Focus on preventing cardiovascular disease by addressing modifiable risk factors, as over 90% of CVD is due to preventable causes. There is much that can be done for prevention.
Implement ASCVD prevention strategies, especially those targeting ApoB/LDL, as early as possible in life to minimize cumulative exposure. Prevention is better implemented when started earlier to prevent unchecked atherosclerosis propagation.
Actively work to minimize lifetime exposure to ApoB (and LDL cholesterol) by starting interventions earlier and aiming for lower concentrations. This strategy minimizes the ‘area under the curve’ of ApoB exposure, reducing long-term risk.
Treat causal agents of ASCVD, such as high blood pressure and elevated ApoB, early in life, even if short-term risk scores are low. Ignoring these high values does a disservice by allowing silent vascular damage to continue.
Adopt a long-term perspective on health, focusing on preventing major adverse cardiac events over a lifetime (e.g., 40 years) rather than just short-term (e.g., 10-year) risk. This approach emphasizes comprehensive prevention for sustained health.
Prioritize and emphasize healthy lifestyle practices, including diet and exercise, from childhood as a fundamental strategy for preventing obesity and cardiometabolic diseases. This is crucial for reversing alarming trends in cardiovascular disease mortality.
Engage in regular physical activity to improve overall cardiovascular risk, aid in weight maintenance, and increase fitness levels. Being more fit is one of the strongest favorable factors for lower cardiovascular risk.
Follow a Mediterranean-style dietary pattern, which is generally low in saturated fats, high in unsaturated fats, fruits, vegetables, and whole grains, for cardiovascular health. This diet is palatable and supported by observational and clinical trial data.
Actively address mental health, including managing stress, anxiety, and depression, as psychological factors directly and indirectly impact cardiovascular health. Stress can activate the sympathetic nervous system, increasing heart rate, blood pressure, and inflammation.
Recognize that managing cardiovascular risk effectively requires a combined approach of pharmacotherapy (if needed) and consistent healthy lifestyle changes, including diet and exercise. This comprehensive strategy is essential for optimal patient outcomes.
Prioritize healthy living in the first half of life to maximize options and minimize morbidity and mortality in the second half. This includes choices around menopause and cardiovascular health, giving you more flexibility later in life.
Be aware of Familial Hypercholesterolemia (FH) and advocate for screening, especially if LDL is above 190 mg/dL or there’s a family history of premature ASCVD. Early treatment is critical to prevent early onset myocardial infarction, which affects 30% of untreated women with FH before age 60.
For high-risk individuals, especially those with established ASCVD, ensure lipid-lowering therapy is intensified to reach LDL goals, utilizing combination therapy including PCSK9 inhibitors if necessary. Many patients are undertreated and not at goal, leading to continued risk.
Understand that statins are effective for women in both primary and secondary prevention of ASCVD, providing similar benefits to men without interaction by sex. Misconceptions that statins don’t work in women are false, as meta-analyses confirm their efficacy.
For very high-risk patients (e.g., recent coronary syndrome), initiate high-intensity statin therapy upfront and consider early combination therapy to achieve aggressive LDL lowering. This approach aims for optimal LDL reduction as quickly as possible.
If statins are not tolerated or insufficient, explore alternative lipid-lowering agents like ezetimibe, PCSK9 inhibitors, or bempedoic acid with your doctor to reach LDL goals. These options provide additional pathways to manage high cholesterol effectively.
If experiencing statin-associated muscle symptoms, discuss a re-challenge with your doctor, as many reported symptoms may be due to the nocebo effect rather than the medication itself. Up to 90% of reported symptoms in some trials were elicited by placebo.
If statin-reluctant or intolerant, discuss starting with a very low dose (e.g., Rosuvastatin 5mg) to build trust and demonstrate tolerance. This can be a strategy to gradually increase or combine therapies later once the patient is comfortable.
Understand that there is no strong data supporting the effectiveness of CoQ10 or Vitamin D supplements in preventing statin-associated muscle symptoms, though they may be taken for comfort. Physicians do not actively prescribe them for this purpose due to lack of evidence.
Consider measuring Lipoprotein(a) (Lp(a)) to assess residual cardiovascular risk, especially if LDL is low, as elevated Lp(a) can still contribute significantly to ASCVD risk. It is causally related to ASCVD and calcific aortic stenosis.
If you have elevated Lp(a) and another indication for intensive lipid lowering (e.g., elevated LDL, ASCVD), discuss PCSK9 inhibitors with your doctor, as they can modestly lower Lp(a) by 20-25%. Individuals with higher Lp(a) levels have shown greater benefit from these therapies.
Improve cardiometabolic health in young adults and women of reproductive age, ideally before pregnancy, to prevent adverse pregnancy outcomes and long-term cardiovascular complications. Poor cardiometabolic health before pregnancy increases risks like preeclampsia and gestational diabetes.
Actively work to optimize cardiometabolic health not only before pregnancy but also in the inter-pregnancy period to prevent long-term cardiovascular complications. Women tend to gain weight with each pregnancy, and dysregulation of adipokines may occur.
