Life's Essential 8™ - Women's Cardiovascular Health Program

"Women's hearts matter - they beat differently"

Cardiovascular disease is the leading cause of death in women globally, claiming more women's lives than all cancers combined. Yet for decades, women's cardiovascular health was overlooked - underdiagnosed, undertreated, and underresearched. Women were largely excluded from early cardiovascular trials, symptoms were dismissed as "anxiety," and heart disease was considered a "man's disease."

The reality: 1 in 3 women dies from cardiovascular disease. In the United States, CVD kills approximately 400,000 women annually - more than the next 7 causes of death combined. Yet awareness remains dangerously low: only 44% of women recognize CVD as their leading killer.

Women face unique cardiovascular risks throughout their lives - from pregnancy complications that predict future disease, to menopause-related metabolic changes, to sex-specific risk factors and atypical symptoms. Traditional risk assessment tools (developed primarily in men) underestimate women's risk, leading to delayed diagnosis and treatment.

This program addresses these critical gaps by providing comprehensive, evidence-based cardiovascular care tailored specifically to women - across all life stages, recognizing the biological, hormonal, and social factors that uniquely impact women's cardiovascular health.

Program Overview

Why Women Need Specialized Cardiovascular Care

Aspect	Sex/Gender Differences	Clinical Implication
Anatomy	• Smaller hearts, coronary arteries • Thinner vessel walls • Different plaque morphology	• More microvascular dysfunction (angina without obstructive CAD) • Spontaneous coronary artery dissection (SCAD) more common • Different stent sizing, procedural considerations
Symptoms	• Less likely to present with "classic" chest pain • More "atypical" symptoms: Fatigue, shortness of breath, nausea, back/jaw pain	• Delayed recognition by patients AND providers • Longer time to treatment • Higher mortality post-MI
Risk Factors	• Sex-specific: Pregnancy complications (preeclampsia, gestational diabetes), PCOS, early menopause • Traditional risk factors impact differently: Diabetes ↑ risk MORE in women (3-7× vs 2-3× men), Smoking ↑ risk MORE in women	• Standard risk calculators underestimate women's risk • Need to assess pregnancy history, reproductive factors • More aggressive management needed for some risk factors
Hormonal Influences	• Estrogen protective (premenopausal women lower risk) • Menopause → rapid ↑ risk (loss of protection + metabolic changes) • Oral contraceptives, HRT considerations	• CVD risk accelerates post-menopause • Timing of interventions matters (perimenopause = critical window) • Hormonal therapies have CV implications
Treatment Response	• Different pharmacokinetics (body composition, hormones affect drug metabolism) • More side effects from some medications • Less likely to receive guideline-directed therapy	• Dose adjustments may be needed • Monitor side effects closely • Address treatment disparities
Psychosocial	• More depression/anxiety (independent CV risk factors) • Caregiver burden • Healthcare access barriers • Symptoms dismissed ("it's just stress/anxiety")	• Screen for depression, address mental health • Consider social support needs • Advocacy, awareness critical • Validate symptoms, take seriously

Target Population

All adult women (≥18 years) - prevention across lifespan
Special focus populations:
- Women with pregnancy complications (preeclampsia, gestational diabetes, preterm birth)
- Perimenopausal/postmenopausal women (age 45-65+ - highest risk period)
- Women with PCOS, autoimmune diseases
- Young women with premature CVD (<55 years)
- Women from high-risk racial/ethnic groups (African American, Hispanic, South Asian)

Program Goals

Goal	Strategies	Outcomes
Awareness	Education campaigns, community outreach, media engagement	↑ Women recognize CVD as #1 killer ↑ Knowledge of symptoms ↑ Engagement in prevention
Risk Assessment	Comprehensive evaluation including sex-specific factors, validated tools, pregnancy history	Accurate risk stratification Identify high-risk women early Personalized prevention plans
Prevention	Life's Essential 8™ optimization, lifestyle counseling, risk factor management	Achieve optimal LE8 scores ↓ BP, LDL, glucose Healthy weight, diet, activity
Early Detection	Symptom recognition, appropriate testing (stress tests, coronary CTA, etc.), timely diagnosis	↓ Diagnostic delays Detect ischemia, SCAD, microvascular dysfunction Prompt treatment
Treatment	Guideline-directed medications, interventions, cardiac rehabilitation, mental health support	Eliminate treatment disparities Improve outcomes post-MI, stroke Quality of life optimization
Advocacy	Empower women, provider education, research participation, policy engagement	Women advocate for own health Providers recognize women's CVD ↑ Women in research Policy supports women's CV health

