12.6: Treatment
- Page ID
- 42801
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)Symptom management in patients with non-obstructive cardiovascular disease is a challenge. Important to differentiate between vasospastic forms and complaints related to endothelial dysfunction.
Lifestyle behaviors can prevent and reduce the risk of getting heart disease and should therefore be primary focus in the GP-practice. Strategies adapt health lifestyle changes are listed below Adapted from Assessment and Management of cardiovascular risk in women (ESC/ESH/2007):[9]
Smoking: TARGET: permanently stop smoking all forms of tobacco
- Explain detrimental effects
- Assess the degree of addiction and readiness to cease smoking
- Gain commitment
- Establish a smoking cessation strategy (nicotine replacement, counseling and/or pharmacological intervention
- Arrange a schedule of follow up visits to monitor progression.
Diet: TARGET: Adopt healthy diet
- Explain importance of a varied diet and the need to adjust energy intake to achieve and maintain ideal body weight.
- Encourage the consumption of:
- Fruits and vegetables (the five-a-day guideline)
- Whole grain cereal and bread
- Low-fat dairy products
- Fish, especially those rich in omega-3
- Lean meat
- Total fat intake should be no more than 30% of energy intake, with saturated fats comprising in one third of total fat intake.
- Total cholesterol intake < 300mg/day
- Help to identify Foods that are high in saturated fats and cholesterol in order to reduce or remove them.
- Suggest replacement of saturated fats with complex carbohydrates, monounsaturated and polyunsaturated fats from vegetables and fish.
- Stress the importance of avoiding Foods containing high levels of salt. Reduce overall intake of salts.
Physical Fitness: TARGET: Undertake regular physical exercise
- Explain health benefits of increased physical activity (regain and maintain energy levels, improvement of lipid levels, managing bodyweight, relieving stress)
- Encourage to increase physical activity by climbing stairs, walking or cycling
- The standard for physical activity is > 30 minutes of moving activity for 7 days per week
- A health women should exercise at 60-75% of the average maximum heart rate
Obesity: TARGET: Body Mass Index < 25 kg.m2 or waist circumference < 88
- Explain that by consuming 500-1000 calories/day less than required to maintain the current weight, she can lose about 500 grams/week and ultimately achieve weight loss of 5-15%
- Stress that regular exercise assists in weight loss
- Give diet advice (as described earlier)
Lipids
Elevated lipid levels are a significant cardiovascular risk factor. Due to hormonal changes in menopause, total and LD cholesterol levels rise by approximately 10-14%. A low HDL cholesterol as well as high triglycerides is a stronger risk factor for CVD then in men. HDL and triglycerides play an important role in the metabolic syndrome. Women in menopause have an increased risk of developing the metabolic syndrome. This is partly due to the changes in body weight and the distribution of fat tissue since there is a shift from gynoid tot android fat distribution. HDL is hardly influenced by menopause. The dynamic changes in lipid profiles remain an important point in the prevention of cardiovascular disease in women.
Bloodpressure
In women, after the age of 55 the systolic blood pressure rises. After menopause plasmarenine levels increase and there is an increase in the sensitivity for salt. By the age of 60 more then half of all women have clinically manifest hypertension (defined as a blood pressure > 140/90 mmHg). In women hypertension is more often associated with CVA, left ventricular hypertrophy and diastolic dysfunction. These structural changes can give an array of complaints such as dyspnea, palpitations and chest pain.
Post-menopausal hormone therapy
The initation or continuation of hormone replacement therapy should be decided according to the individual patient. Given the many potentially beneficial effects of estrogens on cardiovascular physiology, much expectation was placed on hormone therapy for CVD prevention. However several studies did not support beneficial effects of hormone therapy and in the WHI study (women's health initiative) the study was terminated due to a small increase in CVD. In a woman < 60 years, who recently menopaused with menopausal symptoms and without CVD, the initiation of replacement therapy does not cause early harm. If a woman is at increased risk, HRT therapy is safe to use in the younger women with indications. It should be notes however, that HRT should not be initiated solely for the prevention of cardiovascular disease and should not be regarded as a substitute for antihypertensive treatment.