Newsby Topic: Cardiology Update

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News By Topic: Cardiology Update

An exclusive cardiology collection of interview-based articles by leading experts

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Table of Contents5 New Performance Measures for STEMI & Non-STEMI —Harlan M. Krumholz, MD, FACC, FAHA

9 Managing Perioperative Hypertension —Joseph Varon, MD, FACP, FCCP, FCCM

13 Screening for Depression in Cardiac Patients —J. Thomas Bigger, Jr., MD, FAAN, FAASM

16 Preventing CVD in Women: A Focus on Lifetime Risk & Lifestyle

—Lori Mosca, MD, PhD

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A message from the editorWe at Physician’s Weekly are excited to present you with an eBook dedicated to cardiology. In recent months, our publication has featured a variety of news items in this field, focusing on clinical and evidence-based research and guidelines. The content in these articles relies on the expertise of our contributing physician authors. We anticipate that Physician’s Weekly will continue to feature news in this field of medicine in the coming months, and subsequent eBooks will emerge in the future. We hope that you find this information useful in your practice. Please let us know your thoughts by contacting us at [email protected].

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Harlan M. Krumholz, MD, FACC, FAHAHarold H. Hines, Jr. Professor of Medicine and

Epidemiology and Public Health (Cardiology) Yale University Section of Cardiovascular

Medicine

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visit www.physweekly.com 5visit www.physweekly.com 5

New Performance Measures for STEMI

& Non-STEMIClinical performance measures for adults with STEMI and

non-STEMI have been updated to help physicians implement the most effective treatment strategies and improve quality care

for acute myocardial infarction.

August 24, 2009 • Issue No. 32

Click here to view this article online.

In 2008, the American College of Cardiology (ACC) and the American Heart Association (AHA) up-dated clinical performance measures for the man-

agement of patients with STEMI and non-STEMI for the first time since 2006. The measures, published jointly in the December 9, 2008 issues of Circulation and the Journal of the American College of Cardiology, define key healthcare processes where the supporting evidence is so strong that all patients should be receiv-ing the treatment.

“The ACC/AHA performance measures aren’t meant to stand still,” says Harlan M. Krumholz, MD, FACC, FAHA, who chaired the document. “Rather, they are intended to capture the best practices in contemporary care. As such, continued refinements of these measures are necessary. Coordination with key medical groups who are responsible for the public reporting of perfor-mance measures, such as CMS and the Joint Commis-sion, is also paramount.”

Performance Measures Vs GuidelinesDr. Krumholz says it is important to clarify that per-formance measures and guideline recommendations

are not synonymous. “Guidelines make recommenda-tions about care for patients with a given condition. The guidelines convey the rationale and strength of evidence for each recommendation. Performance mea-sures regarding actions in clinical care are more than recommendations. They identify aspects of care for which the failure to act in a certain way is judged as poor clinical performance. The evidence bar is high-er for a performance measure than it would be for a guideline recommendation.” Performance measures provide a means to monitor clinical practice and to promote quality improvement. Test measures are also utilized for quality improvement but are not consid-ered suitable for holding people accountable.

Out With the Old…For the first time in the preparation of the updated ACC/AHA clinical performance measures, the writ-ing committee decided that early use of b-blockers for heart attack should be retired. New scientific evi-dence makes the clinical decision to give or withhold b-blockers more complex. For certain patients being treated with IV b-blockers, early use may be associated with increased risk. The previous measures did recom-

http://www.physweeklyarchives.com/article.asp?issueid=710&articleid=5932

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mend excluding patients who were not considered ide-al candidates for the early use of b-blockers (eg, those with heart failure or low blood pressure), but there was concern that the existing measure might be inadver-tently leading clinicians to treat patients who had an increased risk with these drugs. As such, the decision was made to eliminate this particular performance measure in order to avoid overtreatment.