Life Stage Approach

Women's cardiovascular risk evolves across lifespan - program addresses unique needs at each stage

Stage 1: Reproductive Years (18-40 years)

Key Considerations

Foundation building: Establish healthy habits early (easier to maintain than change later)
Pregnancy planning: Optimize CV health before conception (control BP, glucose, weight)
Pregnancy complications: Preeclampsia, gestational diabetes, preterm birth = long-term CV risk markers
Contraception: Cardiovascular implications (estrogen-containing contraceptives + smoking = ↑ thrombosis risk)
PCOS: Affects 10% women - insulin resistance, metabolic syndrome, future diabetes/CVD risk

Program Components

1. Preconception Counseling

For all women planning pregnancy:
- CV risk assessment: BP, weight, glucose, lipids, smoking status
- Optimization goals: BP <130/80, normal glucose/HbA1c, healthy BMI (18.5-25), smoking cessation
- Medication review: Stop ACE-I/ARBs (teratogenic), statins (safety unclear - usually stopped)
- Folic acid supplementation: 400-800 mcg/day (prevents neural tube defects, may ↓ preeclampsia risk)
For women with CV disease or risk factors:
- Cardiology consultation: Assess pregnancy risk (modified WHO classification)
- High-risk conditions: Pulmonary HTN, severe AS, Marfan with aortic dilation, peripartum cardiomyopathy history - pregnancy may be contraindicated or require intensive monitoring
- Moderate-risk: Repaired congenital heart disease, prosthetic valves, prior MI - pregnancy possible with close monitoring
- Shared decision-making: Risks vs benefits, alternative family-building options if pregnancy contraindicated

2. Pregnancy Monitoring & Postpartum Care

Complication	Long-term CV Risk	Postpartum Management
Preeclampsia (HTN + proteinuria after 20 weeks)	• ↑ 2-4× risk HTN • ↑ 2× risk stroke, CAD • Earlier CVD onset (10-15 years sooner)	• BP monitoring: 7-10 days postpartum, 6 weeks, annually lifelong • Aspirin 81 mg daily (may ↓ recurrent preeclampsia in future pregnancies) • Aggressive lifestyle modification • Treat HTN promptly (don't wait for 140/90 - consider 130/80 threshold)
Gestational Diabetes	• ↑ 7-10× risk type 2 diabetes • ↑ 2× risk CVD • 50% develop diabetes within 10 years	• Glucose testing: 6-12 weeks postpartum (OGTT or HbA1c), then every 1-3 years lifelong • Intensive lifestyle intervention (DPP model - ↓ 58% progression to diabetes) • Metformin if high risk (HbA1c ≥6.0%) + unable to achieve lifestyle goals • Breastfeeding encouraged (↓ future diabetes risk)
Preterm Birth (<37 weeks)	• ↑ 2× risk CVD • ↑ HTN risk • Particularly if recurrent or very preterm (<32 weeks)	• CV risk assessment postpartum • Annual BP, metabolic screening • Lifestyle optimization • Consider underlying causes (chronic HTN, diabetes, autoimmune disease)
Placental Abruption, Stillbirth	• ↑ CVD risk (vascular dysfunction)	• Thorough evaluation for underlying thrombophilia, autoimmune disease • CV risk factor management
Peripartum Cardiomyopathy (PPCM)	• Heart failure in late pregnancy or early postpartum • 25-50% have persistent LV dysfunction • ↑ Risk recurrence future pregnancies	• Cardiology follow-up lifelong • HF management (ACE-I, beta-blockers) • Contraception counseling (future pregnancy very high risk if EF <30-40%) • Avoid subsequent pregnancies if persistent dysfunction

⚠️ Critical message: Pregnancy complications are NOT "over when pregnancy ends" - they're WARNING SIGNS of future CVD risk. Require lifelong surveillance and prevention.

