Skip to main content

Advertisement

Log in

Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

Current Cardiovascular Risk Reports Aims and scope Submit manuscript

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among women. Despite improvements in cardiovascular disease prevention efforts, there remain gaps in cardiovascular disease awareness among women, as well as age and racial disparities in ASCVD outcomes for women. Disparity also exists in the impact the traditional risk factors confer on ASCVD risk between women and men, with smoking and diabetes both resulting in stronger relative risks in women compared to men. Additionally there are risk factors that are unique to women (such as pregnancy-related factors) or that disproportionately affect women (such as auto-immune disease) where preventive efforts should be targeted. Risk assessment and management must also be sex-specific to effectively reduce cardiovascular disease and improve outcomes among women. Evidence supports the use of statin therapy for primary prevention in women at higher ASCVD risk. However, some pause should be given before prescribing aspirin therapy in women without known ASCVD, with most evidence supporting the use of aspirin for women ≥65 years not at increased risk for bleeding. This review article will summarize (1) traditional and non-traditional assessments of ASCVD risk and (2) lifestyle and pharmacologic therapies for the primary prevention of ASCVD in women.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med. 2007;356(23):2388–98. doi:10.1056/NEJMsa053935.

    Article  CAS  PubMed  Google Scholar 

  2. Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169(19):1762–6. doi:10.1001/archinternmed.2009.318.

    Article  PubMed  Google Scholar 

  3. Wenger NK. Transforming cardiovascular disease prevention in women: time for the Pygmalion construct to end. Cardiology. 2015;130(1):62–8. doi:10.1159/000370018.

    Article  PubMed  Google Scholar 

  4. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129(3):399–410. doi:10.1161/01.cir.0000442015.53336.12.

  5. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123(11):1243–62. doi:10.1161/CIR.0b013e31820faaf8. In 2004, the AHA, in collaboration with numerous other organizations, first undertook a systemic and critical review of the literature regarding the primary prevention of ASCVD specifically among women and published female-specific clinical recommendations. These guidelines were updated in 2007 and again in 2011.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Gholizadeh L, Davidson P. More similarities than differences: an international comparison of CVD mortality and risk factors in women. Health care Women Int. 2008;29(1):3–22. doi:10.1080/07399330701723756.

    Article  PubMed  Google Scholar 

  7. Wilmot KA, O'Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation. 2015;132(11):997–1002.

  8. Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb KJ. Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. Circ Cardiovasc Qual Outcomes. 2010;3(2):120–7. doi:10.1161/CIRCOUTCOMES.109.915538.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Kleindorfer D, Khoury J, Broderick JP, Rademacher E, Woo D, Flaherty ML, et al. Temporal trends in public awareness of stroke: warning signs, risk factors, and treatment. Stroke J Cereb Circ. 2009;40(7):2502–6. doi:10.1161/STROKEAHA.109.551861.

    Article  Google Scholar 

  10. Ferris A, Robertson RM, Fabunmi R, Mosca L, American Heart Association, American Stroke Association. American Heart Association and American Stroke Association national survey of stroke risk awareness among women. Circulation. 2005;111(10):1321–6. doi:10.1161/01.CIR.0000157745.46344.A1.

    Article  PubMed  Google Scholar 

  11. Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes 3rd NA, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(1):104–23. doi:10.1161/CIR.0b013e3181fa3cf4.

    Article  PubMed  Google Scholar 

  12. Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(7):e257–354. doi:10.1161/CIRCULATIONAHA.106.177292.

    Article  PubMed  Google Scholar 

  13. Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76–99. doi:10.1161/01.cir.0000437740.48606.d1.

    Article  PubMed  Google Scholar 

  14. Berry JD, Dyer A, Cai X, Garside DB, Ning H, Thomas A, et al. Lifetime risks of cardiovascular disease. N Engl J Med. 2012;366(4):321–9. doi:10.1056/NEJMoa1012848.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  15. Goff Jr DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino Sr RB, Gibbons R, et al. ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935–59. doi:10.1016/j.jacc.2013.11.005. Acknowledging some of the problems with previous risk estimation tools such as the ATP-III version of the Framingham Risk Score for hard CHD, the 2013 ACC/AHA guidelines developed a new Pooled Cohort Equation from racially and geographically diverse prospective cohorts. This new risk assessment tool estimates 10-year risk for global ASCVD (i.e. MI and stroke), and has separate equations by gender and by race (non-Hispanics whites and blacks).

