CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 3, May/June 2011
120
AFRICA
has remained unchanged. Other class III interventions that also
remain unchanged include the use of antioxidant supplements
such as vitamins E, C and beta-carotene, and folic acid with or
without vitamin B
6
and B
12
supplementation. The routine use of
aspirin in healthy women under 65 years of age is not recom-
mended to prevent MI.
In 2004, the Global Risk Assessment was advocated to
stratify patients’ CHD risk. It utilises the Framingham risk score,
whereby, based on the level of risk, drug therapy for hypercho-
lesterolaemia is advised, according to the National Cholesterol
Education Panel Adult Treatment Panel III (NCEP ATP III)
targets.
In the 2007 update of these guidelines, emphasis was placed
on pre-clinical detection of disease to identify asymptomatic
individuals at high risk who could benefit from early interven-
tion.
13
A new algorithm for risk classification was adopted that
stratified women into three categories. Women at ‘high risk’ are
those with documented CVD (such as established CHD, cerebro-
vascular disease, peripheral arterial disease or abdominal aortic
aneurysm), DM, chronic kidney disease, or a 10-year predicted
risk for CHD of 20% or more. ‘At-risk’ women have one or
more major CVD risk factors [such as cigarette smoking, poor
diet, physical inactivity, obesity (particularly central adiposity),
family history of premature CVD (male relative below 55 years
or female relative below 65 years), hypertension, dyslipidaemia,
evidence of subclinical vascular disease (e.g. coronary calcifica-
tion), metabolic syndrome, poor exercise capacity on treadmill
test, and abnormal heart rate recovery after stopping exercise].
Women are regarded as ‘at optimal risk’ if they have no major
CVD risk factors and engage in a healthy lifestyle.
Despite these guidelines, there are problems with risk strati-
fication of women. There is a general underestimation of CHD
risk, which has focused on short-term (10-year) risk and on MI
and CHD death. Women with a high prevalence of subclinical
disease are scored as low risk.
6,14
In non-Caucasian populations
there are problems of risk estimation, and in the elderly there is
also an underestimation of risk. A woman aged 75 years with
several risk factors will score below a 10% 10-year predicted
risk for CHD.
15,16
Few women qualify for lipid-lowering therapy
for prevention of CHD.
In the most recent updated 2011 guidelines, these anomalies
have been addressed.
17
The focus is now on long-term risk for
CVD rather than solely on 10-year risk for CHD. The new cut-
off point for defining ‘high risk’ is a risk of 10% or more of death
from any cardiovascular event in the next 10 years (previously it
was 20% or more). Other modifications include the use of new
risk-stratification scores (the updated Framingham CVD risk
profiles and the Reynolds risk score for women).
18,19
New major
risk categories are patients with systemic autoimmune collagen
vascular disease (such as systemic lupus erythematosus and
rheumatoid arthritis) as these disorders are known to be associat-
ed with a significantly increased relative risk for CVD.
20
Women
with a history of pre-eclampsia, gestational DM or pregnancy-
induced hypertension are also deemed to be at major risk.
21,22
When assessing risk, it is advised that the use of CVD risk
biomarkers (such as ultra-sensitive C-reactive protein) and imag-
ing technologies (such as coronary calcium-scoring assessment
and carotid intima–media thickness) be reserved for refining risk
estimates in patients where there is uncertainty about the need to
start statin therapy.
23,24
The 2011 guidelines also focus on stroke and heart failure.
As women age, their risk for stroke and HF tends to increase in
excess of the risk for CHD.
A new concept of ‘ideal cardiovascular health’ has been
proposed and should be adhered to in all women. This is the
absence of clinical CVD and the presence of ideal levels of
total cholesterol (
<
5.2 mmol/l), untreated blood pressure less
than 120/80 mmHg, untreated fasting blood glucose less than
5.6 mmol/l, body mass index less than 25 kg/m
2
, and a lifestyle
that includes smoking abstinence and physical activity (for
adults aged 20 years or more of at least 150 minutes per week
of moderate-intensity exercise, and at least 75 minutes per week
of vigorous-intensity exercise, or a combination of both). When
achieved or maintained into middle age, the overall pattern of
ideal cardiovascular health is associated with greater longevity,
reduction in risks for CVD events and greater quality of life in
older age.
25
In the new millennium, there is no longer any doubt about
what strategies and treatment are required to reduce CVD in
women. The major hurdle is to implement these guidelines early.
This is particularly so in low- and middle-income countries. If
we are to have any impact on the looming pandemic of CVD in
the developing world, such as sub-Saharan Africa, we should not
hesitate to adopt these updated guidelines.
NAOMI RAPEPORT, MB BCh (Wits), FCP (SA), FACP, FACP
(Hon),
Milpark Hospital, Johannesburg, South Africa
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