3. PCOS Management

Diagnosis: 2 of 3 criteria - Irregular periods (oligomenorrhea), Hyperandrogenism (hirsutism, acne, elevated testosterone), Polycystic ovaries on ultrasound
CV risk factors: Insulin resistance (70%), metabolic syndrome (40-50%), obesity (50-60%), dyslipidemia, ↑ future diabetes (4-7×), HTN
Management:
- Weight loss (5-10% if overweight) - improves insulin sensitivity, ovulation, metabolic parameters
- Metformin - improves insulin resistance, may restore ovulation, modest weight loss
- Oral contraceptives - regulate menstruation, ↓ androgens (BUT monitor BP, lipids - OCPs can worsen in some)
- Lifestyle - diet (low glycemic index), exercise (150-300 min/week)
- Screening - annual glucose, lipids, BP

4. Contraceptive Counseling

Estrogen-containing contraceptives (combined OCPs, patch, ring):
- Contraindicated if: Age >35 + smoking (↑↑ thrombosis risk), HTN (>160/100), migraine with aura (↑ stroke), prior thrombosis, known thrombophilia
- Caution if: Age >35, controlled HTN (130-160/80-100), obesity, diabetes, dyslipidemia - may use but monitor BP, consider alternative
- Safe if: Young, healthy, no risk factors
Progestin-only methods (mini-pill, IUD, implant, injection):
- No estrogen → no thrombosis risk
- Safe even in women with CV contraindications to estrogen
- Preferred if age >35 + smoking, HTN, diabetes, prior thrombosis
Non-hormonal options: Copper IUD, barrier methods, sterilization

Clinical Vignette

Maria, 32 years old

Presented for postpartum visit 8 weeks after delivery. Had preeclampsia at 36 weeks (BP 155/98, proteinuria), delivered by C-section. Baby healthy. Maria recovered well, BP normalized postpartum (now 125/78 off medications). She's breastfeeding, not planning more children soon.

Assessment: History of preeclampsia = lifelong 2-4× ↑ CV risk.

Plan:

Education: Explain long-term CV risk, need lifelong prevention
BP monitoring: Home BP monitor, check weekly, annual visit (don't wait for symptoms)
Lifestyle: DASH diet, 150 min/week exercise (currently sedentary - start walking with baby in stroller), maintain healthy weight (BMI currently 23 - good)
Aspirin 81 mg daily: May ↓ recurrent preeclampsia risk if future pregnancy, possible CV benefit (discuss with OB)
Contraception: Prefers IUD - place Mirena (progestin-only, safe, effective, doesn't interfere breastfeeding)
Metabolic screening: Annual BP, fasting lipids, glucose (at higher risk for diabetes, metabolic syndrome)
Future pregnancy planning: If considers pregnancy, preconception visit - aspirin 81 mg starting 12 weeks gestation (↓ recurrent preeclampsia 10-20%), close monitoring
Follow-up: 6 months, then annually cardiology prevention clinic

Stage 2: Perimenopause & Early Postmenopause (40-60 years)

Key Considerations

Menopausal transition: Average age 51 (range 45-55). Hormonal fluctuations → symptoms + metabolic changes.
CV risk acceleration: Within 10 years post-menopause, women's CVD risk approaches men's (loss of estrogen protection + metabolic syndrome development)
Metabolic changes: ↑ Visceral adiposity (even without weight gain), ↑ insulin resistance, dyslipidemia (↑ LDL, ↓ HDL, ↑ triglycerides), ↑ BP
Critical prevention window: Perimenopause/early postmenopause = opportunity for aggressive risk factor modification before CVD develops

Program Components

1. Comprehensive Risk Assessment

Beyond standard ASCVD calculator (which underestimates women's risk):

Assessment Component	Tools/Tests	Interpretation
Traditional Risk Factors	Age, BP, lipids, diabetes, smoking, family history	ASCVD 10-year risk calculator (baseline)
Sex-Specific Factors	• Pregnancy history (preeclampsia, GDM, preterm) • Age at menopause (early <45 = ↑ risk) • PCOS • Autoimmune diseases (RA, lupus - 2-3× ↑ CVD)	Risk enhancers - consider treating at lower traditional risk thresholds
Subclinical Atherosclerosis	• Coronary artery calcium (CAC) score • Carotid intima-media thickness (IMT)	If CAC >0 (especially >100) → high risk, treat aggressively even if calculator shows "intermediate"
Advanced Lipids	ApoB, Lp(a), LDL particle number	If borderline by standard lipids, advanced testing refines risk
Inflammatory Markers	hs-CRP	If >2 mg/L = ↑ risk (particularly if other risks borderline)

Example: 52-year-old woman

Standard ASCVD risk: 8% (borderline - might not treat)
BUT: History of preeclampsia + early menopause age 48 + CAC score 85
Revised risk: HIGH → Statin indicated, aggressive BP/lifestyle management

