Heart disease is the number one killer of women in the United States and accounted for over half a million deaths in women in 1998. When comparing this staggering statistic to deaths due to all forms of cancer, which killed half as many women that same year, cardiovascular disease (CVD) should be a primary health concern for women today. This issue of Advanced Studies in Medicine covers the proceedings of the National Summit for Cardiovascular Care in Women, which was held in Santa Barbara, California, August 3 - 5, 2001. The primary objectives of this summit were: (1) improving cardiovascular care in women, in particular preventive cardiology, (2) understanding the unmet need in cholesterol-lowering therapy, (3) identifying risk factors in women and improving the management of these factors, and (4) developing optimum lipid management strategies.
Morbidity and mortality benefits of lipid-lowering therapy have been well documented in primary and secondary prevention studies. However, as Carla Sueta, MD, PhD, University of North Carolina, points out in her article, the results of these trials have not been fully implemented in clinical practice. In patients with coronary artery disease the prescription rate for lipid-lowering agents is as low as 39%. Equally important is the statistic that only about half of these patients are achieving goal low-density lipoprotein (LDL) levels. In addition, studies have shown that diabetic patients are 20% less likely to receive lipid-lowering therapy than those without diabetes, despite the fact that diabetes is a well-known risk factor for CVD. An improvement in lipid management currently observed in clinical practice needs to be made in order to reduce cardiovascular mortality.
Appropriate lipid management in all patients, including women, involves many aspects including the education of physicians treating such patients. Part of this educational effort includes the establishment of clinical practice guidelines. The National Cholesterol Education Program Adult Treatment Panel (ATP) recently released their third report updating clinical guidelines for cholesterol testing and management (ATP III). Several important changes were made from previous ATP II guidelines in the development of ATP III including the introduction of coronary heart disease (CHD) risk equivalents, discussion of the metabolic syndrome, establishment of non-high-density lipoprotein goals, and Framingham risk projections to identify higher risk primary prevention patients. In this issue, Karol Watson, MD, PhD, Co-Director, Lipid Clinic, University of California at Los Angeles, discusses the ATP III guidelines. New target LDL goals are defined as <100 mg/dL for patients with established CVD as well as those determined to be a CHD risk equivalent. As Dr Watson mentions in her article, changes in ATP III may classify more patients as qualifying for more aggressive therapy and such therapy may be initiated earlier than under ATP II.
As stressed in ATP III, the primary prevention of CHD is grounded in lifestyle changes such as:
(1) reduced intake of saturated fact and cholesterol, (2) increased physical activity, and (3) weight control. The adoption of ATP III warrants aggressive treatment of hyperlipidemia. Therefore, the addition of drug treatment should be considered when these lifestyle changes prove insufficient in meeting LDL goals. Lipid levels should be followed every 6-12 weeks so that alterations to the pharmacologic regimen may be performed as necessary. Currently, 4 different classes of lipid-lowering agents are available: statins, nicotinic acid, fibric acid derivatives, and bile acid sequestrants. In addition, cholesterol absorption inhibitors represent a new class of agents currently under investigation. Perhaps due to the relatively flat dose-response curve of statins, several landmark secondary prevention trials evaluating statin monotherapy did not meet the ATP III LDL goal of <100 mg/dL. Combination therapy with statins and niacin or bile acid sequestrants has demonstrated greater reduction in LDL levels than with statin monotherapy. As Sandra Lewis, MD, Director of Research, Portland Cardiovascular Institute, points out in her article, specific patient characteristics must be considered in selecting the most appropriate lipid-lowering agent. For example, concurrent medical history, concomitant medications, and childbearing potential must be evaluated in women prior to initiating therapy.
In any effort to reduce cardiovascular events, it is critical that barriers to optimal lipid management be identified and eliminated. Lori Mosca, MD, PhD, MPH, Director, Preventive Cardiology, New York Presbyterian Hospital, outlines patient, physician, health system, and societal barriers to achieving lipid goals. Patients need to recognize the need for reducing CVD risk including lifestyle changes and lipid management. While both men and women are impacted with a variety of barriers, some are specific to women. A general lack of awareness of the importance of CVD as a primary cause of morbidity and mortality in women is an important barrier in preventive cardiology. In general, risk reduction efforts for women need to target self-esteem, stress management, time, knowledge, and skills; however, treating physicians need to individualize intervention strategies in order to achieve maximal benefit.
In addition to the 4 articles presented in this issue, some of the latest literature has focused on CVD in women. Recent study has demonstrated that physical activity and physical fitness provide cardiovascular benefits in men as well as women including positive effects on blood pressure, lipid metabolism, insulin resistance, and obesity. In addition, men have been found to be more likely than women to be compliant to a healthy lifestyle before and after coronary artery bypass graft surgery. The selected abstracts that conclude this issue of Advanced Studies in Medicine address those and other topics focusing on the subject of cardiovascular health in women.
The fact that CVD is an important public health issue for both men and women is undeniable. In order to reduce morbidity and mortality associated with CVD more aggressive lipid management strategies should be initiated. In addition, barriers to achieving lipid goals in all patients need to be addressed.
*Director of Preventive Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.