Johns Hopkins cardiologists are calling for an
expansion of the criteria widely used by physicians to
detect and assess a postmenopausal woman's chances of
developing cardiovascular disease, the leading cause of
death among women in the United States.
In an editorial appearing in the Journal of the
American Medical Association online Feb. 14, Roger
Blumenthal and colleagues say that a family history of
heart disease and blood levels of a protein tied to vessel
inflammation, C-reactive protein, should quickly be added
to traditional assessments of women's risk of suffering a
heart attack, stroke or severe chest pain (angina).
"Physicians should incorporate these factors into
their testing and decision making about which women are
most likely to develop cardiovascular disease, and
physicians should intervene with lifestyle changes and drug
treatment before symptoms start to appear," said
Blumenthal, an associate professor and director of the
Ciccarone Preventive Cardiology Center at the School of
Medicine and its
Heart Institute. "Our best means of prevention is
through early identification of those most at risk."
Blumenthal says that these changes could help
ameliorate the discrepancy between the death rate for men
and women from cardiovascular disease, which has steadily
declined for men over the last 20 years but has remained
relatively the same for women.
The new risk-factor list would strengthen existing
assessment tools, including the Framingham Risk Estimate,
which gauges how likely a person is to suffer a fatal or
nonfatal heart attack within 10 years and calculates risk
based on a summary score of such factors as age, blood
pressure, cholesterol levels and smoking.
The Johns Hopkins experts base their editorial call on
research conducted elsewhere, and published in the same
issue of JAMA, that looked at the predictive value of more
than 35 risk factors not included in the Framingham score
but reported to play a role in heart disease and stroke.
They found clear evidence that only family history and
C-reactive protein, or hsCRP for short, had significant,
additional predictive value in determining women really at
moderate or high risk of future cardiovascular disease. The
new method changed risk scores for at least 20 percent of
the women studied.
"These are the best data yet to show how we should be
assessing our female patients," said Blumenthal, whose own
research showed in 2005 that the gold standard Framingham
tool failed to identify approximately one-third of women
over age 60 who had advanced hardening and narrowing of the
arteries for their age and gender.
The latest findings are not surprising, the Hopkins
team says. Family history--where either a parent or a
sibling suffered a coronary event--doubles a woman's own
chances of arterial disease. High blood levels of
C-reactive protein, in excess of 3 milligrams per liter,
also double the risk. And the effects are multiplied if
both factors are present, with a woman's risk rising almost
fourfold.
Also in 2005, Blumenthal and his team suggested
additional screening, using CT scans of the arteries and
calcium scoring, to better find women who would likely
benefit from aspirin and statin therapy. Such additional
tests, he says, should still be considered for those women
with no symptoms and at least two traditional risk factors
who are not obvious candidates for lifelong drug therapy
with aspirin and lipid-lowering drugs.
But, he notes, the latest analysis, which was funded
by the Donald W. Reynolds Foundation, provides a thorough
review of many potential risk factors and should be applied
for all postmenopausal women. Results are available online
at
www.reynoldsriskscore.org.
Evaluation of the women in the current study included
analysis of race, age, body mass index, menopause status,
frequency of exercise, alcohol use, postmenopausal hormone
use and dietary supplements of vitamin E, other
multivitamins and aspirin. Blood factors studied were
equally varied and included levels of homocysteine,
creatinine, fibrinogen and hemogloblin A1C levels.
The information came from the U.S. Women's Health
Study, which tracked for a decade more than 24,000 healthy
women to see who developed coronary heart disease and who
didn't. All women were over age 45.
Editorial co-author and cardiologist Erin Michos, a
clinical fellow at Johns Hopkins, said, "Our goal is to
make heart attacks less likely to occur, and to do so by
strongly considering therapies such as aspirin,
cholesterol-lowering medications and possibly blood
pressure medications for individuals at higher risk."
In addition to the researchers' call for change,
Michos says that existing treatment guidelines, the 2001
National Cholesterol Education Program Adult Treatment
Panel, which currently emphasize the Framingham score,
should be revised to incorporate family history and hsCRP.
Assistance with the Hopkins editorial was provided by
Khurram Nasir.
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