2. Menopause Symptom Management (CV Considerations)

Symptom	Treatment Options	CV Considerations
Vasomotor (Hot flashes, night sweats)	• HRT: Estrogen + progestin (or estrogen alone if post-hysterectomy) • Non-hormonal: SSRIs (paroxetine, venlafaxine), gabapentin, cognitive behavioral therapy • Lifestyle: Dress in layers, fans, avoid triggers (spicy foods, alcohol, stress)	HRT CV effects (controversial): • Timing hypothesis: Early postmenopause (<10 years or age <60) - HRT neutral/possibly beneficial CV effect • Late postmenopause (>10 years or age >60) - HRT ↑ CV risk (WHI trial) • Contraindications: Prior MI/stroke, active CVD, high risk → NO HRT • Low risk + severe symptoms: HRT reasonable (lowest dose, shortest duration) • Transdermal estrogen preferred (↓ thrombosis risk vs oral)
Genitourinary (Vaginal dryness, atrophy)	• Vaginal estrogen (low-dose, local) • Vaginal moisturizers, lubricants	Vaginal estrogen: Minimal systemic absorption → safe even if CV disease
Mood, Sleep	• HRT may help • Antidepressants if depression • Sleep hygiene, CBT-I	Depression = independent CV risk factor → screen, treat appropriately
Bone Health	• DEXA scan age ≥65 (earlier if risk factors) • Calcium 1,200 mg/day, Vitamin D 800-1,000 IU • Weight-bearing exercise • Bisphosphonates if osteoporosis	Osteoporosis and CVD share risk factors (inflammation, estrogen deficiency) Exercise for bone health = also CV benefit

⚠️ HRT decision complex - individualize based on symptoms, CV risk, timing. Not for CV prevention (despite early hopes) but not absolutely contraindicated if low risk + severe symptoms.

3. Weight Management (Critical This Stage)

Challenge: Menopause → metabolic slowdown + visceral fat ↑ (even if weight stable) → harder to lose weight, easy to gain
Goal: Maintain healthy BMI (<25), prevent visceral adiposity accumulation
Strategies:
- Caloric adjustment: May need ↓ 200-300 kcal/day vs premenopausal to maintain weight (metabolic rate ↓)
- Protein: ↑ To 1.0-1.2 g/kg (preserves muscle mass during weight loss, ↑ satiety)
- Strength training: Essential (builds muscle → ↑ metabolic rate, prevents sarcopenia)
- Mediterranean/DASH diet: Particularly effective this age group
- Avoid: Fad diets, extreme restriction (lose muscle, rebound weight gain)
Pharmacotherapy: If BMI ≥30 (or ≥27 + comorbidities) + lifestyle insufficient → consider GLP-1 agonist (semaglutide - effective, CV benefits in SELECT trial)

4. Lipid Management

Menopause effect: LDL ↑ 10-20%, HDL ↓, triglycerides ↑ (even without weight gain)
Screening: Fasting lipid panel at menopause, then every 4-6 years (or more often if abnormal/on treatment)
Treatment:
- Lifestyle first: Mediterranean diet, plant sterols (2g/day), exercise, weight loss
- Statin if: 10-year ASCVD risk ≥7.5% OR risk enhancers (pregnancy complications, early menopause, CAC >0, family history premature CVD)
- Goal: LDL <100 mg/dL (primary prevention), <70 mg/dL (if high risk or CVD)
- Don't withhold statins due to "age/female" - women benefit equally from statins (CTT meta-analysis)

5. Blood Pressure Management

Menopause effect: BP ↑ average 5 mmHg systolic (hormonal changes + vascular aging + weight gain)
Prevalence HTN: Premenopausal ~25%, Postmenopausal ~55% (age 60+: >75%)
Management:
- Lifestyle: DASH diet (particularly effective in women), sodium <1,500 mg/day, weight loss, exercise
- Home BP monitoring: Essential (white coat HTN common in women)
- Medications: If lifestyle insufficient or BP ≥130/80
  - First-line: Thiazide diuretic, ACE-I, ARB, or CCB
  - Goal: <130/80 (most women), <140/90 if age >65 + frail/high fall risk

Clinical Vignette

Susan, 53 years old

Presents for annual exam. Menopause 2 years ago (last period age 51). Complains of hot flashes (disrupting sleep), weight gain 10 lbs despite "trying to diet." No prior CVD. Mother had MI age 62. Non-smoker. BP today 138/84. Labs: LDL 155 mg/dL, HDL 48 mg/dL, triglycerides 175 mg/dL, glucose 102 mg/dL, BMI 28 (was 26 premenopause).