  16. DeFilippis AP, Young R, Carrubba CJ, McEvoy JW, Budoff MJ, Blumenthal RS, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med. 2015;162(4):266–75. doi:10.7326/M14-1281.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women’s Health Study. JAMA Internal Med. 2014;174(12):1964–71. doi:10.1001/jamainternmed.2014.5336.

    Article  Google Scholar 

  18. Yeboah J, Sillau S, Delaney JC, Blaha MJ, Michos ED, Young R, et al. Implications of the new American College of Cardiology/American Heart Association cholesterol guidelines for primary atherosclerotic cardiovascular disease event prevention in a multi ethnic cohort: Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J. 2015;169(3):387–95. doi:10.1016/j.ahj.2014.12.018. e3.

    Article  PubMed  Google Scholar 

  19. Kavousi M, Leening MJ, Nanchen D, Greenland P, Graham IM, Steyerberg EW, et al. Comparison of application of the ACC/AHA guidelines, Adult Treatment Panel III guidelines, and European Society of Cardiology guidelines for cardiovascular disease prevention in a European cohort. JAMA J Am Med Assoc. 2014;311(14):1416–23. doi:10.1001/jama.2014.2632.

    Article  Google Scholar 

  20. Hennekens CH. Risk factors for coronary heart disease in women. Cardiol Clin. 1998;16(1):1–8.

    Article  CAS  PubMed  Google Scholar 

  21. Peters SA, Huxley RR, Woodward M. Do smoking habits differ between women and men in contemporary Western populations? Evidence from half a million people in the UK Biobank study. BMJ Open. 2014;4(12), e005663. doi:10.1136/bmjopen-2014-005663.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Jousilahti P, Vartiainen E, Tuomilehto J, Puska P. Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14786 middle-aged men and women in Finland. Circulation. 1999;99(9):1165–72.

    Article  CAS  PubMed  Google Scholar 

  23. Jonsdottir LS, Sigfusson N, Gudnason V, Sigvaldason H, Thorgeirsson G. Do lipids, blood pressure, diabetes, and smoking confer equal risk of myocardial infarction in women as in men? The Reykjavik Study. J Cardiovasc Risk. 2002;9(2):67–76.

    Article  PubMed  Google Scholar 

  24. Njolstad I, Arnesen E, Lund-Larsen PG. Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study. Circulation. 1996;93(3):450–6.

    Article  CAS  PubMed  Google Scholar 

  25. Grundtvig M, Hagen TP, German M, Reikvam A. Sex-based differences in premature first myocardial infarction caused by smoking: twice as many years lost by women as by men. Eur J Cardiovasc Prev Rehab Off J Eur Soc Cardiol Working Groups on Epidemiol Prev Cardiac Rehab Exerc Physiol. 2009;16(2):174–9. doi:10.1097/HJR.0b013e328325d7f0.

    Google Scholar 

  26. Centers for Disease Control and Prevention NCfHS, Division of Health Interview Statistics, data from the National Health Interview Survey. Age-adjusted rate per 100 of civilian, noninstitutionalized population with diagnosed diabetes, by race and sex, United States, 1980–2011. In: Diabetes Public Health Resource. Centers for Disease Control and Prevention. 2014. http://www.cdc.gov/diabetes/statistics/prev/national/figraceethsex.htm.

  27. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332(7533):73–8. doi:10.1136/bmj.38678.389583.7C.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Natarajan S, Liao Y, Cao G, Lipsitz SR, McGee DL. Sex differences in risk for coronary heart disease mortality associated with diabetes and established coronary heart disease. Arch Intern Med. 2003;163(14):1735–40. doi:10.1001/archinte.163.14.1735.

    Article  PubMed  Google Scholar 

  29. Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension. 2001;37(5):1199–208.

    Article  CAS  PubMed  Google Scholar 

  30. van den Hoogen PC, van Popele NM, Feskens EJ, van der Kuip DA, Grobbee DE, Hofman A, et al. Blood pressure and risk of myocardial infarction in elderly men and women: the Rotterdam study. J Hypertens. 1999;17(10):1373–8.

