What is the evidence‑based approach to assess, prevent, and treat cardiovascular disease in adult women, incorporating traditional and female‑specific risk factors, lifestyle modification, pharmacologic therapy, and follow‑up?

Cardiovascular Disease Prevention and Management in Women

Women require a comprehensive, evidence-based approach to cardiovascular disease prevention that addresses both traditional risk factors and female-specific conditions, with aggressive lifestyle modification and pharmacotherapy guided by absolute risk stratification.

Risk Assessment and Stratification

Calculate 10-year absolute cardiovascular risk to guide all preventive interventions. 1, 2

• High-risk women (≥20% 10-year risk OR established CVD OR diabetes) require the most aggressive interventions 3
• Intermediate-risk women (10-20% 10-year risk) warrant selective pharmacotherapy based on additional risk factors 3
• Lower-risk women (<10% 10-year risk) focus primarily on lifestyle interventions 3

Female-Specific Risk Enhancers

Identify and document these conditions as they elevate cardiovascular risk and lower thresholds for pharmacotherapy: 1, 4, 5

• Adverse pregnancy outcomes (preeclampsia, gestational diabetes, gestational hypertension, preterm birth) 1, 4, 5
• Premature menopause (age <40 years) 1, 4
• Polycystic ovary syndrome 4, 5
• Autoimmune diseases 4, 5
• History of infertility or assisted reproductive technology 5

Screen women with these conditions within 3 months postpartum and maintain heightened surveillance throughout life. 1

Lifestyle Interventions (Class I Recommendations)

Smoking Cessation

All women must not smoke and must avoid environmental tobacco exposure. Provide counseling, nicotine replacement, and pharmacotherapy in conjunction with behavioral programs. 3

Physical Activity

• Minimum 30 minutes of moderate-intensity activity (brisk walking) on most, preferably all, days of the week 3
• For weight loss or weight maintenance: 60-90 minutes of moderate-intensity activity on most days 3
• Women with recent acute coronary syndrome, coronary intervention, angina, cerebrovascular event, peripheral arterial disease, or heart failure with LVEF ≤40% require comprehensive cardiovascular rehabilitation or physician-guided exercise programs 3, 6

Dietary Modifications

Implement a heart-healthy diet rich in fruits, vegetables, whole grains, low-fat dairy, fish (especially oily fish twice weekly), and lean protein sources. 3, 6, 1

Specific dietary limits: 3, 6, 1

• Saturated fat: <7-10% of total calories (7% for high-risk women)
• Cholesterol: <200-300 mg/day
• Trans fatty acids: as low as possible (<1% of energy)
• Sodium: <2.3 g/day (approximately 1 teaspoon salt)
• Alcohol: ≤1 drink per day

Weight Management

Target BMI 18.5-24.9 kg/m² and waist circumference <35 inches through balanced physical activity, caloric intake, and formal behavioral programs when indicated. 3, 6, 1

Omega-3 Fatty Acids

Consider omega-3 supplementation (850-1000 mg EPA+DHA) as adjunct therapy in women with established coronary heart disease; higher doses (2-4 g) for elevated triglycerides. 3

Depression Screening

Screen women with coronary heart disease for depression and refer/treat when indicated. 3, 6, 2

Blood Pressure Management

Target Blood Pressure

• <120/80 mm Hg optimal through lifestyle approaches 3
• <130/80 mm Hg for women with chronic kidney disease or diabetes 3, 2
• <140/90 mm Hg for all others 3

Pharmacotherapy (Class I, Level A)

Initiate antihypertensive therapy when BP ≥140/90 mm Hg (or ≥130/80 mm Hg with diabetes/chronic kidney disease). 3

• Thiazide diuretics should be part of the regimen for most patients unless contraindicated 3
• High-risk women: initiate with β-blockers AND/OR ACE inhibitors/ARBs, adding thiazides as needed 3, 2

Lipid Management

Optimal Lipid Targets (Class I, Level B)

Encourage through lifestyle approaches: 3, 6, 2

• LDL-C <100 mg/dL
• HDL-C ≥50 mg/dL
• Triglycerides <150 mg/dL
• Non-HDL-C <130 mg/dL

Statin Therapy for High-Risk Women (Class I, Level A)

High-risk women (established CVD, diabetes, or ≥20% 10-year risk) require statin therapy initiated simultaneously with lifestyle modifications regardless of baseline LDL-C. 3, 1, 2

