Call made for changes in women's heart disease risk-factor list

February 13, 2007

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 (JAMA) online Feb. 14, Roger Blumenthal, M.D., 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," says Blumenthal, an associate professor and director of the Ciccarone Preventive Cardiology Center at The Johns Hopkins University School of Medicine and its Heart Institute. "And physicians should intervene with lifestyle changes and drug treatment before symptoms start to appear," he adds. "Our best means of prevention is through early identification of those most at risk."

Blumenthal says 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 Hopkins experts base their editorial call on research conducted elsewhere and published in the same issue of JAMA, which looked at the predictive value of more than 35 risk actors 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," says 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 sex.

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 also undergoing 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

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.

"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," says editorial co-author and cardiologist Erin Michos, M.D., a clinical fellow at Hopkins.

In addition to 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, M.D., M.P.H.

Johns Hopkins Medicine

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