    Article  PubMed  Google Scholar 

  31. Psaty BM, Furberg CD, Kuller LH, Cushman M, Savage PJ, Levine D, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality: the cardiovascular health study. Arch Intern Med. 2001;161(9):1183–92.

    Article  CAS  PubMed  Google Scholar 

  32. Miura K, Nakagawa H, Ohashi Y, Harada A, Taguri M, Kushiro T, et al. Four blood pressure indexes and the risk of stroke and myocardial infarction in Japanese men and women: a meta-analysis of 16 cohort studies. Circulation. 2009;119(14):1892–8. doi:10.1161/CIRCULATIONAHA.108.823112.

    Article  PubMed  Google Scholar 

  33. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group Circ. 1997;96(7):2468–82.

    CAS  Google Scholar 

  34. Despres JP, Couillard C, Gagnon J, Bergeron J, Leon AS, Rao DC, et al. Race, visceral adipose tissue, plasma lipids, and lipoprotein lipase activity in men and women: the Health, Risk Factors, Exercise Training, and Genetics (HERITAGE) family study. Arterioscler Thromb Vasc Biol. 2000;20(8):1932–8.

    Article  CAS  PubMed  Google Scholar 

  35. Jacobs Jr DR, Mebane IL, Bangdiwala SI, Criqui MH, Tyroler HA. High density lipoprotein cholesterol as a predictor of cardiovascular disease mortality in men and women: the follow-up study of the Lipid Research Clinics Prevalence Study. Am J Epidemiol. 1990;131(1):32–47.

    PubMed  Google Scholar 

  36. Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. Diabetes, blood lipids, and the role of obesity in coronary heart disease risk for women. The Framingham study. Ann Intern Med. 1977;87(4):393–7.

    Article  CAS  PubMed  Google Scholar 

  37. Castelli WP. Cholesterol and lipids in the risk of coronary artery disease—the Framingham Heart Study. Can J Cardiol. 1988;4(Suppl A):5A–10.

    PubMed  Google Scholar 

  38. Lloyd-Jones DM, Nam BH, D’Agostino Sr RB, Levy D, Murabito JM, Wang TJ, et al. Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: a prospective study of parents and offspring. JAMA J Am Med Assoc. 2004;291(18):2204–11. doi:10.1001/jama.291.18.2204.

    Article  CAS  Google Scholar 

  39. Garawi F, Devries K, Thorogood N, Uauy R. Global differences between women and men in the prevalence of obesity: is there an association with gender inequality? Eur J Clin Nutr. 2014;68(10):1101–6. doi:10.1038/ejcn.2014.86.

    Article  CAS  PubMed  Google Scholar 

  40. Krauss RM, Winston M, Fletcher BJ, Grundy SM. Obesity: impact on cardiovascular disease. Circulation. 1998;98(14):1472–6.

    Article  CAS  Google Scholar 

  41. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67(5):968–77.

    Article  CAS  PubMed  Google Scholar 

  42. Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. Am J Epidemiol. 2008;167(7):875–81. doi:10.1093/aje/kwm390.

    Article  PubMed Central  PubMed  Google Scholar 

  43. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med. 2015;162(2):123–32. doi:10.7326/M14-1651.

    Article  PubMed  Google Scholar 

  44. Schnabel RB. Is it all determined at menarche? Circulation. 2015;131(3):227–9. doi:10.1161/CIRCULATIONAHA.114.013736.

    Article  PubMed  Google Scholar 

  45. Charalampopoulos D, McLoughlin A, Elks CE, Ong KK. Age at menarche and risks of all-cause and cardiovascular death: a systematic review and meta-analysis. Am J Epidemiol. 2014;180(1):29–40. doi:10.1093/aje/kwu113.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Prentice P, Viner RM. Pubertal timing and adult obesity and cardiometabolic risk in women and men: a systematic review and meta-analysis. Int J Obes. 2013;37(8):1036–43. doi:10.1038/ijo.2012.177.

    Article  CAS  Google Scholar 

  47. Remsberg KE, Demerath EW, Schubert CM, Chumlea WC, Sun SS, Siervogel RM. Early menarche and the development of cardiovascular disease risk factors in adolescent girls: the Fels Longitudinal Study. J Clin Endocrinol Metab. 2005;90(5):2718–24. doi:10.1210/jc.2004-1991.