…In With the NewFour new performance measures were included in the updated guide from the ACC/AHA (Table 1). An important addition, according to Dr. Krumholz, is a new assessment of the time to treatment for patients with STEMI who are transferred from one hospital to another. “Acute reperfusion remains an important focus of quality assessment,” he says. “If patients go to the hospital and need an emergency PCI, the sys-tem has improved in offering the procedure in a more timely fashion. However, if patients go to a hospital that doesn’t offer the necessary intervention and they are then transferred to one that does, there is uncer-tainty about how often there are unnecessary delays. We’re also unsure about the reasons for such delays.”

He adds that this new performance measure will help track delivery of effective therapies so that gaps in qual-ity care can be identified, and clinical outcomes can be improved.

Several measures for STEMI were also revised in the updated clinical performance measures (Table 2). Among those, one major revision was the utiliza-tion of statin therapy at discharge—as opposed to any lipid-lowering therapy—regardless of LDL cho-lesterol levels. “This is an important change because not all lipid-lowering agents are the same, and there is some uncertainty about the net clinical benefit of some drugs,” Dr. Krumholz says. “There’s a difference between prescribing drugs that reduce LDL cholesterol and giving drugs that are known to improve survival. The benefits of statins in this setting are clear, and the measurement makes the preference for statins clear.” The other modifications were minor and include revi-sions or corrections to denominator exclusions.

In addition to the aforementioned revisions, the use of nine test measures was also discussed in the ACC/AHA document. A major revision was changing LDL

cholesterol assessment from a performance measure to a test measure. In the past, LDL cholesterol assess-ment as a performance measure was considered a “best practice” because these results determined the need for lipid-lowering therapy and/or behavioral modifica-tion. However, since statin prescription at discharge has become the new standard, the writing committee changed it to a test measure. Other new test measures include assessing whether there have been excessive initial doses of heparin, enoxaparin, abciximab, epti-fibatide, and tirofiban, drugs for which overdosing is common. Updated structural measures include estab-lishing antico agulant dosing protocols and error track-ing systems. Administration of clopidogrel at discharge is also important.

The evidence bar is higher for a performance measure than it would be for a guideline recommendation.

—Harlan M. Krumholz, MD, FACC, FAHA

Table 1 New STEMI Performance Measures

• Evaluate left ventricular systolic function during hospitalization.

• Assess time from ED arrival at STEMI referral facility to ED discharge from STEMI referral facility in patients transferred for PCI.

• Assess time from ED arrival at STEMI referral facility to PCI at STEMI receiving facility among trans-ferred patients.

• Refer STEMI patients for cardiac rehabilitation from inpatient setting for secondary prevention.

Source: Adapted from: Krumholz HM, et al. J Am Coll Cardiol. 2008;52:2046-2099.


ReferencesKrumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction) Developed in Collaboration With the American Academy of Family Physicians and American College of Emergency Physicians Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine. J Am Coll Cardiol. 2008;52:2046-2099.

Krumholz HM, Anderson JL, Brooks NH, et al; American College of Cardiology; American Heart Association Task Force on Performance Measures; Writing Committee to Develop Performance Measures on ST-Elevation and Non-ST-Elevation Myocardial Infarction. ACC/AHA clinical performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures on ST-Elevation and Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2006;47:236-265.

Spertus JA, Eagle KA, Krumholz HM, et al. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147-1156.

Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons, endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50: e1-e157.

Table 2 Revised STEMI Performance Measures

Source: Adapted from: Krumholz HM, et al. J Am Coll Cardiol. 2008;52:2046-2099.

Revised measure

Changed to specify statins only; deleted denominator requirement that LDL-C is >100 mg/dL.

Minor revisions to denominator exclusions.



Revised denominator exclusions.

Revised denominator exclusions.

Corrected denominator statement; added left bundle-branch block; omitted “who received fibrinolytic therapy or primary PCI”.


Previous measure

Lipid-lowering therapy at discharge

Aspirin at arrival

Aspirin prescribed at discharge

b-blockers prescribed at discharge

ACE inhibitor or angiotensin receptor blocker for left ventricular systolic dysfunction

Time to fibrinolytic therapy

Time to PCI

Adult smoking cessation advice/counseling

Dr. Krumholz says the performance measurement sets may help accelerate the appropriate translation of scientific evidence into clinical practice. “These docu-ments are intended to provide clinicians and institu-tions with tools to measure the quality of their care and to identify opportunities for improvement. We hope that application of these measures will further help im-

prove the quality of medical care in a way that we can quantitatively measure.”

