Put Your Red Dress On
February is Heart Month, and the next two issues of Circulation spotlight women’s heart health, a topic that has come to the fore after having been virtually ignored for decades. February 6, 2004, was “National Wear Red Day for Women,” and the widely circulated red dress pins are ongoing reminders of the importance of preventing heart disease in women.
The contributors for these two special issues of Circulation are among the most influential and acclaimed women in the field of heart disease. The problem of heart disease in women is compelling, they said.
“It is remarkable that we have arrived to a point in history when we can dedicate an entire issue of Circulation, the most prestigious specialty journal in cardiology, to the topic of cardiovascular disease in women, said Lori Mosca, MD, PhD, Associate Professor of Medicine at Columbia University College of Physicians and Surgeons.
“The landmark volume reflects the tremendous advances in science, the critical mass of leaders, and the dedication of the American Heart Association surrounding the issue of heart disease in women. This is most appropriate because it is their No. 1 killer.”
Co-contributor Nanette K. Wenger, MD, Professor of Medicine (Cardiology) at Emory University School of Medicine said, “The Institute of Medicine Landmark Report identified that ‘sex matters’—that men and women respond differently to diseases and drugs. Therefore, given the major differences in heart disease in women and men that have been elucidated in recent years, a women’s theme issue is important.”
“Of course, coronary disease is the leading cause of death for US women—so preventive intervention should come to the forefront. The major article for the practicing physician will be the new AHA Guidelines on Prevention for Women [in the February 10, 2004, issue; Circulation. 2004;109:672–693]. This is a guideline done in cooperation with 11 other professional societies and endorsed by more than 20 medical organizations. As such, it reflects the consensus of the clinical care community both about the importance of coronary prevention for women and of the specifics for so doing.”
What Women Do Not Know
Women are more aware than they have ever been of the risk heart disease poses to their sex, but the numbers are still woefully short of ideal. A study in this week’s issue of Circulation (Circulation. 2004;109:573–579) describes the problem in a survey led by Dr Mosca.
She and her colleagues identified a shift in awareness from 1997, when a similar study was performed. In the intervening years, the percentage of women who identify heart disease as the leading cause of death in women has increased, from 30% in 1997 to 46% in 2003. Awareness was lower in black, Hispanic, and younger women, the researchers noted. Only 38% of women said that their doctor had ever discussed heart disease with them.
Researchers surveyed 1024 women over the age of 25 years in June and July of 2003 by telephone. Sixty-eight percent of the women were white, 12% black, 12% Hispanic, and 8% other ethnicity.
Although the authors noted an encouraging trend in recognizing heart disease as a major problem for women, they also said they were concerned because “only 13% of women cite heart disease as their greatest health problem.” The lower rates of awareness among black and Hispanic women were also a matter of concern, they noted.
“A majority of women, particularly Hispanic women and those <45 years of age, feel uninformed about heart disease, and many women do not know specific levels of their risk factors, such as cholesterol. These data suggest there are important opportunities to educate women about CVD [cardiovascular disease] risk and prevention,” the authors wrote.
“Our data suggest that intervention is needed to close this gap in awareness,” the authors wrote. “The AHA, in collaboration with numerous organizations, has issued new guidelines for women from 20 years of age to optimize lifestyle and medical management of risk factors to reduce the burden of CVD.”
Preventing Heart Disease in Women
In the preface to the “Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women” in this week’s issue of Circulation (Circulation. 2004;109:672–693), the expert panel led by Lori Mosca, MD, PhD, Associate Professor of Medicine at Columbia University College of Physicians and Surgeons, outlines the first set of evidence-based guidelines for prevention heart disease in women. They note that the group they seek to protect has a wide range of risk levels.
The need for proof that preventive treatments work was demonstrated with the results of the Women’s Health Initiative and the Heart and Estrogen/Progestin Replacement Study, both of which showed adverse cardiovascular effects from the use of hormone therapy in women.
“These studies underscore the importance of evidence-based practice for chronic disease prevention. Optimal translation and implementation of science to improve preventive care should include a rigorous process of evaluation and clear communication about the quantity and quality used to support clinical recommendations,” the panel wrote.
“The concept of cardiovascular disease as a categorical, ‘have-or-have-not’ condition has been replaced with a growing appreciation for the existence of a continuum of CVD risk,” they wrote. The recommendations run the gamut from lifestyle interventions (such as cessation of cigarette use) to treating major risk factors (such as blood pressure) and using preventive drug interventions.
The guidelines recommend against the use of hormone therapy, antioxidant vitamins, and aspirin in low-risk women as methods of preventing heart disease or reducing its recurrence. They note that the evidence is clear that heart disease prevention is possible in both men and women.
“These recommendations are meant to assist clinicians on the basis of our current state of evidence and supersede previous AHA prevention guidelines with regard to women. Because health care is a blend of science and art, we emphasize that guidelines are not a substitute for good clinical judgment,” the panel concluded.
Lowering Homocysteine Provides No Benefit
Lowering homocysteine levels was studied in stroke patients followed for 2 years, said researchers from Wake Forest University School of Medicine in a report in the February 3, 2004, issue of the Journal of the American Medical Association (JAMA. 2004;291:565–575OpenUrlCrossRefPubMed).
Researchers from the Vitamin Intervention for Stroke Prevention (VISP) trial enrolled 3680 subjects who had suffered a stroke that had not disabled them. The group was drawn from 56 university-affiliated hospitals, neurology practices, and the Veterans Affairs medical centers in the United States, Canada, and Scotland. All patients received the best medical and surgical care plus a daily multivitamin. In addition, they were assigned to receive once-daily doses of 25 mg pyridoxine, 0.4 mg cobalamin, and 2.5 mg folic acid. A total of 1827 received this high-dose regimen, whereas 1853 received the low-dose regimen of 200 μg of pyridoxine, 6 μg of cobalamin, and 20 μg of folic acid.
Total homocysteine levels were 2 μmol/L greater in the high-dose group than in the low-dose group, but neither dosage amount had any effect on the recurrence of stroke, coronary heart disease, or death (the primary end point). The risk of ischemic stroke was 9.2% for the high-dose group and 8.8% for the low-dose group at the end of 2 years.
However, there was an association between baseline homocysteine levels and the occurrence of stroke, coronary heart disease, and death. Because of this and other observational studies that link homocysteine levels to vascular risk, the authors, led by James F. Toole, MD, of Wake Forest University School of Medicine in Winston-Salem, NC, recommend further exploration of the hypothesis that lowering homocysteine can have a beneficial effect on heart disease risk.