    Article  CAS  PubMed  Google Scholar 

  48. Canoy D, Beral V, Balkwill A, Wright FL, Kroll ME, Reeves GK, et al. Age at menarche and risks of coronary heart and other vascular diseases in a large UK cohort. Circulation. 2015;131(3):237–44. doi:10.1161/CIRCULATIONAHA.114.010070.

    Article  PubMed  Google Scholar 

  49. Jacobsen BK, Heuch I, Kvale G. Association of low age at menarche with increased all-cause mortality: a 37-year follow-up of 61,319 Norwegian women. Am J Epidemiol. 2007;166(12):1431–7. doi:10.1093/aje/kwm237.

    Article  PubMed  Google Scholar 

  50. Tamakoshi K, Yatsuya H, Tamakoshi A, Group JS. Early age at menarche associated with increased all-cause mortality. Eur J Epidemiol. 2011;26(10):771–8. doi:10.1007/s10654-011-9623-0.

    Article  PubMed  Google Scholar 

  51. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol. 2007;50(22):2128–32. doi:10.1016/j.jacc.2007.05.056.

    Article  PubMed  Google Scholar 

  52. Rosano GM, Vitale C, Marazzi G, Volterrani M. Menopause and cardiovascular disease: the evidence. Climacteric J Int Menopause Soc. 2007;10 Suppl 1:19–24. doi:10.1080/13697130601114917.

    Article  CAS  Google Scholar 

  53. Gambacciani M, Ciaponi M, Cappagli B, De Simone L, Orlandi R, Genazzani AR. Prospective evaluation of body weight and body fat distribution in early postmenopausal women with and without hormonal replacement therapy. Maturitas. 2001;39(2):125–32.

    Article  CAS  PubMed  Google Scholar 

  54. Ferrannini E. Physiological and metabolic consequences of obesity. Metab Clin Exp. 1995;44(9 Suppl 3):15–7.

    Article  CAS  PubMed  Google Scholar 

  55. Matthews KA, Crawford SL, Chae CU, Everson-Rose SA, Sowers MF, Sternfeld B, et al. Are changes in cardiovascular disease risk factors in midlife women due to chronological aging or to the menopausal transition? J Am Coll Cardiol. 2009;54(25):2366–73. doi:10.1016/j.jacc.2009.10.009.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  56. Ouyang P, Michos ED, Karas RH. Hormone replacement therapy and the cardiovascular system lessons learned and unanswered questions. J Am Coll Cardiol. 2006;47(9):1741–53. doi:10.1016/j.jacc.2005.10.076.

    Article  CAS  PubMed  Google Scholar 

  57. Manson JE, Allison MA, Rossouw JE, Carr JJ, Langer RD, Hsia J, et al. Estrogen therapy and coronary-artery calcification. N Engl J Med. 2007;356(25):2591–602. doi:10.1056/NEJMoa071513.

    Article  CAS  PubMed  Google Scholar 

  58. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA J Am Med Assoc. 2007;297(13):1465–77. doi:10.1001/jama.297.13.1465.

    Article  CAS  Google Scholar 

  59. Parikh NI, Cnattingius S, Dickman PW, Mittleman MA, Ludvigsson JF, Ingelsson E. Parity and risk of later-life maternal cardiovascular disease. Am Heart J. 2010;159(2):215–21. doi:10.1016/j.ahj.2009.11.017. e6.

    Article  PubMed  Google Scholar 

  60. Ness RB, Harris T, Cobb J, Flegal KM, Kelsey JL, Balanger A, et al. Number of pregnancies and the subsequent risk of cardiovascular disease. N Engl J Med. 1993;328(21):1528–33. doi:10.1056/NEJM199305273282104.

    Article  CAS  PubMed  Google Scholar 

  61. Group HSCR, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. doi:10.1056/NEJMoa0707943.

    Article  Google Scholar 

  62. Fadl HE, Ostlund IK, Magnuson AF, Hanson US. Maternal and neonatal outcomes and time trends of gestational diabetes mellitus in Sweden from 1991 to 2003. Diabet Med J Br Diabet Assoc. 2010;27(4):436–41. doi:10.1111/j.1464-5491.2010.02978.x.

    Article  CAS  Google Scholar 

  63. Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009;373(9677):1773–9. doi:10.1016/S0140-6736(09)60731-5.

