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HIGHLIGHTS FROM THE ELEVENTH ANNUAL CARDIOVASCULAR DISEASE PREVENTION INTERNATIONAL SYMPOSIUM
Audio-Digest Obstetrics/Gynecology
Volume 60, Issue 13
July 7, 2013

Guidelines for Prevention of Cardiovascular Disease in Women – Nanette Wenger, MD
Exercise in Reduction of Risk for Cardiovascular Disease – Laurence S. Sperling, MD

   
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Obstetrics/Gynecology Program Info  Accreditation InfoCultural & Linguistic Competency Resources

Highlights from the Eleventh Annual Cardiovascular Disease Prevention International Symposium

Educational Objectives

The goals of this program are to improve prevention of cardiovascular (CV) disease. After hearing and assimilating this program, the clinician will be better able to:

1. Discuss the evolving epidemiology of CV disease in women in the United States.

2. Categorize women into CV risk strata based on detailed medical history, physical examination, and simple markers.

3. Counsel a woman about diet, lifestyle interventions, and use of medications based on her risk category.

4. List the physiologic benefits, at the cellular and molecular levels, that are associated with regular physical activity.

5. Distinguish between pathologic and adaptive findings on the echocardiograms and electrocardiograms of athletes.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Wenger receives grant/research support from, and serves on the Trial Steering Committees, Trial Adjudication Committees, and Trial Data Safety and Monitoring Boards for Abbott Laboratories, Gilead, Merck & Co, and Pfizer; she also serves as a consultant for Abbott Women’s Advisory Board, Amgen, AstraZeneca, Gilead, Merck & Co, and Pfizer. Dr. Sperling and the planning committee reported nothing to disclose.

Guidelines for Prevention of
Cardiovascular Disease in Women

Nanette Wenger, MD, Professor of Medicine (Cardiology) Emeritus, Emory University School of Medicine, and Consultant, Emory Heart and Vascular Center, Atlanta, GA

Mortality trends: coronary heart disease (CHD) leading cause of death for women in United States (US), with 0.5 million cardiovascular (CV) deaths and 250,000 deaths from CHD in women annually; since 1984, more women than men in US have died from CHD; one woman in US dies of CV disease (CVD) each minute; 10,000 women <40 yr of age experience myocardial infarction (MI) annually; women, especially younger women, have higher death rates from MI and coronary artery bypass grafting than age-matched men; until 2000, decline in CV mortality in US observed in men, but since then, because of changes in clinical practice, CV mortality has declined for both sexes; decline in mortality steeper for women, but women still have higher mortality rate than men; about half of benefit achieved is related to therapy for established disease, and half due to improved prevention

Mortality in young women: despite declining mortality for women in their 80s, 70s, 60s, and 50s, mortality rates increasing for women in 30s, 40s, and early 50s; in young men, mortality rates stable, but not declining; findings represent reversal of benefit observed over 4 decades (probably due to epidemic of obesity); survey by American Heart Association (AHA) found only half of women would call 911 for symptoms of MI (indicating need for education of women)

“Owner’s manual for the heart”: technical specifications muscular pump approximately size of fist, weighing <1 lb; beats >100,000 times/day, pumps 2000 gal/day of blood or 5 qt/min through 60,000 miles of vasculature; “warranty” on heart lasts average of 81 yr for white woman and 77 yr for black woman, if operating instructions followed carefully; motivation for manual designed to teach patients that favorable changes in lifestyle decrease CV risk factors and prevent CVD; intensity of interventions must be matched to level of risk; behavioral changes and reshaping of practice patterns can dramatically decrease CV events; important messages from CV guidelines highlighted in color; “directions for operation” drawn from AHA’s Effectiveness-based Guidelines for Prevention of CVD (2011)

