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Ask the doctor: How should I be screened for cardiovascular disease?

Q. I have a family history of cardiovascular disease. Although I don’t have high blood pressure, high cholesterol, diabetes, or any other risk factor, I’m concerned about how my cardiologist is screening me, because women can have small-vessel disease and not necessarily arterial disease. How should I be screened?

A. In general, the decision to screen a woman for cardiovascular disease depends on her risk for the disease and whether she has symptoms. The risks include some things that are out of our control, such as a strong family history (that is, heart attack or stroke in a father or brother before age 55 or in a mother or sister before age 65). But we can prevent or lessen many other risks through lifestyle changes, or, if necessary, medications. Major risk factors include obesity, smoking, physical inactivity, high blood pressure, high cholesterol, and diabetes. All of these affect both genders, but several have a greater impact on women. For example, diabetes raises the risk of heart disease in women more than in men.

Metabolic syndrome is another risk factor. A woman is diagnosed with metabolic syndrome if she has three or more of the following: a waistline (measured at the navel) of 35 inches or more, higher-than-normal triglycerides, lower-than-normal HDL (good) cholesterol, higher-than-normal blood pressure, and higher-than-normal fasting blood sugar. There’s some evidence that, for women, metabolic syndrome is the most important risk factor for having an early heart attack.

Certain pregnancy complications also raise the risk for cardiovascular problems. These complications include pre-eclampsia (high blood pressure and protein in the urine), gestational diabetes, and pregnancy-induced hypertension. Pre-eclampsia doubles a woman’s risk of ischemic heart disease, stroke, and blood clots in the five to 15 years following a pregnancy. The American Heart Association has updated its prevention guidelines for women to include pregnancy complications as well as systemic lupus erythematosus (lupus) and rheumatoid arthritis — both of which disproportionately affect women — as cardiovascular risk factors.

Perhaps you have one or more of these less familiar risk factors along with your family history. But unless you also have symptoms, such as chest discomfort, shortness of breath, or lightheadedness, there’s no evidence that you should have further screening, such as with exercise stress testing. Women also often ask me about screening with electron beam computed tomography (EBCT) to get a coronary calcium score. So far, the calcium score is not considered a risk factor. The U.S. Preventive Services Task Force advises against routine screening with EBCT or exercise stress testing for adults who are at low risk for heart disease and says that even in adults at increased risk, there’s not enough evidence to recommend for or against these tests.

Criteria for ideal cardiovascular health in women

Total cholesterol:

< 200 mg/dL (untreated)

Blood pressure:

< 120/80 mm Hg (untreated)

Fasting blood glucose:

< 100 mg/dL (untreated)

Body mass index:

< 25 kg/m²

Physical activity:

? 150 minutes/week moderate intensity or ? 75 minutes/week vigorous intensity

DASH*-like eating plan

Abstinence from smoking

*Dietary Approaches to Stop Hypertension (DASH),

Source: Adapted from Mosca L, et al. Circulation (2011), Vol. 123, No. 12, pp. 1243-62

It’s true that women are more likely than men to have microvessel disease, a condition in which the smaller blood vessels that feed the heart muscle fail to dilate properly, depriving the heart of oxygen and causing chest pain. But the best test for microvessel disease, called fractional flow reserve, is not a screening test. It’s an invasive procedure that’s reserved for women who have symptoms and a positive exercise stress test and plan to undergo cardiac catheterization.

One thing I should mention about your family history: if a close relative suffered a sudden early death (for any reason), you should probably have an electrocardiogram (ECG), if you haven’t had one already — to establish a baseline and to look for any evidence of an increased risk for abnormal heart rhythms.

The most important thing you can do to protect yourself from cardiovascular disease is to stay on top of your risk factors and aim for a healthy lifestyle (see “Criteria for ideal cardiovascular health in women”). I can’t emphasize healthy living enough. The Nurses’ Health Study found that women who had a healthy lifestyle, including a prudent diet, regular exercise, and not smoking, reduced their risk by an astounding 80%.

— Paula A. Johnson, M.D.
Harvard Women’s Health Watch Editorial Board

Posted by: Dr.Health

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