    Article  CAS  PubMed  Google Scholar 

  64. Lauenborg J, Mathiesen E, Hansen T, Glumer C, Jorgensen T, Borch-Johnsen K, et al. The prevalence of the metabolic syndrome in a Danish population of women with previous gestational diabetes mellitus is three-fold higher than in the general population. J Clin Endocrinol Metab. 2005;90(7):4004–10. doi:10.1210/jc.2004-1713.

    Article  CAS  PubMed  Google Scholar 

  65. Pirkola J, Pouta A, Bloigu A, Miettola S, Hartikainen AL, Jarvelin MR, et al. Prepregnancy overweight and gestational diabetes as determinants of subsequent diabetes and hypertension after 20-year follow-up. J Clin Endocrinol Metab. 2010;95(2):772–8. doi:10.1210/jc.2009-1075.

    Article  CAS  PubMed  Google Scholar 

  66. Fadl H, Magnuson A, Ostlund I, Montgomery S, Hanson U, Schwarcz E. Gestational diabetes mellitus and later cardiovascular disease: a Swedish population based case–control study. BJOG Int J Obstet Gynaecol. 2014;121(12):1530–6. doi:10.1111/1471-0528.12754.

    Article  CAS  Google Scholar 

  67. Evans CS, Gooch L, Flotta D, Lykins D, Powers RW, Landsittel D, et al. Cardiovascular system during the postpartum state in women with a history of preeclampsia. Hypertension. 2011;58(1):57–62. doi:10.1161/HYPERTENSIONAHA.111.173278.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  68. Ahmed R, Dunford J, Mehran R, Robson S, Kunadian V. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol. 2014;63(18):1815–22. doi:10.1016/j.jacc.2014.02.529.

    Article  PubMed  Google Scholar 

  69. Stekkinger E, Zandstra M, Peeters LL, Spaanderman ME. Early-onset preeclampsia and the prevalence of postpartum metabolic syndrome. Obstet Gynecol. 2009;114(5):1076–84. doi:10.1097/AOG.0b013e3181b7b242.

    Article  PubMed  Google Scholar 

  70. Drost JT, Arpaci G, Ottervanger JP, de Boer MJ, van Eyck J, van der Schouw YT, et al. Cardiovascular risk factors in women 10 years post early preeclampsia: the Preeclampsia Risk EValuation in FEMales study (PREVFEM). Eur J Prev Cardiol. 2012;19(5):1138–44. doi:10.1177/1741826711421079.

    Article  PubMed  Google Scholar 

  71. Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet. 2005;366(9499):1797–803. doi:10.1016/S0140-6736(05)67726-4.

    Article  PubMed  Google Scholar 

  72. Lin YS, Tang CH, Yang CY, Wu LS, Hung ST, Hwa HL, et al. Effect of pre-eclampsia-eclampsia on major cardiovascular events among peripartum women in Taiwan. Am J Cardiol. 2011;107(2):325–30. doi:10.1016/j.amjcard.2010.08.073.

    Article  PubMed  Google Scholar 

  73. Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28(1):1–19. doi:10.1007/s10654-013-9762-6. This meta-analysis of 43 studies found that women with a history of pre-eclampsia had an approximately a doubling of risk for subsequent cardiovascular and cerebrovascular events.

    Article  PubMed  Google Scholar 

  74. Hoffman LK, Ehrmann DA. Cardiometabolic features of polycystic ovary syndrome. Nat Clin Pract Endocrinol Metab. 2008;4(4):215–22. doi:10.1038/ncpendmet0755.

    Article  CAS  PubMed  Google Scholar 

  75. Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab. 1999;84(1):165–9. doi:10.1210/jcem.84.1.5393.

    CAS  PubMed  Google Scholar 

  76. Orio Jr F, Palomba S, Cascella T, De Simone B, Di Biase S, Russo T, et al. Early impairment of endothelial structure and function in young normal-weight women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2004;89(9):4588–93. doi:10.1210/jc.2003-031867.

    Article  CAS  PubMed  Google Scholar 

  77. Talbott EO, Guzick DS, Sutton-Tyrrell K, McHugh-Pemu KP, Zborowski JV, Remsberg KE, et al. Evidence for association between polycystic ovary syndrome and premature carotid atherosclerosis in middle-aged women. Arterioscler Thromb Vasc Biol. 2000;20(11):2414–21.

