New Guidelines on Women's Heart Risk

American Heart Association Warns of Heart Attack Risk for Women With Some Pregnancy Complications

By Denise Mann
WebMD Health News

Reviewed by Laura J. Martin, MD

Feb. 15, 2011 -- Women who have been diagnosed with preeclampsia, pregnancy-induced hypertension, or diabetes during pregnancy are now considered at risk for heart attack or stroke going forward, according to newly updated guidelines from the American Heart Association (AHA).

The 2011 update to the AHA's cardiovascular prevention guidelines for women recategorizes a woman's risk for heart disease. It also serves up some gender-specific prevention advice on diet and daily aspirin therapy in women at high risk of coronary heart disease in order to prevent heart attacks.

The guidelines are being published in the journal Circulation and are based on expert reviews of the medical literature.

Women are now classified in three groups: high risk for heart disease, at risk, or ideal cardiovascular health. The high-risk group changed little from previous years and includes women with established heart disease, chronic kidney disease, or diabetes, among other risk factors.

But "the at-risk group now captures women with pregnancy complications such as preeclampsia, gestational diabetes, or pregnancy-induced hypertension," says guideline chair Lori Mosca, MD, PhD. Mosca is director of preventive cardiology at New York-Presbyterian Hospital and a professor of medicine at Columbia University Medical Center in New York City.

"These complications are the equivalent of a failed stress test," she says. Doctors use exercise stress tests to diagnose heart disease.

"If you do develop one of these conditions during pregnancy, it is an unmasking of the risk that tells us your vascular system doesn't function ideally," Mosca says.

"These complications are an opportunity to detect early that there is a problem," she says. You can then follow up with your primary care doctor to evaluate your overall cardiac risk and quickly start appropriate prevention strategies.

"If you developed gestational diabetes, follow up and say, 'What can I do to prevent heart disease and diabetes?'" she says. Your doctor may recommend weight loss, aggressive lifestyle changes, and possibly medication, she says. "We are unmasking a problem early so that we can prevent full-blown cardiovascular disease."

Educating Women About Heart Risk

The new information about pregnancy complications and heart risk is "a big deal," says guideline author Ileana L. Piña, MD, a professor of medicine and epidemiology and biostatistics at Case Western Reserve University in Cleveland.

"Your blood pressure may return to normal after pregnancy and your blood sugar may return to normal too, but don't ignore these symptoms," she says.

Some of the onus about getting the word out about pregnancy complications and heart risks falls on ob-gyns, says Mary Rosser, MD, PhD, an assistant professor in the department of obstetrics and gynecology and women's health at Montefiore Medical Center in the Bronx, N.Y.

"We are seeing younger women and providing their primary care [and] we can make an impact," she says.

"When I see patients with gestational diabetes, I say even though you are thin, you are still at risk for developing diabetes later on in life so you need to stay on top of this," she says.

Other inflammatory diseases such as rheumatoid arthritis (RA) and lupus also place a woman at risk for heart disease, according to the updated guidelines.

Diseases like RA and lupus are more common in women and sometimes have heart disease manifestations.

Dietary Recommendations for Women

While the new guidelines cast a wider net to catch women at risk for heart disease, they also call for aggressive steps to control known risk factors such as high blood pressure and obesity.

For example, the guidelines call for less than 1,500 milligrams of salt per day for all women. Sugar is limited to five or fewer servings per week.

"We have a lot more data that the sodium content of food in America is too high and the prevalence of hypertension in this country is also high," Piña says. "We believe that lowering sodium content can markedly lower blood pressure, particularly among African-American women whose hypertension is salt-sensitive."

As for sugar, "the high content of sugar in foods is more fodder for the current obesity epidemic and obesity is highly correlated with the onset of diabetes and metabolic syndrome," she says. Metabolic syndrome is a cluster of risk factors linked to development of heart disease. "Cutting down on sugar will aid in weight loss, lower blood sugar, and your cholesterol will also go down," she says.

"It is a bit radical, especially the sodium intake," says Suzanne Steinbaum, MD, director of women and heart disease at Lenox Hill Hospital in New York City. Steinbaum reviewed the guidelines for WebMD but did not serve on the writing committee.

"The sugar issue is in response to the obesity epidemic and is a way to get women to pay attention to the effects of sugars on the metabolic syndrome and weight gain," she says.

The updated guidelines also state that folic acid and antioxidant vitamins such as vitamin E, C, and beta-carotene should not be used to prevent cardiovascular disease in women. What's more, hormone replacement therapy should not be used to prevent heart attacks or strokes.


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"If you eat a healthy diet, you don't need supplements," Steinbaum says. "Folic acid may reduce levels of homocysteine, but it does not seem to translate to a lower risk for heart disease." Homocysteine is an amino acid in blood that had been linked to heart risk.

Aspirin and Women

Daily aspirin therapy prevents a recurrent problem in men and women who already have heart disease, Mosca says. But "there is softening of the guidelines when it comes to aspirin as a way of preventing heart disease in otherwise healthy women."

"The decision about aspirin should take into consideration if she has controlled blood pressure or any risk of gastrointestinal bleeding because these are aspirin side effects that are very common and we don't want doctors to just jump on it and tell all women to take an aspirin a day," she says.

"We now understand that while women have been shown to respond similarly to men for many interventions, they may have different side effect profiles," she says. Many women are not taking medications as prescribed or recommended because of side effects or fear of side effects.

"There is a real call in the guidelines for scientists and policy makers to have data by gender for positive and negative side effects," Mosca says.

The bottom line is clear. "You do not need to develop heart disease no matter what your family history is," Steinbaum says. "You need to live a healthy life and if you watch your risk factors, exercise and eat a healthy diet, heart disease doesn't need to happen to you."

Piña agrees. "Know your risk. Find out your cholesterol and blood pressure numbers and where they should be, and take control."

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SOURCES: Mosca, L. Circulation, 2011.Lori Mosca, MD, PhD, director, preventive cardiology, New York-Presbyterian Hospital, New York City.Ileana L. Piña, MD, professor of medicine and epidemiology and biostatistics, Case Western Reserve University, Cleveland.Suzanne Steinbaum, MD, director, women and heart disease, Lenox Hill Hospital, New York City.Mary Rosser, MD, PhD, assistant professor, department of obstetrics and gynecology and women's health, Montefiore Medical Center, Bronx, N.Y.

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