Hormone Replacement Therapy in Women with Coronary Artery Disease
HRT should not be initiated for the secondary prevention of cardiovascular disease in women with coronary artery disease, as it provides no cardiovascular benefit and may increase early risk of cardiovascular events. 1
Guidelines for HRT Use in Women with CAD
Primary Recommendations
- HRT should not be initiated for secondary prevention of cardiovascular disease in women with established CAD 1
- For women already on long-term HRT who have CAD, the decision to continue or stop therapy should be based on established non-coronary benefits/risks and patient preference 1
- If a woman develops an acute cardiovascular event while on HRT, consider discontinuing the therapy or implementing venous thromboembolism (VTE) prophylaxis during hospitalization 1
Risks Associated with HRT in Women with CAD
- In the Heart and Estrogen/progestin Replacement Study (HERS), women with established CAD showed a significant 52% increase in cardiovascular events during the first year of HRT use compared to placebo 1
- HRT increases the risk of venous thromboembolism nearly 3-fold compared to placebo, with a 5-fold increased risk in the first 90 days after myocardial infarction 1
- Women randomized to estrogen in clinical trials showed increased risk of fatal stroke and more severe neurological impairments after stroke 1
- The FDA label for estrogen products specifically lists active arterial thromboembolic disease (stroke and MI) as contraindications 2
Evidence Against HRT for Secondary Prevention
- The HERS trial demonstrated no reduction in overall rate of CHD events in postmenopausal women with established coronary heart disease during an average follow-up of 4.1 years 2
- The Estrogen Replacement and Atherosclerosis (ERA) Trial showed no benefit of estrogen therapy on angiographic progression of disease in women with documented coronary stenosis 1
- The Women's Estrogen for Stroke Trial (WEST) found estrogen was not effective for preventing recurrent stroke or death in women with established cerebrovascular disease 1
- Current evidence does not support using HRT for either primary or secondary prevention of CHD 3
Special Considerations During Acute Coronary Events
- If a woman develops an acute cardiovascular event while on HRT, it is prudent to consider discontinuing HRT during hospitalization 1
- The risk of VTE is increased 5-fold in the first 90 days after MI, even after adjustment for hospitalization 1
- If discontinuation is not possible during hospitalization, appropriate VTE prophylaxis should be used during immobilization 1
- Reinstitution of HRT after an acute event should be based on non-coronary benefits/risks and patient preference 1
Alternative Approaches for Women with CAD
- Focus on established preventive strategies for CHD in postmenopausal women with CAD 1:
- Selective estrogen receptor modulators (SERMs) have shown beneficial effects on some surrogate markers of CVD, but clinical benefit remains unproven 1
- Hormone therapy and SERMs should not be used for primary or secondary prevention of CVD (Class III, Level A recommendation) 1
Common Pitfalls and Caveats
- Despite observational studies suggesting cardioprotective effects, randomized controlled trials have not confirmed benefits of HRT for CAD prevention 1, 3
- The "timing hypothesis" suggests HRT initiated soon after menopause might have cardiovascular benefits, but current evidence still does not support using HRT for CHD prevention 3
- If surgery is required, discontinue estrogens at least 4-6 weeks before procedures associated with increased thromboembolism risk 2
- Women with CAD who are already on long-term HRT require individualized decision-making based on non-coronary benefits/risks 1