    Article  CAS  PubMed  Google Scholar 

  78. Fairweather D, Frisancho-Kiss S, Rose NR. Sex differences in autoimmune disease from a pathological perspective. Am J Pathol. 2008;173(3):600–9. doi:10.2353/ajpath.2008.071008.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  79. del Rincon ID, Williams K, Stern MP, Freeman GL, Escalante A. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis Rheum. 2001;44(12):2737–45.

    Article  PubMed  Google Scholar 

  80. Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger Jr TA, Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol. 1997;145(5):408–15.

    Article  CAS  PubMed  Google Scholar 

  81. Ridker PM, Buring JE, Shih J, Matias M, Hennekens CH. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation. 1998;98(8):731–3.

    Article  CAS  PubMed  Google Scholar 

  82. Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342(12):836–43. doi:10.1056/NEJM200003233421202.

    Article  CAS  PubMed  Google Scholar 

  83. Khera A, McGuire DK, Murphy SA, Stanek HG, Das SR, Vongpatanasin W, et al. Race and gender differences in C-reactive protein levels. J Am Coll Cardiol. 2005;46(3):464–9. doi:10.1016/j.jacc.2005.04.051.

    Article  CAS  PubMed  Google Scholar 

  84. Bellasi A, Lacey C, Taylor AJ, Raggi P, Wilson PW, Budoff MJ, et al. Comparison of prognostic usefulness of coronary artery calcium in men versus women (results from a meta- and pooled analysis estimating all-cause mortality and coronary heart disease death or myocardial infarction). Am J Cardiol. 2007;100(3):409–14. doi:10.1016/j.amjcard.2007.03.037.

    Article  CAS  PubMed  Google Scholar 

  85. Lakoski SG, Greenland P, Wong ND, Schreiner PJ, Herrington DM, Kronmal RA, et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham Risk Score: the Multi-Ethnic Study of Atherosclerosis (MESA). Arch Intern Med. 2007;167(22):2437–42. doi:10.1001/archinte.167.22.2437.

    Article  PubMed  Google Scholar 

  86. Blaha MJ, Blumenthal RS, Budoff MJ, Nasir K. Understanding the utility of zero coronary calcium as a prognostic test: a Bayesian approach. Circ Cardiovasc Qual Outcomes. 2011;4(2):253–6. doi:10.1161/CIRCOUTCOMES.110.958496.

    Article  PubMed  Google Scholar 

  87. Budoff MJ, McClelland RL, Nasir K, Greenland P, Kronmal RA, Kondos GT, et al. Cardiovascular events with absent or minimal coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J. 2009;158(4):554–61. doi:10.1016/j.ahj.2009.08.007.

    Article  PubMed Central  PubMed  Google Scholar 

  88. Mora S, Redberg RF, Cui Y, Whiteman MK, Flaws JA, Sharrett AR, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA J Am Med Assoc. 2003;290(12):1600–7. doi:10.1001/jama.290.12.1600.

    Article  CAS  Google Scholar 

  89. Gulati M, Black HR, Shaw LJ, Arnsdorf MF, Merz CN, Lauer MS, et al. The prognostic value of a nomogram for exercise capacity in women. N Engl J Med. 2005;353(5):468–75. doi:10.1056/NEJMoa044154.

    Article  CAS  PubMed  Google Scholar 

  90. Blair SN, Kampert JB, Kohl 3rd HW, Barlow CE, Macera CA, Paffenbarger Jr RS, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA J Am Med Assoc. 1996;276(3):205–10.

    Article  CAS  Google Scholar 

  91. Kokkinos PF, Holland JC, Pittaras AE, Narayan P, Dotson CO, Papademetriou V. Cardiorespiratory fitness and coronary heart disease risk factor association in women. J Am Coll Cardiol. 1995;26(2):358–64.

    Article  CAS  PubMed  Google Scholar 

  92. Xu X, Bao H, Strait K, Spertus JA, Lichtman JH, D’Onofrio G, et al. Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction. Circulation. 2015;131(7):614–23. doi:10.1161/CIRCULATIONAHA.114.012826.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  93. Dupre ME, George LK, Liu G, Peterson ED. Association between divorce and risks for acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2015;8(3):244–51. doi:10.1161/CIRCOUTCOMES.114.001291.

