Women who suffer from a dangerous high blood pressure condition and other complications of pregnancy are at risk of getting cardiovascular disease later in life, the American Heart Association reports in recently updated guidelines that aim to start efforts to prevent heart disease earlier than in the past.
In its 2007 guidelines, the heart association indicates preeclampsia may be "an early indicator" of a risk of cardiovascular disease. This year, pregnancy complication history, which also includes gestational diabetes, is linked with medical and family histories to top a list of six factors physicians should use in evaluating a woman's risk of heart disease.
Female patients with autoimmune diseases such as lupus and rheumatoid arthritis also should be considered at risk for heart disease and be screened for additional risk factors, according to the guidelines.
Cardiovascular disease includes stroke, heart attacks, leaking valves and electrical problems leading to heart failure.
"Those are the two biggest additions [to the guidelines] as far as stratifying risk, things we need to look at," said cardiologist Beth Piccione, of the UPMC Cardiovascular Institute at UPMC Horizon in Greenville, who speaks on women's heart health.
Instead of measuring a woman's risk of disease across 10 years, as in the 2007 report, the new guidelines recommend looking at the risk in her lifetime. By changing the way women are evaluated for how likely they will get heart disease, the way they are treated to prevent it can change. The sooner their risks are established, the sooner treatment and prevention can begin.
The guidelines also call for more stringent exercise, including muscle-strengthening activities, and the use of blood thinners for women with histories of an irregular heartbeat, known as atrial fibrillation. The condition is more common in women than men but, Dr. Piccione said, "the man is more likely to be on appropriate therapy."
The guidelines stress that certain subgroups, including those defined by race or socioeconomic status, endure "striking disparities in cardiovascular health" that need to be recognized and addressed by doctors. Specifically, they noted the higher prevalence of such risk factors as high blood pressure among African-American women and diabetes in those of Hispanic descent.
"Notably, the highest coronary heart death rates and the highest overall [cardiovascular disease] morbidity and mortality occur in black women," according to the guidelines.
They also point to polycystic ovarian disease as a risk factor. "It's very commonly accompanied by obesity and high cholesterol. Polycystic ovarian disease affects women who are very young," said cardiologist Indu Poornima, director of the Women's Heart Center at Allegheny General Hospital. "We don't understand why more of them have it, but women should be followed early and started on treatment for high blood pressure and high cholesterol, rather than wait until they're 50."
Blood pressure, she added, "is one of the most important factors in reducing risk in women and less than 30 percent ... are being adequately controlled."
As in 2007, the guidelines say that, despite common belief, routine use of aspirin in healthy women under 65 "is not recommended" to prevent heart attacks. Also listed as not useful and "may be harmful" are hormone replacement therapy, antioxident vitamin supplements such as C and E, and folic acid, with the exception of folic acid recommended for pregnant women.
Besides personal, family and pregnancy histories, other factors the heart association says should be used in evaluating risk include symptoms of cardiovascular disease; depression screening in women with heart disease; a physical exam, including blood pressure, body mass index and waist size; and certain laboratory tests.
"One of the important things in screening is the history of depression and not just weight and BMI but the waist size," Dr. Poornima said. "So even women with ideal body weight who have an abdominal waist circumference of greater [than 35 inches] are at higher risk."
Including family history when doctors assess the risk of coronary disease in their patients is not common, she added.
Among the new risk categories is one called "ideal cardiovascular health," which includes women with ideal blood pressure, and glucose and cholesterol levels who exercise regularly and eat a healthy diet.
Under the old guidelines, Dr. Poornima said, a 40-year-old woman with high blood pressure and high cholesterol would not have been treated for those conditions because her age was relatively low, and she would not have been considered at risk of getting cardiovascular disease within 10 years time. Now she would be assessed under the category of lifetime risk and treated for both.
"A 40-year-old woman may not be developing a heart attack in 10 years, but because of the high blood pressure and high cholesterol she could develop a heart attack at 60," Dr. Poornima said, "So if we treat her at 40, the chance of preventing a heart attack is much higher."
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