• Target LDL-C <100 mg/dL 3
• Very-high-risk women: target LDL-C <70 mg/dL (Class IIa, Level B), may require combination therapy 3, 1, 2
• Preferred agents: moderate-to-high intensity statins (atorvastatin 10-80 mg or rosuvastatin 5-40 mg) 1

Statin Therapy for Intermediate and Lower-Risk Women

Intermediate-risk women (10-20% 10-year risk): 3

• Initiate statin if LDL-C ≥130 mg/dL despite lifestyle therapy

Lower-risk women (<10% 10-year risk): 3

• Consider statin if LDL-C ≥190 mg/dL with 0-1 risk factors
• Consider statin if LDL-C ≥160 mg/dL with multiple risk factors

HDL and Triglyceride Management

When HDL-C is low or non-HDL-C elevated after achieving LDL-C goal: 3, 6

• High-risk women: initiate niacin or fibrate therapy (Class IIa, Level B)
• Intermediate-risk women: consider niacin or fibrate therapy (Class IIb, Level B)

Critical caveat: Prescription niacin only—dietary supplements must not be substituted; over-the-counter niacin requires physician approval and monitoring. 3

Diabetes Management

Target HbA1c <7.0% if achievable without significant hypoglycemia (Class I, Level C). 3, 6, 2

Diabetes in women confers 2.42-fold increased CVD mortality risk and eliminates premenopausal cardioprotection—treat as CHD risk equivalent requiring aggressive intervention. 2

Antiplatelet Therapy

High-Risk Women (Class I, Level A)

Aspirin 75-325 mg daily is mandatory unless contraindicated. 3, 6, 2

If aspirin intolerant: substitute clopidogrel (Class I, Level B). 3, 6, 2

Intermediate-Risk and Older Women

• Women ≥65 years: consider aspirin 81-100 mg daily if blood pressure controlled and benefit for ischemic stroke/MI prevention outweighs bleeding risk (Class IIa, Level B) 3
• Women <65 years: consider aspirin if benefit for ischemic stroke prevention outweighs risk (Class IIb, Level B) 3
• Intermediate-risk women: consider aspirin 75-162 mg if blood pressure controlled and benefit outweighs gastrointestinal bleeding risk (Class IIa, Level B) 3

β-Blocker Therapy (Class I, Level A)

β-blockers must be used indefinitely in all women after myocardial infarction, acute coronary syndrome, or with left ventricular dysfunction (with or without heart failure symptoms) unless contraindicated. 3, 6, 2

ACE Inhibitor/ARB Therapy (Class I, Level A)

ACE inhibitors are mandatory in women with: 3, 6, 2

• Post-myocardial infarction status
• Clinical heart failure or LVEF ≤40%
• Diabetes mellitus

If ACE inhibitor intolerant: substitute ARB (Class I, Level B). 3, 6, 2

Atrial Fibrillation Management

Women with chronic or paroxysmal atrial fibrillation: 3

• Warfarin to maintain INR 2.0-3.0 unless low stroke risk (<1%/year) or high bleeding risk (Class I, Level A)
• Aspirin 325 mg if warfarin contraindicated or low stroke risk (Class I, Level A)

Hormone Therapy (Class III, Level A)

Combined estrogen plus progestin hormone therapy must NOT be initiated or continued for cardiovascular disease prevention in postmenopausal women. 3

Other forms of menopausal hormone therapy should NOT be used for CVD prevention pending further evidence. 3

Discontinue statins 1-2 months before attempting conception and immediately upon pregnancy recognition. 1

Monitoring and Follow-Up

Initial assessment: 1, 2

• Lipid panel, liver enzymes, creatine kinase before statin initiation
• Calculate 10-year ASCVD risk using pooled cohort equations (women aged 40-75 years)

Follow-up monitoring: 1, 2

• Reassess lipid panel 4-12 weeks after statin initiation
• Lipid panel every 3-6 months until goals achieved, then annually
• Monitor for myopathy symptoms and hepatic dysfunction
• Screen for depression in women with established CVD

Special Diagnostic Considerations for Microvascular Dysfunction

Women with persistent stable chest pain and nonobstructive coronary artery disease require invasive coronary function testing to diagnose coronary microvascular dysfunction. 6

Alternative diagnostic modalities: 6

• Stress PET myocardial perfusion imaging with myocardial blood flow reserve measurement
• Stress cardiac MRI with MBFR measurement
• Stress echocardiography with coronary flow velocity reserve measurement

Women with documented myocardial ischemia but minimal obstructive disease have 9.4% rate of death or MI over 4 years—comprehensive risk factor reduction is essential. 6