What are the requirements for cardiac clearance prior to initiating hormone replacement therapy (HRT)?

From the Guidelines

Cardiac clearance is not required for most patients starting hormone replacement therapy (HRT), but a thorough cardiovascular risk assessment is recommended, especially for those with pre-existing cardiovascular disease or significant risk factors. When considering HRT, it is essential to weigh the benefits against the potential risks, particularly the increased risk of cardiovascular events and breast cancer associated with combination therapy, as noted in the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. The guidelines suggest that hormone therapy with estrogen plus progestin, or estrogen alone, should not be given de novo to postmenopausal women after unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) for secondary prevention of coronary events, and postmenopausal women who are already taking estrogen plus progestin, or estrogen alone, at the time of UA/NSTEMI should not continue hormone therapy, except in specific cases where the benefits outweigh the risks 1. Similar recommendations are made for postmenopausal women after ST-elevation myocardial infarction (STEMI), as stated in the ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction, which advises against initiating hormone therapy with estrogen plus progestin for secondary prevention of coronary events and recommends discontinuing hormone therapy in women who have had a STEMI 1. Key considerations for initiating HRT include:

• Baseline cardiovascular risk assessment
• Evaluation of existing heart conditions, history of thromboembolism, stroke, uncontrolled hypertension, or multiple risk factors
• Monitoring of cardiovascular parameters during hormone therapy
• Weighing the benefits of HRT against the potential risks, particularly for those with significant risk factors or pre-existing cardiovascular disease. In clinical practice, the decision to initiate HRT should be made on a case-by-case basis, taking into account the individual patient's risk profile and medical history, as well as the potential benefits and risks of therapy, as supported by the guidelines and evidence from studies such as the Heart and Estrogen/progestin Replacement Study (HERS) and the Women’s Health Initiative 1.

From the Research

Cardiac Clearance Requirements for HRT

The requirements for cardiac clearance prior to initiating hormone replacement therapy (HRT) are not explicitly stated in the provided studies. However, the studies suggest that the timing and type of HRT may impact cardiovascular risk.

• The study by 2 found that the timing of HRT initiation and duration may be important factors to consider when prescribing HRT, especially in women with adverse cardiometabolic profiles and pre-existing conditions such as coronary/carotid atherosclerosis.
• The study by 3 suggested that transdermal estradiol and micronized progesterone may be a safer choice for HRT, particularly in women at risk of adverse events.
• The study by 4 found that postmenopausal hormone use appears to decrease the risk for major coronary events in women without previous heart disease, but may increase the risk for stroke in women taking 0.625 mg or more of oral conjugated estrogen daily.
• The study by 5 found that hormone therapy in both primary and secondary prevention conferred no protective effects for all-cause mortality, cardiovascular death, non-fatal myocardial infarction, angina, or revascularisation, but increased the risk of stroke and venous thromboembolic events.
• The study by 6 found that initiation of HRT after acute myocardial infarction is associated with more cardiac events during follow-up, particularly in women who began HRT after their MI.

Key Considerations

• Women with increased baseline thromboembolic risk may require alternative non-hormonal medications as first-line treatment 2.
• Transdermal estradiol alone or with micronized progesterone may be considered when non-hormonal options are not effective 2.
• HRT should be used for the shortest time possible and in the lowest possible dose, preferably with transdermal administration, in women who initiate HRT more than 10 years after menopause onset 2.
• An individualized treatment approach, including baseline CVD risk assessment, should be applied when prescribing HRT 2.