HRT After MI Linked With Transitory
Increased Risk of Recurrent Coronary Events

WESTPORT, CT (Reuters Health) July 23, 2001 - The results of a new study suggest that postmenopausal women who begin hormone replacement therapy (HRT) after an initial myocardial infarction (MI) are at increased risk of are current cardiac event during the first 60 days of starting therapy. The findings, reported in the July 23rd issue of the Archives of Internal Medicine, support data from the HERS study.

Using a cohort from the Group Health Cooperative, a health maintenance organization, Dr. Susan R. Heckbert, from the University of Washington in Seattle, and colleagues collected data on HRT use among 981 postmenopausal women who survived a first MI.

During a median follow-up of 3.5 years, the researchers identified 186 recurrent cardiac events among these women. The investigators found no difference in the risk of cardiac events between women who were current users of HRT and those who did not use HRT (relative hazard 0.96)."The use of hormones overall neither increased or decreased the risk of having a second heart attack; but the risk of having a second heart attackd id vary depending on how recently a women started hormones," Dr. Heckbert told Reuters Health.

During the first 2 months after MI, new hormone users had twice the risk of a second heart attack compared with non-hormone users. However, among women who been on HRT for 1 year or more, the risk of a second heart attack was 25% lower than among non-hormone users, she added. The results of this observational study, Dr. Heckbert said, support results from the 1998 HERS study. "Our findings, as well as those from the HERS study, suggest that [HRT] may not be appropriate for the purpose of preventing a second heart attack among women who have had a first heart attack," she advised.

However, Dr. Heckbert noted that both studies found that risk of heart attack was lower among women who had been on hormone therapy for 1 year or more."So it may be appropriate for women already on hormone therapy to continue therapy," she said.

Dr. Heckbert told Reuters Health that the results of her study agree with the new secondary cardiovascular disease prevention guidelines for the use of HRT announced by the American Heart Association (see Reuters Health report, July 23). Arch Intern Med 2001;161:1709-1713.

AHA Recommends New HRT Guidelines for CVD - (Cardio Vascular Disease)WESTPORT, CT (Reuters Health) July 23, 2001 - The American Heart Association (AHA) advises hormone replacement therapy (HRT) not be initiated solely for its potential protective effects against cardiovascular disease (CVD)."The new position is based on recent scientific studies with conflicting results about the role of HRT in reducing the risk of coronary heart disease in postmenopausal women," according to an AHA statement.

"These new guidelines are an effort to help physicians help their patients make informed decisions about the use of HRT for both primary and secondary prevention of cardiovascular disease," Dr. Lori Mosca of the New York Presbyterian Hospital of Columbia and Cornell Universities told Reuters Health. Dr. Mosca is the lead author of the guidelines, which appear in the July 24th issue of Circulation.

In 1999, the AHA released guidelines that suggested decisions about HRT use by postmenopausal women be individualized. "We got a lot of feedback from physicians that we needed to be clearer about specific situations," Dr. Mosca said. Even though there were no definitive data, she added, many physicians believed there was a need for experts in cardiovascular medicine to come to a consensus on HRT and its use in preventing CVD.

The new guidelines, she noted, consider the use of HRT for primary and secondary prevention. Our recommendations for secondary prevention are much stronger than our recommendations for primary prevention, because the data for secondary prevention are based on randomized clinical trials, while the data for primary prevention are based only on epidemiological studies,surrogate endpoint studies and basic science, she said.

"For primary prevention, the AHA allows the decision for use of HRT to include a consideration of the cardiovascular events," Dr. Mosca said,"whereas in secondary prevention, they do not feel that the notion of CVD protection should be considered."

"A woman with multiple CVD risk factors might want to consider HRT," Dr. Mosca continued. "However, if a woman is at high risk for thromboembolic events or breast cancer, she might want to consider not beginning HRT."Dr. Robert D. Langer from the University of California at San Diego agrees with the new AHA recommendations. "It is important that HRT be seen as a single therapy with benefits in many areas that impact health and quality of life for postmenopausal women," he commented in a statement. "But based on the results of existing clinical trials of one particular form of HRT, it cannot be considered mono therapy for cardiovascular protection."

Summary Recommendations for HRT* and CVD

 

Secondary Prevention

• HRT should not be initiated for the secondary prevention of CVD.

• The decision to continue or stop HRT in women with CVD who have been undergoing long-term HRT should be based on established non coronary benefits and risks and patient preference.

• If a woman develops an acute CVD event or is immobilized while undergoing HRT, it is prudent to consider discontinuance of the HRT or to consider VTE prophylaxis while she is hospitalized to minimize risk of VTE associated with immobilization. Reinstitution of HRT should be based on established noncoronary benefits and risks, as well as patient preference. Primary Prevention

• Firm clinical recommendations for primary prevention await the results of ongoing randomized clinical trials.

• There are insufficient data to suggest that HRT should be initiated for the sole purpose of primary prevention of CVD.

• Initiation and continuation of HRT should be based on established noncoronary benefits and risks, possible coronary benefits and risks, and patient preference.

The decision for women who have been undergoing long-term HRT should be based on established non coronary benefits and risks and patient preference.

If a woman develops an acute CVD event or is immobilized while undergoing HRT, it is prudent to consider discontinuance of the HRT or to consider VTE prophylaxis while she is hospitalized to minimize risk of VTE associated with immobilization. Reinstitution of HRT should be based on established noncoronary benefits and risks, as well as patient preference.

Primary Prevention

• Firm clinical recommendations for primary prevention await the results of ongoing randomized clinical trials.

• There are insufficient data to suggest that HRT should be initiated for the sole purpose of primary prevention of CVD.

• Initiation and continuation of HRT should be based on established non coronary benefits and risks, possible coronary benefits and risks, and patient preference.

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