Assessment:

ASCVD 10-year risk: 6.5% (intermediate)
BUT risk enhancers: Family history premature CVD (mother MI <65), metabolic syndrome emerging (↑ BP, triglycerides, glucose, waist circumference), menopausal lipid changes
→ Classify as HIGH RISK

Plan:

Risk refinement: Order CAC score. If >0 → definitely statin. If 0 → may defer statin, intensify lifestyle.
Lifestyle intensive (most important this stage):
- Diet: Mediterranean/DASH, goal 1,500 mg sodium, ↓ 300 kcal/day (current ~1,800, goal ~1,500)
- Exercise: Currently walks 2×/week. Goal: 5×/week 30 min brisk walking + 2×/week strength training (resistance bands, weights)
- Weight goal: Lose 10 lbs (BMI 26 → reduce visceral fat, improve all metrics)
- Referral: Dietitian (3 sessions covered by insurance), consider group DPP program if prediabetes worsens
BP: Home monitoring 1 week (morning + evening), bring log to follow-up. If confirm ≥130/80 → start lisinopril 10 mg daily.
Lipids: Await CAC. If elevated or >0 → atorvastatin 10-20 mg. Goal LDL <100 mg/dL.
Glucose: Prediabetes (102 mg/dL). HbA1c 5.8% (confirms). Lifestyle + metformin 500 mg daily (prevent progression).
Hot flashes: Moderate severity, disrupting sleep. Options discussed:
- Low-dose HRT (estradiol patch 0.025 mg + progesterone 100 mg nightly) - CV risk intermediate, likely safe if start now (within 10 years menopause), reevaluate annually
- Non-hormonal: Paroxetine 7.5 mg if prefers avoid hormones
- She chooses HRT trial (symptoms severe, low CV risk currently)
Follow-up: 3 months - recheck BP, lipids, weight, symptoms. Adjust medications as needed. Then every 6 months prevention clinic.

Stage 3: Postmenopause & Aging (60+ years)

Key Considerations

Highest CVD risk period: CVD incidence accelerates age 60+ (hormonal protection long gone + risk factor accumulation + aging vascular changes)
Comorbidities accumulate: HTN (>75%), dyslipidemia (>50%), diabetes (~25%), multiple medications (polypharmacy)
Atypical presentations common: Silent MIs, HF with preserved EF (HFpEF - 80% are women), atrial fibrillation
Frailty considerations: Balance fall risk, medication side effects, quality of life vs aggressive risk factor control

Program Components

1. Comprehensive Geriatric CV Assessment

Functional status: ADLs (activities daily living), IADLs (instrumental ADLs), mobility, exercise capacity
Cognitive screening: Mini-Cog, Montreal Cognitive Assessment (MoCA) - impacts medication adherence, self-management
Frailty assessment: Fried criteria (weight loss, exhaustion, weakness, slow gait, low activity) - predicts outcomes, guides treatment intensity
Polypharmacy review: Medication reconciliation, deprescribing when appropriate (Beers criteria - avoid certain medications in elderly)
Fall risk: History of falls, orthostatic hypotension testing, vision/hearing, home safety assessment
Social support: Living situation, caregiver availability, transportation, financial resources

2. Individualized Treatment Goals

Clinical Scenario	BP Goal	LDL Goal	HbA1c Goal (if diabetic)	Rationale
Robust (Active, healthy, no frailty, life expectancy >10 years)	<130/80	<100 (primary prevention) <70 (CVD)	<7.0-7.5%	Full benefit of risk reduction, time to see benefits, tolerate treatments well
Intermediate (Some comorbidities, mild frailty, life expectancy 5-10 years)	<140/90	<100	<7.5-8.0%	Balance benefits vs side effects/burden, individualize
Frail/Limited Life Expectancy (Multiple comorbidities, ADL dependence, life expectancy <5 years)	<150/90 (Avoid <110 systolic)	Symptomatic treatment only (don't start new statins)	<8.0-8.5% (Avoid hypoglycemia)	Prioritize quality of life, symptom management, avoid treatment harms (falls, hypoglycemia). Benefits take years - may not live to see them.

