Updated guidelines for CVD prevention in women encompass clinical practice findings
Mosca L. Circulation. 2011;doi:10.1161/CIR.0b013e31820faaf8
The 2011 update to the American Heart Association’s guidelines for the prevention of CVD in women has incorporated benefits and risks associated with clinical practice findings, besides those observed in clinical research. Further, the guidelines also feature changes regarding the CVD risk classification threshold.
The AHA first published women-specific clinical recommendations for prevention of CVD in 1999. One of the major changes with the present guidelines compared with earlier ones, executive writing committee and expert panel members of the guidelines wrote, was that the benefits and risks observed in clinical practice of preventive therapies were strongly considered, and recommendations were not limited to evidence of benefits observed in clinical research.
“Hence, in the transformation from ‘evidence-based’ to ‘effectiveness-based’ guidelines for the prevention of CVD in women, the panel voted to update recommendations to those therapies that have been shown to have sufficient evidence of clinical benefit for CVD outcomes,” the writing committee and panel members wrote.
The updated guidelines now include modifications to the risk classification algorithm that acknowledge several 10-year risk equations for predicting 10-year global CVD risk, such as the updated Framingham CVD risk profile and Reynolds risk score for women. The new threshold for defining high risk is at least a 10% 10-year risk of all CVD, instead of an at least 20% Framingham 10-year predicted risk for CHD alone, which had previously identified women at high risk in the 2007 update.
“Indeed, it is difficult for a woman<75 years of age, even with several markedly elevated risk factors, to exceed a 10% (let alone a 20%) 10-year predicted risk for CHD with the Adult Treatment Panel III risk estimator,” the guideline authors wrote.
Besides recognizing the importance of racial, ethnic and socioeconomic traits in determining a patient’s risk for CVD, the guidelines also include several illnesses that put a woman at risk, including gestational diabetes, preeclampsia and pregnancy-induced hypertension, as well as those that put her at high risk, including clinically manifest CHD and diabetes.
Because most of the data used to develop these guidelines was based on trials of CHD prevention, the authors said future guidelines “should consider recommendations for specific outcomes of particular importance to women, such as stroke.” This, they said, is particularly critical because 55,000 more women die of stroke than men every year before they reach the age of 75 years
__________________________________________________ ________________________
Resource use increased among Medicare beneficiaries with HF at end of life
Unroe K. Arch Intern Med. 2011;171:196-203.
During the last 6 months of life, days of intensive care, hospice use and cost all increased for Medicare beneficiaries with HF during an 8-year period, according to findings from the Archives of Internal Medicine.
“Heart failure is listed on one in eight death certificates in the United States. Although some people live with HF for years, more than one-quarter of Medicare beneficiaries die within 1 year of the incident diagnosis, and 36% die within 1 year of a HF–related hospitalization,” the researchers wrote. “In this longitudinal analysis … we found that most patients [with HF] frequently accessed the health care system and spent some time in the hospital.”
The retrospective cohort study featured 229,543 Medicare beneficiaries with HF who died from 2000 to 2007. Investigators analyzed the beneficiaries’ resource use during the last 180 days of life, including all-cause hospitalizations, hospice, home health, ICU days, skilled nursing facility stays, durable medical equipment, outpatient physician visits and cardiac procedures.
Throughout the study period, about 80% of beneficiaries were hospitalized in the last 6 months of life. Investigators found that days in intensive care rose (3.5 to 4.6; P<.001), as did use of hospice (19% to 40%; P<.001) and unadjusted mean cost per beneficiary (26% increase; $28,766 to $36,216; P<.001).
When age, race, sex, geographic region and comorbid conditions were adjusted for, cost still increased by 11%. Renal disease, black race and chronic obstructive pulmonary disease were each independent predictors of higher costs, whereas increasing age was a strong independent factor for lower costs. Additionally, regional differences remained after adjustment, with higher costs of care found in the Northeast and West vs. the South.