Harlan M. Krumholz, MD, FACC, FAHA, has indicated to Physician’s Weekly that he has worked as a consultant for United Health, CMS, and VHA, Inc. For more information on this article, including references, please visit: www.physweekly.com.

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Joseph Varon, MD, FACP, FCCP, FCCMClinical Professor of Medicine University of Texas Health Science

Center at Houston St. Luke’s Episcopal Hospital University of Texas Medical Branch

at GalvestonProfessor, Acute and Continuing Care University of Texas School of Nursing,

Houston

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Managing Perioperative Hypertension

Perioperative hypertension is associated with high morbidity and mortality in patients undergoing surgery, but using careful

management strategies and individualized treatments when necessary can optimize outcomes.

April 20, 2009 • Issue No. 15


According to recent estimates, approximately 72 million Americans suffer from hypertension, and the World Health Organization estimates

that a third of the global population will have hy-pertension by 2025. “About 1% to 2% of patients with hypertension will have a ‘hypertensive crisis’ in which they have an acute elevation of blood pressure [BP],” explains Joseph Varon, MD, FACP, FCCP, FCCM. “Many of these cases will occur in the pe-rioperative setting. Despite attempts to standardize approaches to perioperative hypertension, clinicians lack a consensus concerning treatment thresholds and appropriate therapeutic targets.”

The perioperative period, according to Dr. Varon, is unique with regards to hypertension. “Perioperative

hypertension has become remarkably common,” he says. “It’s estimated that about a quarter of people entering the operating room have preexisting hyper-tension [Table 1]. During surgical procedures, BP can become elevated in several ways. In some cases, it may result from the inappropriate administration of anesthesia. In others, it can occur through pain resulting from the procedure itself or from elevated levels of anxiety that patients may experience. BP lev-els may also rise postoperatively in cases where long-term antihypertensive medications are discontinued prior to surgery.”

Identifying Patients at RiskPrevious investigations have indicated that hyperten-



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sive events occur most commonly with carotid sur-gery, abdominal aortic surgery, peripheral vascular procedures, and intraperitoneal or intrathoracic sur-gery. Other procedures associated with perioperative

hypertension include neurosurgery, transplantations, and surgeries for major trauma or burns. “Periopera-tive hypertension is more common among patients undergoing cardiac surgery,” Dr. Varon says. “Hyper-tensive urgencies and emergencies occur in about half of patients during and immediately following cardiac surgery. In addition, any patient who has preexisting hypertension can get perioperative hypertension.”

When perioperative BPs are elevated or fluctuate considerably, studies have shown that patients are at

risk for poor outcomes and/or severe complications, including myocardial ischemia. Some investigations have demonstrated that patients who have chronic hypertension and diastolic BPs of 110 mm Hg or

higher are at risk for perioperative cardiac complica-tions. Patients with uncontrolled hypertension un-dergoing carotid endarterectomy have been shown to experience significantly more postoperative neu-rologic deficits than those with better control.

Manage Patients CarefullyConsidering the substantial risks associated with pe-rioperative hypertension, patients must be managed carefully, especially if they have known hypertension (Table 2). “The approach to treating perioperative hypertension is different than that of chronic hyper-tension,” Dr. Varon explains. “The initial approach to treatment is prevention. Many patients who de-velop postoperative hypertension do so as a result of their long-term antihypertensive regimens being withdrawn. This withdrawal of therapy should be minimized in the perioperative period.”

When treatment is necessary, therapy should be in-dividualized for each patient. “The goal is to avoid perioperative BP fluctuations,” says Dr. Varon. “Pa-tients on antihypertensive therapy should maintain compliance to their treatment regimens prior to sur-gery. This includes the morning of surgery. The only exclusion should be if patients are taking ACE in-hibitors and ARBs; that’s because this patient group is at risk for developing hypotension during surgery. However, in most cases, maintaining antihyperten-sive treatment regimens may contribute to fewer in-traoperative BP fluctuations.”

