Primary prevention of atherosclerotic cardiovascular disease in women

Heart disease is often miscast as a man’s problem, and the tools to prevent it were largely built on men. This review focuses on what prevention should look like for women.

The authors blend the universal with the sex-specific. Standard levers apply — risk-based statins, lifestyle, and selective use of coronary calcium and hsCRP to refine borderline risk — but some factors hit women harder: smoking and diabetes carry higher relative risk in women than in men. On aspirin they counsel restraint: routine use offers little net benefit in primary prevention except in selected women 65 and older with low bleeding risk.

The practical takeaway is a disciplined, absolute-risk approach: use the Pooled Cohort Equations, add CAC or hsCRP when they’d change the decision, start statins when risk warrants, and don’t reflexively prescribe aspirin to younger women. The resistance comes from habits — LDL-target thinking and reflexive aspirin — that the risk-based approach displaces.

We rate the evidence moderate: a peer-reviewed, conflict-free narrative synthesis of guidelines and trials, but not systematic. Its clinical significance is moderate — important, guideline-aligned guidance for preventing disease in half the population, valuable precisely because women have been understudied, though it refines rather than overturns practice.