3. Heart Failure Prevention & Management

HFpEF predominates in older women: ~80% elderly HF patients are women, most have HFpEF (preserved EF ≥50%)
Prevention: Optimal BP control (most important), treat obesity, manage diabetes, address OSA, control AFib
Diagnosis: Often delayed (dyspnea attributed to "aging," deconditioning). Maintain high suspicion. BNP/NT-proBNP if suspected. Echo confirms (diastolic dysfunction, normal EF).
Treatment: Diuretics (symptom relief), SGLT2 inhibitor (empagliflozin, dapagliflozin - ↓ HF hospitalizations in EMPEROR-Preserved, DELIVER trials), BP control, treat comorbidities, cardiac rehabilitation

4. Atrial Fibrillation Management

Prevalence: ↑ With age - ~10% age 65-75, ~20% age >80. Women live longer → more AFib burden overall.
Stroke risk: Women with AFib have ~40% higher stroke risk than men with AFib (sex = risk factor in CHA₂DS₂-VASc score)
Anticoagulation:
- Indicated if CHA₂DS₂-VASc ≥2 (almost all women with AFib age >65 meet threshold)
- DOACs preferred (apixaban, rivaroxaban, edoxaban, dabigatran) - safer than warfarin (↓ intracranial hemorrhage), more convenient (no INR monitoring)
- Bleeding risk assessment (HAS-BLED) - but don't withhold anticoagulation just due to age. Benefits > risks in most.
- Falls NOT absolute contraindication (would need fall 295 times/year for fall risk to outweigh stroke prevention benefit)
Rate vs rhythm control: Rate control often preferred in elderly (beta-blockers, CCBs - diltiazem/verapamil). Rhythm control (antiarrhythmics, ablation) if symptomatic despite rate control.

5. Multidisciplinary Care

Cardiology: CV risk management, HF, AFib
Primary care: Coordination, preventive care, comorbidity management
Geriatrics: Comprehensive geriatric assessment, polypharmacy management, advance care planning
Pharmacist: Medication review, adherence strategies, patient education
Cardiac rehabilitation: Exercise prescription, nutritional counseling, psychological support
Social work: Resources, home health, placement if needed
Palliative care: If advanced disease/frailty - symptom management, goals of care discussions

Clinical Vignette

Dorothy, 78 years old

Presents with progressive dyspnea on exertion over 6 months. Can no longer walk to mailbox without stopping. Denies chest pain. Has HTN (on lisinopril 20 mg, HCTZ 12.5 mg), hyperlipidemia (atorvastatin 40 mg), osteoarthritis. Lives alone, independent ADLs, daughter nearby. BP today 145/78. Exam: Bibasilar crackles, trace peripheral edema, JVP elevated 10 cm. Labs: BNP 450 pg/mL (elevated). ECG: Atrial fibrillation (new). Echo: EF 55% (normal), severe diastolic dysfunction, moderate LA enlargement.

Diagnosis: HFpEF, new-onset atrial fibrillation

Plan:

HFpEF management:
- Diuretics: Furosemide 20 mg daily (symptom relief, titrate to euvolemia)
- SGLT2i: Empagliflozin 10 mg daily (↓ HF hospitalizations - EMPEROR-Preserved)
- BP optimization: Currently 145/78 - add amlodipine 5 mg daily (CCB for HTN + AFib rate control)
- Continue statin (secondary prevention now that has CVD)
- Dietary: Sodium restriction <2g/day, fluid 1.5-2L/day, daily weights (↑ 3 lbs in 2 days → call)
Atrial fibrillation:
- Rate control: Amlodipine 5 mg (above) + add metoprolol succinate 25 mg daily. Target HR 60-100 rest, <110 with activity.
- Anticoagulation: CHA₂DS₂-VASc = 5 (female + age 75-84 + HTN + HF) → HIGH stroke risk. Apixaban 5 mg BID (DOAC preferred, safer than warfarin). Assess bleeding risk: No history GI bleed, no falls, creatinine normal → safe.
Functional optimization:
- Cardiac rehabilitation: Refer - structured exercise improves symptoms, functional capacity, quality of life in HFpEF
- PT evaluation: Gait, balance, fall risk assessment
Monitoring:
- F/u 1 week: Symptoms, weight, BP, HR
- F/u 1 month: Repeat echo, BNP (assess response to therapy), adjust medications
- Teach: Daily weights, symptom diary, when to call (worsening dyspnea, weight gain, dizziness)
Advance care planning: Discuss goals, preferences if decompensate (hospitalization vs comfort care), complete advance directive

