75 mg/d seems as effec­tive as higher dosages. The decision about the exact stroke risk level at which the potential benefits outweigh harms is an individual one. Some women may decide that avoiding a stroke is of great value but experiencing a gastrointestinal bleeding event is not a major prob­lem. These women would probably decide to take low-dose aspirin at a lower stroke risk level than those who are more concerned about having a bleeding event. Women younger than 55 years should be discouraged from taking aspirin for CVD prevention.

Guidelines on the assessment of CVD risk and on lifestyle management to reduce risk have been published jointly by the American College of Cardiology (ACC) and the American Heart Association (AHA) (see Resources).

Hypertension

Hypertension, generally defined as blood pressure higher than 140/90 mm Hg, affects 68 million adults in the United States. The incidence of hypertension increases with each decade of life. Approximately one half of U.S. women in their 50s are hypertensive, and the prevalence continues to increase thereafter. At every age, African-American women have a higher prevalence of hypertension than white women. Hypertension increases the risk of CVD events, including CHD, congestive heart failure, stroke, peripheral vascular disease, and renal failure. Untreated hypertension is a major cause of mortality, with risk directly proportional to the degree of hypertension.

Classification

In 2004, the National Heart, Lung, and Blood Institute published its Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), which classifies blood pressure levels as normal, prehypertension, stage 1 hypertension, or stage 2 hypertension (Table 3-2).

Table 3-2. Classification of Blood Pressure for Adults 18 Years and Older

Abbreviation: BP, blood pressure.

Reprinted from National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 04-5230. Bethesda (MD): NHLBI; 2004. Available at: http://www. nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Retrieved September 10, 2013.

Identification and Evaluation

Obstetrician-gynecologists can assume a pivotal role in the prevention of hypertension-related morbidity and mortality. Suggestions for modify­ing lifestyle can be incorporated into patient counseling to prevent the development of chronic hypertension. Identification and management of women with prehypertension or stage 1 hypertension are within the capa­bilities of the obstetrician-gynecologist (see Table 3-2). More advanced stages should be referred for specialist consultation.

Blood pressure readings higher than 120/80 mm Hg should alert the physician to begin counseling for lifestyle modifications to prevent the development of chronic hypertension. However, a single blood pressure measurement is insufficient for diagnosis. At least two measurements should be made and the average recorded. Proper technique is crucial to measuring blood pressure accurately. The method recommended by JNC 7 is shown in Box 3-7. Particularly important is proper assessment of Korotkoff heart sounds.

Laboratory assessments in women with hypertension include uri­nalysis, complete blood count, serum chemistries (eg, potassium, sodium, creatinine, and fasting glucose measurements), and lipid profile. Electrocardiography should be performed, and if ventricular hypertrophy is indicated, echocardiography should be considered.

Management

The goal of managing hypertension is to achieve a systolic blood pres­sure below 140 mm Hg and a diastolic blood pressure less than 90 mm Hg. Whether individuals 60 years of age or older should have a higher systolic blood pressure goal is controversial. Panel members appointed to the Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) recommend a systolic blood pressure treatment goal of less than 150 mm Hg for this pop­ulation; during the development of these guidelines, the National, Heart, Lung, and Blood Institute decided to discontinue developing guidelines, so these recommendations do not reflect the views of the Institute.

Box 3-7. Recommended Techniques of Blood Pressure Measurement ^

• A properly calibrated and validated instrument should be used for blood pressure measurement.

• Patients should be seated in a chair with their feet on the floor, their backs supported, and their arms bared and supported at the level of their hearts. Patients should refrain from smoking or ingesting caffeine for at least 30 minutes before the blood pressure measurement.

• Blood pressure measurement should be taken after 5 minutes of rest.

• The appropriate-sized cuff should be used to ensure accuracy. The blad­der of the blood pressure cuff should encircle at least 80% of the arm.

• Systolic and diastolic blood pressures should be recorded. Systolic blood pressure is defined by the first appearance of Korotkoff heart sounds (phase I), and diastolic blood pressure is defined by the disappearance of Korotkoff heart sounds (phase V).

