Evaluation of the American Heart Association cardiovascular disease prevention guideline for women.

BACKGROUND: The 2007 update to the American Heart Association (AHA) guidelines for cardiovascular disease prevention in women recommend a simplified approach to risk stratification. We assigned Women's Health Initiative participants to risk categories as described in the guideline and evaluated clinical event rates within and between strata. METHODS AND RESULTS: The Women's Health Initiative enrolled 161 808 women ages 50 to 79 years and followed them prospectively for 7.8 years (mean). Applying the 2007 AHA guideline categories, 11% of women were high risk, 72% at-risk, and 4% at optimal risk; 13% of women did not fall into any category, that is, lacked risk factors but did not adhere to a healthy lifestyle (moderate intensity exercise for 30 minute most days and <7% of calories from saturated fat). Among high risk, at-risk, and optimal risk women, rates of myocardial infarction/coronary death were 12.5%, 3.1%, and 1.1% per 10 years (P for trend <0.0001); the event rate was 1.3% among women who could not be categorized. We observed a graded relationship between risk category and cardiovascular event rates for white, black, Hispanic, and Asian women, although event rates differed among ethnic groups (P for interaction=0.002). The AHA guideline predicted coronary events with accuracy similar to current Framingham risk categories (area under receiver operating characteristic curve for Framingham risk, 0.665; for AHA risk, 0.664; P=0.94) but less well than proposed Framingham 10-year risk categories of <5%, 5% to 20%, and >20% (area under receiver operating characteristic curve for Framingham risk, 0.724; for AHA risk, 0.664; P<0.0001). CONCLUSIONS: Risk stratification as proposed in the 2007 AHA guideline is simple, accessible to patients and providers, and identifies cardiovascular risk with accuracy similar to that of the current Framingham algorithm. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00000611.

Abdominal aortic aneurysm events in the women's health initiative: cohort study.

OBJECTIVE: To assess the association between potential risk factors and subsequent clinically important abdominal aortic aneurysm events (repairs and ruptures) in women. DESIGN: Large prospective observational cohort study with mean follow-up of 7.8 years. SETTING: 40 clinical centres across the United States. PARTICIPANTS: 161 808 postmenopausal women aged 50-79 enrolled in the women's health initiative. MAIN OUTCOME MEASURES: Association of self reported or measured baseline variables with confirmed abdominal aortic aneurysm events assessed with multiple logistic regression. RESULTS: Events occurred in 184 women and were strongly associated with age and smoking. Ever smoking, current smoking, and amount smoked all contributed independent risk. Diabetes showed a negative association (odds ratio 0.29, 95% confidence interval 0.13, 0.68), as did postmenopausal hormone therapy. Positive associations were also seen for height, hypertension, cholesterol lowering treatment, and coronary and peripheral artery disease. CONCLUSIONS: Our findings confirm the strong positive associations of clinically important abdominal aortic aneurysm with age and smoking in women and the negative association with diabetes previously reported in men.

The Therapeutic Implications of Left Ventricular Hypertrophy in the Hypertensive Patient.

Hypertension can be considered a syndrome broader than the condition of an increased blood pressure per se. Epidemiologic studies have established that high blood pressure is associated with an increased risk of cardiovascular events. Clinical trials of antihypertensive therapy have failed to show a consistent reduction in cardiovascular endpoints. The incidence of coronary disease has been reduced minimally, suggesting that factors beyond just measuring mm Hg in the hypertensive may be important in the genesis of atherosclerotic disease in hypertensive patients. Patients with hypertension appear to have an exaggerated vulnerability to the consequences of lipid abnormalities. In addition, hypertension is associated with insulin resistance and altered glucose tolerance. The increased plasma concentrations of insulin may produce proliferative effects on vascular smooth muscle and connective tissue, and these changes may adversely affect vascular integrity, leading to hypertrophy and facilitation of the arthersclerosis process. The left ventricle also appears to be involved in hypertension and this involvement may be independent of blood pressure. An increase in the muscle mass of the left ventricle as well as changes in its diastolic-filling characteristics occur early on with hypertension and may contribute to an adverse cardiovascular outcome. The arterial circulation is also involved. Alterations in structure or function of the vascular tree are reflected in diminished arterial compliance. These changes can be demonstrated prior to the appearance of clinical manifest hypertension. Based on these observations, treatment designed to reduce cardiovascular risk in hypertensive patients from cardiovascular events must not be based on blood pressure reduction alone but must take into account all the components of the hypertension syndrome.