In general, Dr. Varon says treatment goals should be based on patients’ preoperative BP. “A conservative target would be about 10% to 15% above baseline, but more aggressive approaches to lowering BP may

Patients on antihypertensive therapy should maintain compliance to their treatment regimens

prior to surgery. This includes the morning of surgery.—Joseph Varon, MD, FACP, FCCP, FCCM

Table 1 A Closer Look at Perioperative Hypertension

• Acute hypertension is common after major surgery and may be associated with an increased risk of serious cardiac and neurologic complications.

• Perioperative hypertension occurs in 25% of hypertensive patients that undergo surgery.

- During surgery, patients with and without preexist-ing hypertension are likely to develop blood pressure elevations and tachycardia during the induction of anesthesia.

- Common predictors of perioperative hypertension include a previous history of hypertension, especially a diastolic blood pressure >110 mm Hg, and the type of surgery.

• Patients with a systolic blood pressure >180 mm Hg, or a diastolic blood pressure that is >115 mm Hg and evidence of end-organ dysfunction have a “hypertensive crisis,” a term referring to hypertensive emergencies.

- Hypertensive urgencies and emergencies occur in approximately 50% of patients during and immediately after cardiac surgery.

Source: Adapted from: Varon J, et al. Vasc Health Risk Manag. 2008;4:615-627.


be necessary for patients at very high risk of bleed-ing or for those with severe heart failure. To optimize safety and efficacy with perioperative hypertension treatments, it’s critical to carefully monitor responses to therapy and adjust therapies appropriately. After surgery, clinicians can safely transition patients to effective oral antihypertensive regimens so that the long-term risks of hypertension and cardiovascular diseases can be managed appropriately.”

New Therapeutics EmergingWhen selecting agents to control perioperative BP, Dr. Varon says that physicians should consider the clinical situation, patient characteristics, the setting of care, and the experience of the clinicians. “Many IV antihypertensive agents have emerged, provid-ing clinicians with the ability to optimize therapy based on specific needs and conditions. The agents selected should provide an immediate onset of action and have short or intermediate durations of action. They should also be easy to titrate precisely and have strong safety and efficacy profiles for treating peri-operative hypertension. Fortunately, newer agents—fenoldopam, nicardipine, and especially clevidipine, for example—have become valuable pharmacologi-cal additions. These therapies have been shown to reduce the number and extent of BP fluctuations. The hope is that clinicians will become more familiar with these therapies to help reduce the burden of pe-rioperative hypertension.”

Joseph Varon, MD, FACP, FCCP, FCCM, has indicated to Physician’s Weekly that he has worked as a consultant and paid speaker for The Medicines Company and EKR Pharmaceuticals. He has also received grants/research aid from The Medicines Company and EKR Pharmaceuticals. For more information on this article, including references, please visit: www.physweekly.com.

ReferencesVaron J, Marik PE. Perioperative hypertension management. Vasc Health Risk Manag. 2008;4:615-627. Available at: www.pubmedcentral.nih.gov/

Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care. 2003;7:374-384.

Rodríguez G, Varon J. Clevidipine: a unique agent for the critical care practitioner. Crit Care and Shock. 2006;9:37-41.

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003b;289:2560-2572.

Levy JH. The ideal agent for perioperative hypertension and potential cytoprotective effects. Acta Anaesthesiol Scand Suppl. 1993;99:20-25.

Bailey JM, Lu W, Levy JH, et al. Clevidipine in adult cardiac surgical patients: a dose-finding study. Anesthesiology. 2002;96:1086-1094.

Levy JH, Mancao MY, Gitter R, et al. Clevidipine effectively and rapidly controls blood pressure preoperatively in cardiac surgery patients: The results of the randomized, placebo-controlled efficacy study of clevidipine assessing its preoperative antihypertensive effect in cardiac surgery-1. Anesth Analg. 2007;105:918-925.