Special Topics in Women's CV Health

1. Spontaneous Coronary Artery Dissection (SCAD)

Definition: Tear in coronary artery wall (not from plaque rupture) → intramural hematoma → vessel occlusion → MI
Epidemiology: Rare cause MI overall (<4%) BUT accounts for 25-35% of MIs in women <50 years. 90% of SCAD patients are women.
Risk factors: Female sex (hormonal), fibromuscular dysplasia (50% SCAD patients), pregnancy/postpartum (10-20% cases), emotional/physical stress, connective tissue disorders (Ehlers-Danlos, Marfan)
Presentation: Acute MI (chest pain, ST elevation or NSTEMI) in young woman without traditional risk factors
Diagnosis: Coronary angiography shows characteristic appearance (radiolucent flap, contrast staining, long smooth stenosis) WITHOUT atherosclerosis. OCT (optical coherence tomography) or IVUS (intravascular ultrasound) confirms intramural hematoma.
Treatment:
- Conservative (preferred): Medical management - aspirin, beta-blocker, ACE-I/ARB. 70-80% heal spontaneously. PCI ONLY if ongoing ischemia, hemodynamic instability (high complication rate - may propagate dissection).
- Avoid thrombolytics (worsen dissection)
- Long-term: Aspirin, beta-blocker (↓ shear stress), BP control <130/80, avoid strenuous exertion (Valsalva maneuvers), address emotional stress
- Screen for FMD (renal/cerebral arterial abnormalities) - imaging
- Recurrence: 10-20% over 10 years. Vigilant symptom monitoring.
Pregnancy considerations: High-risk - recurrence risk ~10-15%. Requires MFM + cardiology comanagement. If considering pregnancy post-SCAD → extensive counseling.

2. Takotsubo Cardiomyopathy (Stress Cardiomyopathy, "Broken Heart Syndrome")

Definition: Acute LV dysfunction (apical ballooning) triggered by intense emotional/physical stress, mimics MI but WITHOUT coronary obstruction
Epidemiology: 90% women, usually postmenopausal (age 60-75)
Triggers: Emotional stress (death of loved one, bad news, argument), physical stress (surgery, acute illness, asthma attack)
Presentation: Acute chest pain, dyspnea, ECG ST elevation (mimics STEMI) → catheterization shows normal coronaries BUT apical akinesis on ventriculography
Mechanism: Catecholamine surge → direct myocardial toxicity, microvascular dysfunction
Prognosis: Usually recovers within weeks-months (EF normalizes). BUT acute complications: cardiogenic shock (5-10%), arrhythmias, death (1-2%). Recurrence 5-10%.
Treatment: Supportive - ACE-I/ARB, beta-blockers, diuretics if needed. Avoid catecholamines (inotropes may worsen). Anticoagulation if apical thrombus forms (common with akinetic apex).

3. Microvascular Dysfunction (Ischemia with Non-Obstructive Coronary Arteries - INOCA)

Definition: Angina symptoms + objective ischemia (stress test abnormal) BUT normal/near-normal coronary arteries on angiography (<50% stenosis)
Epidemiology: Affects women 2-3× more than men. ~50% women with angina undergoing catheterization have non-obstructive CAD.
Mechanism: Coronary microvascular dysfunction (impaired vasodilation of small vessels), endothelial dysfunction, coronary vasospasm
Diagnosis challenges: Often dismissed as "non-cardiac chest pain," "anxiety" when angiography normal. BUT outcomes NOT benign - ↑ CV events, HF, death vs truly normal.
Diagnosis: Requires advanced testing:
- Coronary flow reserve (CFR) measurement during catheterization (inject adenosine, measure flow - if CFR <2.0 = microvascular dysfunction)
- Acetylcholine provocation test (vasospasm assessment)
- Cardiac MRI (myocardial perfusion abnormalities without obstructive CAD)
Treatment:
- Aggressive risk factor modification (statins, ACE-I, diabetes control)
- Anti-anginal medications: Beta-blockers, CCBs (especially for vasospasm), nitrates, ranolazine
- Aspirin (antiplatelet)
- Cardiac rehabilitation (improves endothelial function)
Important message: Normal angiography does NOT mean "nothing wrong" in symptomatic women. Investigate further, take symptoms seriously.

4. Autoimmune Diseases and CV Risk

Condition	CV Risk	Mechanism	Management
Rheumatoid Arthritis	↑ 1.5-2× CVD risk	Chronic inflammation, accelerated atherosclerosis, endothelial dysfunction	• Aggressive RA control (DMARDs - methotrexate, biologics) • Statin (even if cholesterol not elevated - anti-inflammatory) • Traditional risk factor control • Consider CVD risk 1.5× higher than calculator
Systemic Lupus Erythematosus (SLE)	↑ 2-3× CVD risk Young women with SLE: 50× ↑ MI risk vs age-matched controls	Inflammation, premature atherosclerosis, lupus nephritis, HTN, corticosteroid effects	• Hydroxychloroquine (may ↓ CV risk) • Minimize corticosteroids • Aggressive lipid, BP control • Monitor renal function, proteinuria
Psoriasis (Severe)	↑ 1.5-2× CVD risk	Systemic inflammation	• Treat skin disease (biologics may ↓ CV risk) • Screen for metabolic syndrome • Risk factor management