Risk assessment: for women, lifetime risk for CVD 1 in 2; clinical trials include either high-risk or healthy women, but not women at intermediate risk; Framingham examined 10-yr risk, but lifetime risk more relevant for young women; many women with low Framingham risk have high lifetime risk; in AHA guideline, women classified as high-risk, at-risk, or as having ideal CV health (<5% of population in ideal health category); high-risk includes women with coronary, cerebrovascular, peripheral arterial, or chronic kidney disease, or diabetes mellitus (DM); classification emphasizes importance of identifying women with DM, for whom intensive risk intervention needed (rather than simply control of blood glucose); at-risk includes women who smoke cigarettes or with elevated blood pressure (BP), high cholesterol, obesity, poor diet, physical inactivity, family history, metabolic syndrome, advanced subclinical disease, poor exercise capacity (<4 metabolic equivalents [METs] on treadmill), systemic autoimmune collagen vascular disease (especially systemic lupus erythematosus or rheumatoid arthritis), and history of relevant complications of pregnancy; ideal risk defined by untreated total cholesterol <200 mg/dL, untreated BP <120/80 mm Hg, normal fasting glucose, body mass index <25, abstinence from smoking, and achievement of physical activity goals; physical activity goals all guidelines recommend 150 min/wk of moderate-intensity activity, 75 min of vigorous activity, or combination of both; ideal risk also requires healthy, DASH (Dietary Approaches to Stop Hypertension [HTN])-like diet

Focusing on high risk: National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) underestimates risk for women and precludes intensive interventions that women should receive, but do not; recent Framingham equations that examine 30-yr risk better, but complicated and not widely used; in half of adults, including 50 million women, 10-yr predicted coronary risk <10%, and lifetime risk 40% (illustrating importance of focusing on lifetime risk)

Role of biomarkers and imaging: improving, but many new options may not perform better, cost less, or offer lower radiation risk than simple markers; radiation risk from coronary calcium studies has fallen; use of biomarkers probably most important in refining recommendations for intermediate-risk patients

Newly defined at-risk populations: women with depression or autoimmune disease at increased risk and require screening for CV risk factors; pregnancy represents unique CV and metabolic stressor; some conditions associated with pregnancy suggest subsequent CV risk; women with preeclampsia have doubling of risk for CHD, stroke, and venous thromboembolism (VTE) after delivery (should be followed to monitor for development of these conditions); in addition to asking about pregnancies and live births, obtain history of complications associated with increased CV risk, such as preeclampsia, gestational diabetes, preterm birth, and small-for-gestational-age infant

Prevention

Tobacco use: avoid smoking and environmental exposure; women who stop smoking at <50 yr of age halve their mortality risk over ensuing 15 yr; lung function improves by one-third within few months of stopping; risk for CHD reduced by 50% after 1 yr; after several years, risk for stroke same as that of never smoker

Physical activity: additional benefit conferred by exercising longer than minimum recommended duration; muscle strengthening 2 times/wk added to guidelines for all patients; muscle strength permits more work with less myocardial oxygen demand; Nurses’ Health Study showed vigorous exercise reduces death from CHD by one-third; even sedentary women who began moderate walking program decreased their risk

Diet: institute Mediterranean diet; weight maintenance depends on diet and physical activity; focus on caloric intake and formal behavioral programs; “250-250” rule exercising extra 250 cal/day (35 min moderate intensity exercise) and eating 250 fewer cal/day achieves weekly loss of 1 lb

BP: ideal <120/80 mm Hg, regardless of age; treat with lifestyle interventions first; 140/90 mm Hg reasonable target for most patients; Women’s Health Initiative (WHI) showed that risk for adverse outcomes in women with pre-HTN intermediate between that of normotensive and hypertensive women

Lipids: important numbers for patients to recall 100 (low-density lipoprotein [LDL] <100 mg/dL), 50 (high-density lipoprotein [HDL] >50 mg/dL), and 150 (triglycerides <150 mg/dL); more refined targets needed for high-risk women, such as LDL <70 mg/dL; niacin ineffective, based on recent trials

Diabetes mellitis: numbers used for guidelines still changing; lower blood glucose targets not necessarily better; interventions should not cause significant hypoglycemia; Framingham established that DM in women increases risks for CVD, CHD, cardiac failure, and intermittent claudication, but not stroke; women (especially black women) with DM undertreated for CHD risk factors; guideline emphasizes lifestyle changes; moderate physical activity for 30 min/day and loss of 5% to 7% of body weight lowers risk for DM by 58%