Data from National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 04-5230. Bethesda (MD): NHLBI; 2004. Available at: http:// www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Retrieved September 10, 2013.

and Prevention retains the systolic blood pressure goal of less than 140 mm Hg set by JNC 7. Lifestyle modifications for prevention and manage­ment of hypertension include the following:

• Quitting smoking

• Weight loss (in overweight patients)

• Limiting alcohol intake for women who consume two or more alco­holic beverages daily

• Increasing aerobic physical activity (see also the “Fitness” section earlier in Part 3)

• Reducing sodium intake to less than 2,300 mg/d for the general population and to 1,500 mg/d for people at risk (individuals 51 years or older; African Americans; and those with hypertension, diabetes, or chronic kidney disease)

• Reducing dietary intake of saturated fat and cholesterol

• Ensuring adequate dietary intake of potassium, calcium, and mag­nesium

A variety of pharmacologic therapies are available for managing hyper­tension, including thiazide diuretics, adrenergic blockers, angiotensin­converting enzyme inhibitors, angiotensin II receptor blockers, and calcium channel blockers. Note that angiotensin-converting enzyme inhibitors should be used with caution in women who may become pregnant.

Dyslipidemia ^275

Coronary heart disease is the leading cause of death for men and women in the United States and accounts for approximately 500,000 deaths each year. Clinical trials have shown that a 1% reduction in serum cholesterol levels results in a 2% reduction in CHD rates. Approximately one quarter to one third of individuals who have a first coronary event will die as a result. Although cholesterol level reduction is anticipated to result in a short-term benefit in patients at risk of future CHD, the near-term benefit of decreasing cholesterol levels is greater among patients with established CHD. Thus, primary prevention (ie, prevention for patients without estab­lished CHD) and secondary prevention (ie, prevention for patients with established CHD) are both important goals.

Identification and Evaluation

Abnormal cholesterol levels have been firmly linked to atherosclerosis and cardiovascular and cerebrovascular disease. However, standards that apply to the identification of candidates for testing and frequency of test­ing differ among organizations. Furthermore, the value of lipid screening in women without definite risk factors (eg, tobacco use, hypertension, diabetes, or a family history of CVD) remains disputed. Current guidelines from the American College of Obstetricians and Gynecologists recommend that women without risk factors have a lipid profile assessment (mea­surement of total cholesterol, low-density lipoprotein [LDL] cholesterol, HDL cholesterol, and triglyceride levels) every 5 years, beginning at age 45 years. Earlier screening may be appropriate in women with risk factors (see www.acog.org/About_ACOG/ACOG_Departments/Annual_Womens_ Health_Care/High-Risk_Factors).

The 2013 ACC and AHA guideline for the management of high blood cholesterol levels is based on assessment of atherosclerotic cardiovascular disease risk to determine individuals who would most benefit from choles­terol-lowering therapy. In addition to evaluation of blood cholesterol levels with a fasting lipid profile (Box 3-8), the 2013 ACC and AHA guidelines recommend calculation of 10-year cardiovascular disease risk with a risk calculator developed for the guidelines (see Resources). The well-known Framingham risk score, which incorporates various risk factors to derive an estimated risk of developing CHD within 10 years, was rejected by the 2013 ACC and AHA guideline developers because it was developed with solely a white population and provided risk estimates only for CHD. The new calcu­lator includes levels of total cholesterol and HDL cholesterol (Box 3-8), but the guidelines indicate that evidence is insufficient to establish treatment targets for LDL cholesterol or other non-HDL cholesterol. These guidelines and the risk calculator on which they rely have been criticized.