Table 2 Managing Patients With Perioperative Hypertension

General guidance for managing perioperative hypertension:

• Should be based on the patient’s preoperative blood pressure (BP).

- Conservative targets would be approximately 10% to 15% above baseline.

- More aggressive approaches to lowering BP may be warranted for patients at very high risk of bleeding or with severe heart failure who would benefit from afterload reduction.

• Careful monitoring of patient response to therapy and adjustment of treatment are paramount.

• After surgery, clinicians can transition patients to an effective oral antihypertensive regimen to manage long-term risks.

Considerations for potential courses of treatment:

• Clinicians should attempt to balance the risks associated with hypertension versus the risk of end organ hypoperfusion that may accompany antihypertensive therapy.

• When treatment is necessary, therapy should be individualized.

• The choice of agent in specific cases should be determined by the:

- Clinical situation.

- Patient’s characteristics.

- Setting of care.

- Experience of the clinicians.

• A wide selection of available IV antihypertensive agents has provided clinicians with the ability to optimize therapy based on the specific situational needs.

Source: Adapted from: Varon J, et al. Vasc Health Risk Manag. 2008;4:615-627.

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J. Thomas Bigger, Jr., MD, FAAN, FAASMProfessor of MedicineProfessor of Pharmacology Columbia University College of

Physicians and SurgeonsMedical Director, Clinical Trials Network Columbia University Medical Center New York-Presbyterian Hospital

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A scientific advisory statement has been published to help physicians in the screening, diagnosis, and treatment of

depression among cardiac patients.

March 9, 2009 • Issue No. 10


Published studies have shown that 15% to 20% of patients with myocardial infarction meet the Diagnostic and Statistical Manual of Mental Dis

orders criteria for major depression and even more experience depressive symptoms. The current litera-ture has also documented an association between de-pression among patients with coronary heart disease (CHD) and higher healthcare costs, impaired quality of life, poor adherence to medication and lifestyle guidelines, and a doubling of the mortality rate. De-spite its high prevalence, detection and treatment of depression among CHD patients have been sub-optimal. To address this issue further, the American Heart Association has released a science advisory for clinicians, which recommends systematic screening for depression in CHD patients. The new advisory, which was published in the October 21, 2008 issue of Circulation, was also endorsed by the American Psychiatric Association.

“Depression worsens the prognosis for CHD pa-tients because it can lead to poorer adherence to critical prevention guidelines,” explains J. Thomas

Bigger, Jr., MD, FAAN, FAASM, an author of the new advisory. “Compliance with cardiac drugs that are recommended by guidelines reduce mortality by about 50%, but these benefits won’t be realized if patients fail to adhere to their cardiac medica-tions and lifestyle recommendations. Depression can substantially reduce compliance with cardiac drugs regimens, causing patients to lose the benefits of known therapies.”

A Helpful Screening AlgorithmDr. Bigger says that screening for depression is criti-cal among patients, especially those with CHD. “Depression can’t be managed if clinicians aren’t aware that patients have it,” he says. The scientific advisory statement helps guide physicians in screen-ing cardiac patients for depression, and it created an algorithm for clinicians (Figure). The statement recommends that clinicians use the Patient Health Questionnaire (PHQ)-2 to identify currently de-pressed patients because the survey can be adminis-tered quickly and easily (Table). If the answer is “yes”

Screening for Depression in Cardiac Patients



14

to one or both questions of the first two questions, it is then recommended that all 9 items in the PHQ be answered. Patients with screening scores that indicate a high probability of depression—meaning a PHQ-9 score of 10 or higher—should be referred for a more comprehensive clinical evaluation by a professional qualified to evaluate and determine a suitable individualized treatment plan for depres-sion. “Furthermore,” Dr. Bigger says, “the statement recommends early and repeated screening for depres-sion in cardiac patients.”