For women with FH planning pregnancy, discuss with a lipid specialist about short-term interruptions of statin therapy during conception, pregnancy, and breastfeeding, rather than prolonged non-treatment. Short interruptions are better than decades of untreated high LDL.
Women with FH or established cardiovascular disease should consider long-acting reversible contraception like IUDs or barrier methods, and avoid higher-estrogen oral contraceptives, especially if over 35. This is due to increased risk for atherosclerosis and prothrombotic effects of estrogen.
If you have PCOS, prioritize optimizing a healthy lifestyle and weight management to mitigate associated cardiometabolic risks like hypertension and dyslipidemia. Insulin resistance is a hallmark of PCOS, driving many of these complications.
For women with PCOS who are not trying to become pregnant, discuss GLP-1 receptor agonists with your doctor as a potential option for weight management and improving insulin resistance. These agents may be promising for managing the cardiometabolic phenotype of PCOS.
If struggling with obesity or overweight with risk factors, discuss GLP-1 receptor agonists with your doctor as a potential pharmacological aid for weight loss and improved cardiovascular health, in conjunction with diet and lifestyle. These agents have shown significant weight loss and may be cardiovascularly beneficial.
Do not use hormone replacement therapy (HRT) solely for cardiovascular disease prevention, as more effective and safer alternatives like statins are available. Guidelines do not recommend HRT for this purpose due to mixed outcomes in trials, especially in older women.
If experiencing symptomatic menopause (hot flashes, night sweats) and are under 60 or within 10 years of menopause, discuss hormone therapy with your doctor, provided there are no contraindications. Vasomotor symptoms can be very disabling and are associated with cardiovascular risk.
If experiencing early menopause (before age 45 or 40), consider menopausal hormone therapy until at least the natural age of menopause (around 51), provided there are no contraindications. Early menopause is associated with increased cardiovascular risk.
If considering HRT and cardiovascular risk is uncertain, discuss getting a coronary artery calcium (CAC) score. A zero score may provide reassurance for initiating HRT for vasomotor symptoms, but significant atherosclerotic disease would lead to not recommending it.
Avoid oral estrogens for hormone therapy if you have a history of cardiovascular disease, blood clots, high triglycerides, gallbladder disease, or prior breast and endometrial cancer. These conditions are contraindications due to increased risks of adverse events.
If experiencing only genitourinary symptoms of menopause, vaginal estrogens can be used safely, even if you have cardiovascular disease or a history of stroke. They have minimal systemic absorption, making them a good option for high-risk women.
For women, if serial lipid panels are being monitored, aim to measure them around the same time in the menstrual cycle, ideally during menses (e.g., day 5), for consistent and comparable results. This accounts for natural fluctuations in lipid levels throughout the cycle.
Do not use lipid panels taken during pregnancy as a baseline, as physiological changes cause significant, temporary increases in cholesterol and triglycerides. Obtain a baseline before pregnancy if concerns exist, as levels return to pre-pregnancy levels after delivery.
In high-risk primary prevention patients with very high coronary artery calcium scores (e.g., above 300), consider PCSK9 inhibitors in addition to high-intensity statins to achieve aggressive LDL lowering. A high CAC score indicates significant plaque burden, warranting intensive treatment.
If diagnosed with FH, consider genetic testing to identify specific mutations, which can inform cascade screening for family members and provide a more precise risk assessment. This helps in identifying monogenic FH versus polygenic risk.
Promote healthy lifestyles and dietary changes starting even before birth (in utero) for optimal long-term health. This foundational approach can significantly impact an individual’s health trajectory.
For those entering science and medicine, gain bench lab work experience. This provides a good foundation and understanding of scientific processes.
Engage in hobbies for personal enjoyment and goal-setting, rather than striving for perfection or external validation. The act of doing something and setting goals for yourself can be fun and rewarding, regardless of skill level.
Subscribe to the podcast’s membership program for in-depth health and wellness knowledge. This offers exclusive content to take your understanding to the next level.
Advocate for and support population-level interventions and policy changes that address social determinants of health. This includes improving access to quality food, safe exercise spaces, and reducing sedentary lifestyles to combat widespread health problems.
Advocate for and support increased representation of women in clinical trial leadership and steering committees. Greater female representation correlates with better enrollment of women participants and more sex-specific analyses in studies.
Advocate for patient-centered clinical trial designs that actively involve patients, especially women, to address practical barriers to participation. This includes considering factors like transportation, childcare, and flexible follow-up options.
If considering clinical trial participation, seek education to dispel misconceptions and understand the benefits. Participants often gain access to gold-standard care and study investigators, even if the drug’s efficacy is unknown.
Advocate for less restrictive inclusion/exclusion criteria in clinical trials, particularly for women of childbearing age. Women should be eligible if they have a plan for preventing pregnancy and adequate contraception.
Support and advocate for more clinical trials specifically involving pregnant women to better understand the efficacy and safety of interventions during pregnancy. This is crucial for improving maternal and fetal health outcomes.