CVD is the leading cause of death in women. Women's heart disease risk tends to lag about 10 years behind that of men; thus, at any given age, a woman's baseline risk will be lower than that of a man's baseline risk. While some heart disease risk factors such as age and family history are not modifiable, other risk factors such as hypertension, hyperlipidemia, smoking, obesity, and diabetes are potentially modifiable. Additionally, sex-specific risk factors may impact a woman's risk of future heart disease, including adverse pregnancy outcomes (ie, preeclampsia, gestational diabetes, preterm birth, or small for gestational age birth), premature ovarian failure or early menopause, or comorbidities such as autoimmune disease or the sequelae of cancer treatments (ie, chest wall radiation, or trastuzumab or anthracycline treatment for breast cancer). Each of these may be considered a "risk-enhancer" when considering future CVD risk.
Decision making about preventive treatment is affected by overall cardiovascular risk. The Framingham risk calculator (https://www.mdcalc.com/framingham-risk-score-hard-coronary-heart-disease) can be used to estimate a woman's 10-year risk of CHD based on her age, smoking status, blood pressure, and cholesterol levels. In addition to the risk factors in the Framingham risk calculator, the pooled cohort equations to predict 10-year risk of atherosclerotic CVD (ASCVD) includes self-identified race (White or other versus African American) and diabetes (http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx). The 2018 American Heart Association/American College of Cardiology Multi-society Cholesterol Guideline encourages clinicians to elicit a history of risk-enhancers specific to women and consider elevating a patient to a higher risk category when one or more are present.
Beyond treatment of risk factors such as hypertension, diabetes, and hyperlipidemia, decision making about whether to take aspirin for CVD prevention is important. Some studies have suggested that aspirin may be helpful for primary prevention of stroke in women but not for primary CHD prevention. Recent studies, however, suggest that aspirin may not reduce all-cause mortality when used for primary prevention for those with moderate risk of atherosclerotic disease, including healthy older adults. Guidelines regarding aspirin for primary prevention of CVD are not sex-specific and focus on balancing the overall risk of CVD against the risk of bleeding. CVD, risk factors, and therapeutic options for risk factor reduction and prevention are discussed in Chapter 1-04.