Aspirin: supported by abundant data for high-risk women; clopidogrel reasonable for women with intolerance; aspirin reasonable for women with DM plus additional risk factor; women who received 100 mg aspirin every other day had no decrease in CV events; benefit shown for prevention of stroke, but not MI, and risk for gastrointestinal bleeding increased; sex-based difference evident (decrease in MI seen in men in Physicians’ Health Study, but no benefit for stroke); in older women, stroke and MI reduced, but risk for bleeding almost same magnitude as benefit; individualized approach required

Class III interventions: postmenopausal hormones not appropriate for prevention of CVD; for women and men, clinical trials confirm that vitamins C, E, and β-carotene ineffective; patients in WHI on estrogen plus progestin although percentage increases in risk high, absolute numbers of events low; increases seen in MI, breast cancer, VTE, stroke, dementia, and cancer, but hip fracture and colorectal and uterine cancers reduced (no effect seen on quality of life); estrogen-only group increases seen in stroke, and probable dementia and loss of memory; increases in dementia and memory loss found in all hormone studies of women >65 yr of age; improvements seen in hip fractures, but no change in breast cancer or heart disease; folic acid appropriate for use before and during pregnancy to prevent neural tube defects or autism, but not beneficial for CHD prevention; in Norwegian Vitamin Trial, combination of folate, vitamin B6, and vitamin B12 associated with increased risk

Risk assessment: evaluate medical and family history, including symptoms and history of pregnancy complications; perform simple laboratory tests; for all women, discuss Class I recommendations for smoking cessation, DASH diet, physical activity, and weight management; for high-risk women, refer to cardiac rehabilitation if recent event has occurred; otherwise, use Class I recommendations in guidelines for control of BP and LDL, and use β-blockers, angiotensin-converting enzyme inhibitors, and more advanced therapies, if indicated; in nonhigh-risk women, focus on control of BP and LDL, followed by consideration of other therapies

Exercise in Reduction of Risk for Cardiovascular Disease

Laurence S. Sperling, MD, Professor of Medicine (Cardiology) and Director, Center for Heart Disease Prevention, Emory University School of Medicine

Role of exercise: >50% of Americans irregularly active or sedentary; CV specialists should set examples in community; regular activity does not require visiting gym or sweating; pedometer useful tool for patients learning to become more active

Level of activity: <5000 steps per day considered sedentary; >10,000 steps per day considered active and equivalent to walking 5 miles; study 28 CV specialists asked to wear pedometer at work; worked 10 to 12 hr/day and walked mean of 6000 steps per day; if not active outside work, these individuals almost sedentary

Maximal oxygen consumption (VO2 max): measure of exercise capacity; important prognostic marker; VO2 max influenced by genetics, training, and age, and determined by cardiac output and ability to use O2; VO2 max 35 to 50 mL/kg/min in average young individuals and 65 to 90 mL/kg/min in Olympians; current criteria for considering patients for heart transplantation require VO2 max <14 mL/kg/min

Mortality and illness: individuals in highest quintiles of fitness have lowest mortality; regular physical activity confers CV protection even in patients with HTN or pre-HTN; exercise critical for treating patients with DM and metabolic syndrome; patients with DM with highest MET levels have lower risk for CV events, regardless of ethnicity; walking adequate form of exercise; in women, higher MET levels associated with protection from CV risk

Dose-response relationship: in study of >2000 patients with type 2 DM, linear relationship observed between amount of exercise performed and reduction in total CVD and mortality; most active patients with CAD have greatest documented regression (by coronary angiography) in response to exercise; in patients with stable CHD, exercise program reduced events and more cost effective than percutaneous coronary intervention; exercise associated with 25% reduction in risk (as powerful as any pharmacologic therapy)

Mechanisms of benefits: exercise has antiatherosclerotic, psychologic, antithrombotic, anti-ischemic, and antiarrhythmic benefits; myocardium in patients with CAD, regular activity improves supply-demand mismatch, improves efficiency of coronary blood flow, and alters ischemic threshold; inflammation exercise affects inflammatory markers (eg, C-reactive protein, cellular adhesion molecules, granulocyte-macrophage colony-stimulating factor, monocyte chemoattractant protein-1); exercise among best antioxidant and anti-inflammatory therapies available; vascular exercise promotes lamina shear, which increases nitric oxide (NO) and reduces oxidative stress; exercise induces NO synthase production by endothelial cells, improves endothelial cell function and smooth muscle cell relaxation, and promotes repair mechanisms through induction of endothelial progenitor cells