Implications for Physicians & PatientsAccording to research, the risks of not treating de-pression during or soon after acute coronary syn-dromes and the benefits of depression treatments have not been widely appreciated by cardiologists. “Depression has a substantial impact on adherence to life-saving cardiovascular drugs recommended in clinical guidelines, but too few physicians make this

connection,” says Dr. Bigger. “The key is to develop and utilize depression screening/treatment systems for CHD patients that are both efficient and effec-tive. The hope is that the recommendations made in the scientific advisory statement can enable physi-cians to optimize outcomes for patients.”

Typically, after an acute coronary event, MI pa-tients and those with CHD will experience a peak in depressive symptoms. Some physicians, according to Dr. Bigger, may have been averse to routinely screen-ing their patients for depression because they feel that it is a “normal” reaction to a stressful life event. “Other clinicians believe that the symptoms often diminish over time or they simply don’t have the training required to properly treat a cardiac patient with a positive diagnosis of depression.”

Recent data have demonstrated that sertraline and citalopram are very safe and moderately effective antidepressant therapies for patients with CHD, and

Refer for more comprehensive clinical evaluation by a professionalqualified in the diagnosis and management of depression

Determine appropriate treatment (antidepressants,cognitive behavioral therapy, or adjunctive interventions)

Carefully monitor for treatment adherence,drug efficacy, and safety

At a minimum, screen with 2-item PHQ-2

If “Yes” to either question

Screen with PHQ-9

Emergencydepartment

If safe At risk

If “Yes” to Q.9 “Suicidal,”immediate evaluationfor acute suicidality

Minimal symptomsof short duration

(PHQ-9 score <10)

Mild to moderate,uncomplicated

(PHQ-9 score 10-19)

Major depression(PHQ-9 score ≥20)

Support, education,follow-up within

1 month

If symptomspersist or worsen

Figure A Depression Screening Algorithm for CHD Patients

Abbreviations: CHD, coronary heart disease; PHQ, Paitnet Health Questionnaire

Source: Adapted from: Lichtman JH, et al. Circulation. 2008. 2008; 118:1768-1775.


the scientific advisory recommends that these agents be used as first-line therapies for this patient group. Patients with recurrent depression who previously tolerated and responded well to another antidepres-sant may continue taking it unless it is contraindi-cated because CHD has developed.

“The biggest barrier to managing coincident heart disease and depression is the need for coordination between cardiology/medical personnel and mental health personnel,” says Dr. Bigger. “These groups need to form an integrated management team to optimize benefits for patients. Cardiologists should communicate with the physicians who are respon-dsible for providing therapies for mental health to make them aware of cardiovascular developments and new therapies as well as to seek their advice on patient management. Additionally, depressed patients may benefit from close family monitoring and sup-port of compliance-strengthening procedures. More frequent office visits, phone calls, e-mails, and other messaging modalities should be used to improve adherence to the cardiac therapeutic regimen as well as to improve clinical and behavioral outcomes.”

J. Thomas Bigger, MD, FAAN, FAASM, has indicated to Physician’s Weekly that he has worked as a consultant for Merck & Co, Inc and that he has received research support from the NHLBI, the NIH, and the Dana Foundation. For more information on this article, including references, please visit: www.physweekly.com.

ReferencesLichtman JH, Bigger JT, Blumenthal JA, et al. Depression and coronary heart disease. Recommendations for screening, referral, and treatment. A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2008;118:1768-1775.

Whooley MA, Simon GE. Managing depression in medical outpatients. N Eng J Med. 2000;343:1942-1950.

Glassman AH, O’Connor CM, Califf RM, et al; Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) Group. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288:701-709.

Taylor CB, Youngblood ME, Catellier D, et al; ENRICHD Investigators. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry. 2005;62:792-798.

Lespérance F, Frasure-Smith N, Koszycki D, et al; CREATE Investigators. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA. 2007;297:367-79.

Table PHQ-9* Depression Screening ScalesOver the past 2 weeks, how often have you been bothered by any of the following problems?

• Little interest or pleasure in doing things.

• Feeling down, depressed, or hopeless.

• Trouble falling asleep, staying asleep, or sleeping too much.

• Feeling tired or having little energy.

• Poor appetite or overeating.

• Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down.