Management

Research indicates that elevated LDL cholesterol is a major cause of CHD. In addition, recent clinical trials show that LDL cholesterol-lowering ther­apy reduces the risk of CHD. Treatment for high LDL cholesterol levels can include therapeutic lifestyle changes, drug therapy, or both depending on the risk category of the patient. Therapeutic lifestyle changes include dietary changes to reduce intake of saturated fats and cholesterol and enhance intake of plant stanols, sterols, and soluble fiber; weight reduction; and increased physical activity. Drug therapy options include statins, bile acid sequestrants, and nicotinic acids. However, 2013 guidelines on the man­agement of high blood cholesterol levels issued jointly by the ACC and the AHA recommend primary drug therapy with statins based on evidence that nonstatins do not provide acceptable risk reduction compared with the potential for adverse events.

Thromboembolic Disease

Venous thromboembolic disease represents a spectrum of conditions that range from peripheral thrombosis to pulmonary embolism and stroke.

Data from National Heart, Lung, and Blood Institute. Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda (MD): NHLBI; Available at: http:// www.nhlbi.nih.gov/guidelines/cholesterol/index.htm. Retrieved July 25, 2013 and Eckel RH, Jakicic JM, Ard JD, Hubbard VS, de Jesus JM, Lee IM, et al. 2013 AHA/ ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; DOI: 10.1161/01.cir.0000437740.48606.d1. J Am Coll Cardiol 2013; DOI: 10.1016/j.jacc.2013.11.003.

Risk factors for venous thromboembolic disease include age, prolonged immobility (eg, due to stroke or paralysis), surgery, trauma, malignancy, pregnancy, use of estrogenic medications (eg, hormonal contracep­tives, hormone therapy, raloxifene, and tamoxifen), congestive heart failure, hyperhomocystinemia, diseases that increase blood viscosity (eg, polycythemia, sickle cell disease, and multiple myeloma), and inherited thrombophilia. Patients with inheritable causes of thrombosis usually do not have spontaneous venous thrombosis until they have been exposed to another environmental risk factor, such as pregnancy, trauma, surgery, or immobilization.

Venous thromboembolism is a leading cause of morbidity and mortality in hospitalized patients in the United States. The presence of an asymptom­atic deep vein thromboembolism is strongly linked to the development of a clinically significant pulmonary embolism. Most patients who die from a pulmonary embolism do so within 30 minutes of the event, leaving little time for therapeutic interventions. Thus, it is important to assess patient risk and adopt appropriate preventive measures before surgery or hospital­ization. Evidence-based risk assessment classifications and recommended prophylaxis strategies based on risk have been published by the American College of Chest Physicians (see Resources).

Bibliography­

Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. US Preventive Services Task Force. Ann Intern Med 2009;150:396-404. [PubMed] [Full Text]

Department of Agriculture, Department of Health and Human Services. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: Government Printing Office; 2010. Available at: http://www.cnpp.usda.gov/DGAs2010-PolicyDocument. htm. Retrieved July 24, 2013.

Department of Health and Human Services. The Heart Truth: lecture materials and PowerPoint slides. Available at: http://www.womenshealth.gov/heart-truth/clinical- education/lecture-materials.php. Retrieved July 25, 2013.

Eckel RH, Jakicic JM, Ard JD, Hubbard VS, de Jesus JM, Lee IM, et al. 2013 AHA/ ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of CardiologyZAmerican Heart Association Task Force on Practice Guidelines. Circulation 2013; DOI: 10.1161/01.cir.0000437740.48606.d1. J Am Coll Cardiol 2013; DOI: 10.1016/j.jacc.2013.11.003. [PubMed] [Full Text]

Go AS, Bauman MA, Coleman King SM, Fonarow GC, Lawrence W, Williams KA, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol 2014;63:1230-8 [PubMed] and Hypertension 2014;63:878-85. [PubMed] [Full Text]

Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB S, Gibbons R, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of CardiologyZAmerican Heart Association Task Force on Practice Guidelines. Circulation 2013; DOI: 10.1161/01.cir.0000437741.48606.98. J Am Coll Cardiol 2013; DOI: 10.1016/j.jacc.2013.11.005. [PubMed] [Full Text]

Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. American Heart Association and National Heart, Lung, and Blood Institute [pub­lished errata appear in Circulation 2005;112:e297. Circulation 2005; 112: e298]. Circulation 2005;112:2735-52. [PubMed] [Full Text]

James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013; DOI: 10.1001∕jama.2013.284427.