    Article  PubMed  Google Scholar 

  94. Mehta LS. Cardiovascular disease and depression in women. Heart Failure Clin. 2011;7(1):39–45. doi:10.1016/j.hfc.2010.08.005.

    Article  Google Scholar 

  95. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA J Am Med Assoc. 2014;311(5):507–20. doi:10.1001/jama.2013.284427.

    Article  CAS  Google Scholar 

  96. Engberding N, Wenger NK. Management of hypertension in women. Hypertens Res. 2012;35(3):251–60. doi:10.1038/hr.2011.210.

  97. Gutierrez J, Ramirez G, Rundek T, Sacco RL. Statin therapy in the prevention of recurrent cardiovascular events: a sex-based meta-analysis. Arch Intern Med. 2012;172(12):909–19. doi:10.1001/archinternmed.2012.2145.

    Article  CAS  PubMed  Google Scholar 

  98. Mora S, Glynn RJ, Hsia J, MacFadyen JG, Genest J, Ridker PM. Statins for the primary prevention of cardiovascular events in women with elevated high-sensitivity C-reactive protein or dyslipidemia: results from the Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) and meta-analysis of women from primary prevention trials. Circulation. 2010;121(9):1069–77. doi:10.1161/CIRCULATIONAHA.109.906479.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  99. Kostis WJ, Cheng JQ, Dobrzynski JM, Cabrera J, Kostis JB. Meta-analysis of statin effects in women versus men. J Am Coll Cardiol. 2012;59(6):572–82. doi:10.1016/j.jacc.2011.09.067. This meta-analysis showed that statins were effective for prevention of ASCVD events and all-cause mortality in women similar to men. The benefit of statins was statistically significant for both men and women in both sexes, regardless of baseline risk or type of endpoint and in both primary and secondary prevention.

  100. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889–934. doi:10.1016/j.jacc.2013.11.002.

    Article  PubMed  Google Scholar 

  101. Mora S. Aspirin therapy in women: back to the ABCs. Circ Cardiovasc Qual Outcomes. 2009;2(2):63–4. doi:10.1161/CIRCOUTCOMES.109.854851.

    Article  PubMed  Google Scholar 

  102. Seshasai SR, Wijesuriya S, Sivakumaran R, Nethercott S, Erqou S, Sattar N, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(3):209–16. doi:10.1001/archinternmed.2011.628.

    Article  CAS  PubMed  Google Scholar 

  103. Ridker PM, Cook NR, Lee IM, Gordon D, Gaziano JM, Manson JE, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352(13):1293–304. doi:10.1056/NEJMoa050613.

    Article  CAS  PubMed  Google Scholar 

  104. van Kruijsdijk RC, Visseren FL, Ridker PM, Dorresteijn JA, Buring JE, van der Graaf Y, et al. Individualised prediction of alternate-day aspirin treatment effects on the combined risk of cancer, cardiovascular disease and gastrointestinal bleeding in healthy women. Heart. 2015;101(5):369–76. doi:10.1136/heartjnl-2014-306342. This long-term (15 year) follow-up of the Women’s Health Study (a randomized trial that evaluated alternate day dosing of low-dose aspirin compare to placebo in primary prevention) found that low-dose aspirin was ineffective or harmful in the majority of women in primary prevention. There may be benefit for treatment select women ≥65 years who are not at increased risk of bleeding.

    Article  PubMed  Google Scholar 

  105. Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, Silverman MG, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the Multi-Ethnic Study of Atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7(3):453–60. doi:10.1161/CIRCOUTCOMES.113.000690.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Dr. Roger S. Blumenthal, Director of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, for his review of the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Erin D. Michos.

Ethics declarations

Conflict of Interest

Rebeccah McKibben, Lena Mathews, Mahmoud Al Rifai, and Erin Michos have no relevant disclosures to report.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Funding Source

None.

Additional information

This article is part of the Topical Collection on Women and Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

McKibben, R.A., Al Rifai, M., Mathews, L.M. et al. Primary Prevention of Atherosclerotic Cardiovascular Disease in Women. Curr Cardiovasc Risk Rep 10, 1 (2016). https://doi.org/10.1007/s12170-015-0480-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s12170-015-0480-3

Keywords

Navigation