• Trouble concentrating on things such as reading the newspaper or watching television.

• Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual.

• Thinking that you would be better off dead or that you want to hurt yourself in some way.

*Questions are scored: not at all=0; several days=1; more than half the days=2; and nearly every day=3. Add together the item scores to get a total score for depression severity.

Source: Adapted from: Lichtman JH, et al. Circulation. 2008;118:1768-1775.

16

Preventing CVD in Women: A Focus on Lifetime Risk & LifestyleUpdated guidelines emphasize the lifetime risk for cardiovascular disease in women and offer a new direction for using aspirin, hormone therapy, and vitamin and mineral supplements in the prevention of heart disease and stroke.

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In 1999, the American Heart Association (AHA) published its first Guide to Preventive Cardiology in Women. The guide synthesized the most recent

clinical research data and highlighted unique aspects of risk factor management in women.

Subsequently, in 2003, a systematic review was con-ducted, and evidence-based guidelines for the pre-vention of cardiovascular disease (CVD) in women were released. Since that time, numerous clinical tri-als have been conducted to evaluate differences that exist between men and women in relation to CVD diagnosis and prevention.

A 2007 guideline update provides the most cur-rent clinical recommendations for preventing CVD in women aged 20 and older. They are based on a systematic search of the highest quality science in-terpreted by experts in the fields of cardiology, epi-

demiology, family medicine, gynecology, internal medicine, neurology, nursing, public health, statis-tics, and surgery. The 2007 Guidelines for Preventing Cardiovascular Disease in Women were published in a special women’s health issue of Circulation on March 20, 2007.

The new guidelines offer several important changes from its predecessors (Table 1). Lori Mosca, MD, PhD, who chaired the AHA panel that wrote the guidelines, explains that “the experts wanted to em-phasize the importance of lifestyle and preventing risk factors in the first place so that more aggressive inter-ventions are reserved for the highest-risk women.”

Risk Assessment Most notably, the 2007 guidelines include a new par-adigm for risk assessment, which merges traditional


Lori Mosca, MD, PhDProfessor of MedicineDirector, Preventive Cardiology New York-Presbyterian Hospital Columbia University Medical Center


January 19, 2009 • Issue No. 3



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assessments based on the Framingham risk score with risk factors and family history (Table 2). Some women are at increased risk of heart attack or stroke because they already have CVD and/or multiple risk factors. Others, however, may have subclinical evidence for CVD, such as coronary calcification, but are not classified as intermediate- or high-risk patients based upon Framingham risk calculation alone.

“Appropriate risk stratification in clinical practice is critical because it’s used to help guide therapy,” Dr. Mosca says. “It’s our hope that the new risk assess-ment paradigm will help capture all at-risk women who are in need of preventive interventions.”

Prevention Throughout LifeThe public health impact of CVD in women is not solely related to mortality, as advances in science and medicine allow many women to survive heart disease. For example, 42 million, or about 37%, of American women live with CVD, and the population consid-

ered to be “at risk” is even larger. “Nearly all women are at risk for CVD, underscoring the importance of living a heart-healthy lifestyle,” says Dr. Mosca.

In addition, the new guidelines include expanded rec-ommendations on modifiable lifestyle factors. These include guidance on physical activity, nutrition, and smoking cessation, and more in-depth recommenda-

tions are available on drug treatments for blood pres-sure and cholesterol control.

Major Guideline ChangesLastly, recommendations for hormone therapy, aspi-rin therapy, antioxidants, and folic acid supplements have been revised based on recently published data. “Since the last guidelines were developed, more de-finitive clinical trials have become available,” Dr. Mosca says. “Healthcare providers should consider aspirin in women to prevent stroke, carefully weigh-ing the potential benefits and risks. However, for the

Source: Adapted from: Mosca et al. Circulation. 2007;115:1481-501.

Table 1 Highlighting Major Guideline Changes• Lifestyle changes to help manage blood pressure include

weight control, increased physical activity, alcohol mod-eration, sodium restriction, and an emphasis on eating fresh fruits, vegetables, and low-fat dairy products.