Moyer VA. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. Ann Intern Med 2012;157:367-72. [PubMed] [Full Text]

National Cholesterol Education Program. Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). National Heart, Lung, and Blood Institute. Bethesda (MD): NHLBI; Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm. Retrieved July 25, 2013.

National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 04-5230. Bethesda (MD): NHLBI; 2004. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Retrieved September 10, 2013.

Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:936-49. [PubMed] [Obstetrics & Gynecology]

Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin No. 84. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:429-40. [PubMed] [Obstetrics & Gynecology]

Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; DOI: 10.1016/j.jacc.2013.11.002. Circulation 2013; DOI: 10.1161/01.cir.0000437738.63853.7a. [PubMed] [Full Text]

Yoon PW, Gillespie CD, George MG, Wall HK. Control of hypertension among adults-National Health and Nutrition Examination Survey, United States, 2005­2008. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2012;61(suppl):19-25. [PubMed] [Full Text]

Resources

American College of Cardiology. Guidelines and quality standards. Available at: http://www.cardiosource.org/Science-And-Quality/Practice-Guidelines-and- Quality-Standards.aspx. Retrieved January 30, 2014.

American College of Cardiology, American Heart Association. 2013 prevention guideline tools and risk calculator. Available at: http://www.cardiosource.org/ science-and-quality/practice-guidelines-and-quality-standards/2013-prevention- guideline-tools.aspx. Retrieved January 30, 2014.

American College of Cardiology, American Heart Association. CV risk calcula­tor. Available at: http://my.americanheart.org/professional/StatementsGuidelines/ PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp. Retrieved January 30, 2014.

American College of Obstetricians and Gynecologists. Annual women's health care: high risk factors. Available at: http://www.acog.org/About_ACOG/ACOG_Depart ments/Annual_Womens_Health_Care/High-Risk_Factors. Retrieved October 1, 2013.

American College of Obstetricians and Gynecologists. Cholesterol and your health. Patient Education Pamphlet AP101. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Keeping your heart healthy. Patient Education Pamphlet AP122. Washington, DC: American College of Obste­tricians and Gynecologists; 2004.

American College of Obstetricians and Gynecologists. Managing high blood pres­sure. Patient Education Pamphlet AP123. Washington, DC: American College of Obstetricians and Gynecologists; 2010.

Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clini­cal practice guidelines. American College of Chest Physicians [published erratum appears in Chest 2012;141:1369]. Chest 2012;141:e227S-77S. [PubMed] [Full Text]

Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circula­tion 2011;123:1243-62. [PubMed] [Full Text]

National Heart, Lung, and Blood Institute. Information for health profession­als: cholesterol. Available at: http://www.nhlbi.nih.gov/health/prof/heart/index. htm#chol. Retrieved January 30, 2014.

National Heart, Lung, and Blood Institute. Information for professionals: other heart and vascular diseases. Available at: http://www.nhlbi.nih.gov/health/prof/ heart/index.htm#hd. Retrieved January 30, 2014.

Ozaki A, Bartholomew JR. Venous thromboembolism (deep venous thrombosis & pulmonary embolism). Cleveland (OH): Cleveland Clinic Foundation; 2012. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanage ment/cardiology/venous-thromboembolism. Retrieved July 25, 2013.

Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. U.S. Preventive Services Task Force. Ann Intern Med 2007;147:783-6. [PubMed] [Full Text]

U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 2010;59(RR-4):1-86. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf. September 26, 2013.

U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication No. 08-05114-EF-2, June 2008 Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.uspreventiveservicestaskforce.org/clinic/uspstf08/ lipid/lipidrs.htm. Retrieved July 25, 2013.

Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Phys­icians evidence-based clinical practice guidelines. American College of Chest Physicians [published erratum appears in Chest 2012;141:1129]. Chest 2012; 141:e637S-e668S. [PubMed] [Full Text]