Can we help?
Follow up on this month's He@lthLINK
Phone Numbers
Directory assistance
(203) 688-4242
Patient information
(203) 688-4177
Adult emergency
(203) 688-2222
Children's emergency
(203) 688-3333
Admitting
(203) 688-2221
Children's admitting
(203) 688-3331
Psychiatric admitting
(203) 688-9907
Mailing address:
Yale-New Haven Hospital
20 York Street
New Haven, CT
06510-3202
|
August 8, 2001
News this month Two studies published in medical journals in July suggest hormone replacement therapy (HRT) is not effective in warding off heart disease. It may, in fact, increase the risk of death, heart attacks and other problems among women who begin HRT soon after suffering a heart attack. The idea that HRT provides women with protection against the nation's leading killer has prompted many women and their physicians to opt for HRT in spite of associated cancer risks. Currently, about 38 percent of post-menopausal women use HRT, but reports of these studies have muddied the already murky waters around the decision about which women should and which should not take HRT. Healthy women should not take hormones
after menopause to prevent heart disease…
AHA switches position “This is a shift in our thinking,” said Lori Mosca, director of preventive cardiology at New York Presbyterian Hospital and lead author of the AHA advisory. “We're not saying, 'Don't start it [hormone treatment] for other reasons.' We're saying, 'Don't start it with the expectation that you will have a cardiovascular benefit, because we don't have the data to support that right now.” JACC study After a heart attack, women not already
on HRT shouldn't start purely for the cardioprotective effects.
In the study, published in the Journal of the American College of Cardiology (JACC), Dr. Alexander and her colleagues analyzed data from the Coumadin Aspirin Reinfarction Study database of women who had recently suffered heart attacks. They classified the 1,857 postmenopausal women in the study as prior or current users if they had taken hormones before enrolling in the study, new users if they started taking hormones during the study period, or never users. They then looked to see which women had died, suffered heart attacks or experienced unstable angina during the follow-up period. The researchers discovered that the women who started taking hormones soon after their heart attacks had an increased risk of these so-called cardiac events. Forty-one percent of the new users died, had heart attacks or experienced unstable angina during the follow-up period, compared to only 28 percent of the never users. This increased risk was largely due to the higher incidence of unstable angina in these women. In a related editorial, Drs. Deborah Grady and Stephen B. Hulley, of the University of California at San Francisco, argue that the message from this and other clinical trials is clear. “In light of these adverse effects, and of the many proven approaches to preventing coronary heart disease in high-risk women, it seems clear that postmenopausal hormone therapy should not be used for the purpose of preventing coronary disease unless future data from well-designed randomized trials document such benefit,“ they wrote. Nurse's Health Study findings The study shows postmenopausal women who have had a heart attack or heart disease diagnosis and have been on HRT for less than one year have a 25 percent higher risk of another heart attack or dying of heart disease than similar women who have never been on hormone therapy. Jury still out on whether HRT prevents
heart disease.
However, the study also found that women who had been on HRT for two years or more had a 62 percent decrease in risk. The decrease might reflect the healthier lifestyles of women on HRT, said Manson. “Women who comply long-term tend to be lower risk to begin with. They're more health conscious and generally have better access to medical care,” Manson said, “so it's unclear whether that's a real reduction in risk because of the hormone.” “The jury's still out on whether HRT prevents heart disease,”
Manson said. “Until further research is completed on the risks
and benefits, we would propose revamping current guidelines for
prescribing HRT that include heart disease as a treatment benefit.” 
Physician Referral Online A free and confidential service Physician Referral Online Request an appointment 203-688-2000
|
HRT or no HRT: A complex decision Because a woman's risk of having a heart attack rises sharply in her mid-50s as her estrogen levels diminish, we had long thought that hormone replacement therapy (HRT) might slow the development of heart disease in women. We do know it decreases certain cardiac risk factors, including high cholesterol, but as we look at the data from recent studies, the protective role of HRT is being called into question. These studies provide additional evidence that HRT is not beneficial for slowing coronary heart disease in spite of epidemiologic and observational data. “ The [cardiac] protective role
of HRT is being called into question.”
What do the studies tell us? The Heart and Estrogen/ Progestin Replacement Study (HERS) trial in 1998 followed 2,763 postmenopausal women who had suffered heart attacks or chest pain caused by blocked arteries or had undergone bypass surgery or angioplasty. Those who were randomly assigned to take HRT suffered no fewer heart attacks over four years than the women who were not taking HRT. In fact, during the first year after a cardiac event, women on HRT were at increased risk. That sent up the first red flag. The Estrogen Replacement and Atherosclerosis (ERA) trial, reported in 2000, looked at 309 women with heart disease. Researchers compared those on a placebo with women taking estrogen, progesterone or estrogen plus progesterone. No significant difference was found in the progress of their disease among the four groups. These two most recent studies support the findings that HRT should not be used for secondary prevention, that is, to treat women who already have heart disease. The JACC study found that 41 percent of those who had recently started HRT had another cardiac event, compared to 28 percent of women who had never been on HRT. The investigators did not find an increase in cardiac events in women who were prior or current users of HRT. In the Annals of Internal Medicine article, the researchers who analyzed the effects of HRT among nearly 2,500 nurses with previous heart disease reported that postmenopausal women who have been on HRT for less than one year have a 25 percent higher risk of another heart attack or dying of heart disease than those who have never been on HRT. Those women who had been on HRT for two years or more had a 62 percent decrease in risk compared to those who had not taken HRT. “We do not have the clinical
studies available at this time to answer many of the questions
concerning long-term effects of HRT and heart disease.”
Possible theories are that women who have had recent heart attacks form more blood clots with HRT or that HRT may contribute to inflammation of the blood vessels after a cardiac event. Based on current data, it appears the risk with HRT is primarily within the first year after a cardiac event and past that point, estrogen may have some protective value. We do not have the clinical studies available at this time to answer many of the questions concerning long-term effects of HRT and heart disease. HRT: an individual decision “Any woman considering HRT [should]
have a discussion with her physician about the risk versus benefit
for her individual medical condition.”
But at this point, it's important that any woman considering HRT have a discussion with her physician about the risk versus benefit for her individual medical condition. Use of HRT solely for heart disease prevention should be removed from the risk-versus-benefit equation. Anyone with heart disease or who is at high risk for heart disease should not begin HRT. If a woman is already on HRT and is high-risk for the development of heart disease, she needs to talk to her doctor about whether she should continue. If a woman develops an acute cardiac event, stroke or is immobilized while on HRT, it would be advisable to consider stopping HRT or to consider prescribing anti-clotting medication. If a woman does not have heart disease and does not have significant risk factors for heart disease, we have no firm clinical data to indicate HRT will either increase or decrease her risk of developing the disease. She might decide to opt for HRT if she's at risk for osteoporosis or is experiencing uncomfortable menopausal symptoms; a negative decision might be determined by a family history of breast cancer or stroke. “There are many proven approaches
to prevent and treat heart disease in women.”
HRT: no magic bullet What we do know is that there are many proven approaches to prevent
and treat heart disease in women. We should make sure women at
risk for heart disease as well as those already diagnosed have
the full benefit of the effective medications available, as well
as a complete understanding of lifestyle modifications that can
make a significant difference. Dr. Caulin-Glaser is a cardiologist at Yale-New Haven Hospital, an assistant professor of cardiology at the Yale School of Medicine and medical director of the Temple Cardiac Rehabilitation Center. |