• Besides advising women to quit smoking, counseling, nicotine replacement, or other forms of smoking cessa-tion therapy are recommended.

• Women who need to lose weight or sustain weight loss are recommended to partake in a minimum of 60-90 minutes of moderate-intensity activity (eg, brisk walking) on most (preferably all) days of the week.

• All women should reduce saturated fat intake to less than 7% of calories if possible.

• Oily fish should be consumed at least twice a week.

• Women with heart disease should consider taking 850-1,000 mg supplements of eicosapentaenoic acid and docosahexaenoic acid.

• Women with high triglycerides should consider 2-4 g supplements of eicosapentaenoic acid and docosahexaenoic acid.

• LDL cholesterol levels should be below 70 mg/dL in very high-risk women with heart disease. This may require a combination of cholesterol-lowering drugs.

• Low-dose aspirin therapy should be considered in women aged 65 and older regardless of CVD risk status if benefits are likely to outweigh other risks and blood pressure is controlled.

• Hormone replacement therapy and selective estrogen receptor modulators are not recommended to prevent heart disease in women.

• Antioxidant supplements (eg, vitamins E and C and b-carotene) should not be used for primary or secondary prevention of CVD.

• Folic acid should not be used to prevent CVD.

Appropriate risk stratification in clinical practice is critical because it’s used to help guide therapy.

—Lori Mosca, MD, PhD


prevention of heart disease, aspirin therapy is recom-mended for those aged 65 and older, independent of risk level, when the benefits outweigh the risks. Furthermore, providers shouldn’t use menopausal therapies such as hormone replacement therapy or selective estrogen receptor modulators (eg, raloxifene or tamoxifene) to prevent heart disease. These thera-pies have been shown to be ineffective in protecting the heart and may actually increase the risk of some types of stroke.”

A recent AHA survey showed that many women are confused about methods to prevent heart disease and about the role of aspirin, hormones, and dietary sup-

plements. “The new guidelines clarify the role of di-etary supplements and other agents,” says Dr. Mosca. “They reinforce the methods that have proven to be ineffective and potentially harmful among women in their fight against heart disease.”

Lori Mosca, MD, PhD, has indicated to Physician’s Weekly that she has served as a consultant and is on the advisory board/speaker’s bureau for Abbott Laboratories, Anthera, Eli Lilly Research Laboratories, McNeil Consumer Healthcare, Merck, Organon, Pfizer Inc., ScheringPlough, Unilever, Waterfront Media, and WyethAgmen. For more information on this article, including references, please visit: www.physweekly.com.

ReferencesMosca L, Banka CL, Benjamin EJ, et al. 2007 Update: American Heart Association evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2007;115:1481-501.

Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109:672-693.

Mosca L, Grundy SM, Judelson D, et al. Guide to preventive cardiology for women. Circulation. 1999;99:2480-2484.

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.

Mosca L, Mochari H, Christian AH, et al. National study of women’s awareness, action, and barriers to cardiovascular health. Circulation. 2006;113:525-534.

Anderson GL, Limacher M, Assaf AR, et al; Women’s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA. 2004;291:1701-1712.

Source: Adapted from: Mosca et al. Circulation. 2007;115:1481-501.

Table 2 Classifying CVD Risk in WomenRisk Status

High Risk

At Risk

Optimal Risk

Criteria

• Established coronary heart disease

• Cerebrovascular disease

• Peripheral arterial disease

• Abdominal aortic aneurysm

• >1 major risk factor for CVD including:

- Cigarette smoking

- Poor diet

- Physical inactivity

- Obesity, especially central adiposity

- Family history of premature CVD (CVD at <55 years of age in male relative and <65 years of age in female relative)

• Framingham global risk <10% and a healthy lifestyle with no risk factors

• End-stage or chronic renal disease

• Diabetes mellitus

• 10-Year Framingham global risk >20%

- Hypertension

- Dyslipidemia

- Evidence of subclinical vascular disease

- Metabolic syndrome

- Poor exercise capacity on treadmill test and/or abnormal heart rate recovery after stopping exercise

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