Program Delivery & Services

Clinical Services

Women's Cardiovascular Health Clinic

Initial visit (90 min):
- Comprehensive history: CV risk factors (traditional + sex-specific), pregnancy history, menstrual/menopause history, family history, medications, lifestyle
- Physical exam: BP (both arms), BMI, waist circumference, cardiovascular exam
- Labs: Lipid panel, glucose/HbA1c, hs-CRP (if intermediate risk), thyroid function (if symptoms), renal function
- Risk assessment: ASCVD calculator + sex-specific modifiers
- LE8 scoring: Assess all 8 metrics, identify gaps
- Shared decision-making: Discuss findings, goals, treatment options (lifestyle + medications), patient preferences
- Prevention plan: Detailed action plan (diet, exercise, medications if indicated), written materials, referrals (dietitian, cardiac rehab, etc.)
Follow-up visits (30-60 min):
- Frequency: 3 months initially (adjusting treatments), then 6-12 months (maintenance)
- Monitoring: BP, weight, labs (lipids, glucose), medication adherence/side effects, lifestyle progress
- Adjust treatments as needed
- Ongoing counseling, support, problem-solving
Specialty consultations available:
- Menopause management (HRT discussions)
- Pregnancy cardiology (preconception counseling, high-risk pregnancy monitoring, postpartum care)
- Lipid disorders (familial hypercholesterolemia, severe hypertriglyceridemia)
- Resistant hypertension
- Women post-MI/stroke (secondary prevention)

Educational Programs

Group classes (monthly, 90 minutes each):

"Heart Health 101 for Women" - CV disease in women, risk factors, symptoms
"Nutrition for a Healthy Heart" - DASH/Mediterranean diet, meal planning, grocery shopping
"Getting Active Safely" - Exercise prescription, overcoming barriers, injury prevention
"Stress Management" - Mind-body techniques, relaxation, sleep hygiene
"Navigating Menopause" - Symptoms, HRT, non-hormonal options, CV implications
"Understanding Your Medications" - Statins, BP meds, diabetes drugs - how they work, side effects

Support groups:

Women post-MI/stroke - peer support, shared experiences, coping strategies
Weight management group - behavioral strategies, accountability, encouragement
Young women with heart disease - unique challenges (fertility, parenting, career), social connection

Online resources:

Website: Women's CV health library (articles, videos, recipes, exercise demos)
Patient portal: Labs, visit summaries, secure messaging, appointment scheduling
Mobile app: LE8 tracker, medication reminders, educational modules
Webinars: Monthly live sessions with Q&A

Community Outreach

Health screenings: Free BP, lipid, glucose screenings at community events, workplaces, churches
Go Red for Women: Annual campaign (American Heart Association) - awareness events, walks, fundraising
Employer partnerships: Worksite wellness programs for women employees
Media engagement: Local TV/radio, social media, blog posts - amplify women's heart health messaging
Policy advocacy: Support legislation benefiting women's CV health (insurance coverage for prevention, maternal health policies)

Women's Cardiovascular Health Program - Enroll Today

EPA Bienestar IA is committed to advancing women's cardiovascular health through comprehensive, evidence-based, patient-centered care.

Our program offers:

✅ Specialized care tailored to women across all life stages
✅ Comprehensive risk assessment (traditional + sex-specific factors)
✅ Life's Essential 8™ optimization
✅ Pregnancy and postpartum cardiovascular care
✅ Menopause management with CV considerations
✅ Expert diagnosis and treatment of women-specific CV conditions (SCAD, INOCA, Takotsubo)
✅ Multidisciplinary team (cardiologists, ob/gyns, endocrinologists, dietitians, mental health)
✅ Educational programs and support groups
✅ Community outreach and advocacy

Who should enroll:

✅ All women seeking proactive CV health optimization
✅ Women with pregnancy complications (preeclampsia, gestational diabetes, preterm birth)
✅ Perimenopausal/postmenopausal women
✅ Women with CV risk factors (HTN, high cholesterol, diabetes, obesity, smoking, family history)
✅ Women with established CV disease
✅ Young women with atypical symptoms or concern for CV disease

Schedule Your Women's Heart Health Consultation →

Contact: Dra Giovanna Sanguinetti Colón
Program Director, Women's Health
EPA Bienestar IA
Email: info@epa-bienestar.com
Phone: [Contact number]

Accept most insurance plans. Financial assistance available.