CV Care of Athletes

Physiologic adaptations in athletes: to strength training concentric hypertrophy (produces pressure overload on heart); to endurance dilation (directed at volume overload)

Sudden cardiac death: in collegiate athletes, risk 1 in 45,000; higher in men, black men, and male basketball players, in whom risk 1 in 7000; in marathon runners, risk 0.54 in 100,000; risk higher in male runners, and highest near end of marathon; causes in marathoners, occult CVD, CHD, and hypertrophic cardiomyopathy (HCM); in young athletes in US, primary cause HCM, followed by coronary anomalies and myocarditis

Imaging: distinguishing normal adaptation to exercise from pathology challenging; heart of athlete typically enlarges in symmetric fashion, with modest dilation; diastolic dysfunction observed only in diseased hearts (not in athletes)

Screening athletes: recommendations different in US and Europe; US take detailed history, including questions about chest pain, dyspnea on exertion, syncope, family history of unexplained, early sudden death, HCM, and CHD; perform physical examination, including BP in both arms; electrocardiography (ECG) not routinely recommended for athletes; Europe routine ECG recommended; arrhythmogenic right ventricular (RV) dysplasia primary reason for sudden death in Italian athletes; typical ECG abnormalities in athletes first-degree atrioventricular block and RV conduction delay; isolated left ventricular hypertrophy by voltage on ECG normal variant in athletes (does not require follow-up echocardiography); in US, economic concerns (costs of, eg, screening many people, false-positive results that prompt more tests) limit use of ECG

Public health: avoiding term “exercise” helpful; instead, have patients focus on increasing activity by walking with family or dog; find ways to make healthy choices easy; CV benefit conferred by standing, treadmill desks, bike lanes, walking paths, and helpful signage; changes require help of communities, schools, and churches; investment in comprehensive community-based prevention, worksite wellness, and bicycle and pedestrian trails cost effective

Other benefits of exercise: reduced risk for HTN, DM, cancer, injuries, falls, depression, and loss of cognition

Acknowledgements

Drs. Wenger and Sperling were recorded at Eleventh Annual Cardiovascular Disease Prevention International Symposium, presented by Baptist Health South Florida, and held February 14-17, 2013, in Miami Beach, FL. For information on future CME programs presented by Baptist Health South Florida, please call 786-596-2398, or visit their website at baptisthealth.net/en/physicians/Pages/Continuing-Medical-Education.aspx. The Audio-Digest Foundation thanks the speakers and Baptist Health South Florida for their cooperation in the production of this program.

Suggested Reading

Blair SN et al: Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989;262(17):2395-40; Chobanian AV et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72; Erratum in: JAMA 2003;290(2):197; Fang J et al: Exercise and cardiovascular outcomes by hypertensive status: NHANES I epidemiological follow-up study, 1971-1992. Am J Hypertens 2005;18(6):751-8; Ford ES et al: Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med 2007;356(23):2388-98; Hambrecht R et al: Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. J Am Coll Cardiol 1993;22(2):468-77; Hambrecht R et al: Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004;109(11):1371-8; Kim JH et al: Cardiac arrest during long-distance running races. N Engl J Med 2012;366(2):130-40; Knowler WC et al: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393-403; Lakoski SG 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; Lloyd-Jones DM et al: Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113(6):791-8; Manson JE et al: A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341(9):650-8; Mosca L et al: Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 2011;57(12):1404-23; Pencina MJ et al: Predicting the 30-year risk of cardiovascular disease: the Framingham heart study. Circulation 2009;119(24):3078-84; Ridker PM 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; Roger VL et al: Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation 2012;125(1):e2-e220; Rossouw JE et al: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002;288(3):321-33; Tanasescu M et al: Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation 2003;107(19):2435-9; Tudor-Locke C and Bassett DR Jr: How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004;34(1):1-8; Weintraub WS et al: Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association. Circulation 2011;124(8):967-90.


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