American Heart Association Issues Cautions On Hormone Replacement Therapy For Cardiovascular Disease

For postmenopausal women who have had a heart attack or stroke, the guidelines recommend that HRT not be initiated for secondary prevention. This recommendation is based, in part, on the results of the Heart and Estrogen Replacement Study (HERS), a large-scale study that found no benefit of HRT among women with heart disease. For preventing a first heart attack or stroke, the association recommends reducing risk factors, such as high cholesterol and blood pressure, through lifestyle modifications and, if needed, with medications to improve cholesterol profiles and lower elevated blood pressure. Pending the results of ongoing studies, the guidelines recommend that the decision on HRT use be based primarily on non-heart related benefits and risks.

For those women with diagnosed cardiovascular disease, who are undergoing long term hormone replacement therapy, the decision to continue or stop HRT should be based on established noncoronary benefits and risks, as well as patient preference.

Because the data on HRT has been unclear, many physicians have asked the American Heart Association to clarify its position on HRT says Lori Mosca, M.D., Ph.D., lead author of the American Heart Association’s Science Advisory, titled, “Hormone Replacement Therapy and Cardiovascular Disease.” She is director of preventive cardiology at New York Presbyterian Hospital of Columbia and Cornell universities. “For many years, cardiologists and other health care providers who take care of women have assumed that HRT protects the heart,” Mosca continues. “At this time there is not sufficient evidence to make that claim – our purpose is to clarify the role of hormones in heart disease prevention.”

The statement concludes that for healthy women there is neither a compelling reason to initiate HRT for the sole purpose of primary coronary heart disease prevention, nor a compelling reason to discontinue it if she is doing well with therapy. For now, women and their physicians should shift their attention to lifestyle changes such as smoking cessation, weight loss and physical activity that are known to reduce the risk of cardiovascular diseases (CVD). Also, treatments like cholesterol-lowering drugs and blood pressure medication are proven to protect against CVD and are underutilized in women, she says. Cardiovascular diseases, which include heart attack and stroke, are the leading causes of death in women. After menopause, CVD risk rises sharply.

“For more than 50 million American women over age 50, the decision whether or not to use hormone replacement therapy is a difficult one. These guidelines should help physicians guide patients to the most effective therapies to lower an individual’s risk of cardiovascular disease.” According to Mosca, the established benefits of HRT for the treatment of menopausal symptoms, such as hot flashes, and the prevention of osteoporosis, must be weighed against risks for blood clots, gallbladder disease and a possible increased risk of breast cancer.

“The new guidelines recommend essentially taking HRT out of the risk-benefit equation for women who have already had a heart attack or stroke,” Mosca says. “For postmenopausal women without heart disease, we do not suggest that HRT be taken completely out of the equation. We state that heart disease prevention should not be used as the sole purpose of therapy. It can weigh into the decision, it just shouldn’t drive the decision for women without heart disease. “The prevailing wisdom for decades has been that hormones protect the heart,” Mosca says. “This is based on quite reasonable assumptions. Compared to men, women have a delayed onset of heart disease by about 10 years. It has been assumed that this protection has been afforded to women because they have estrogen and men don’t.” In addition, epidemiological studies have indicated that HRT reduces heart attacks in healthy women. However, because women who are prescribed HRT are often healthier than those who are not, these studies cannot be considered definitive because women are not randomly assigned to treatment.

Two large, randomized studies of healthy women designed to avoid those biases – the Women’s Health Initiative, sponsored by the National Heart, Lung and Blood Institute, and the WISDOM trial in Europe – are expected to report results in five to eight years. “Those studies will provide more definitive answers about HRT for prevention of heart disease in healthy women,” says Mosca.

Co-authors include: Peter Collins, M.D.; David M. Herrington, M.D.; Michael E. Mendelsohn, M.D.; Richard C. Pasternak, M.D.; Rose Marie Robertson, M.D.; Karin Schenck-Gustafsson, M.D., Ph.D.; Sidney C. Smith, Jr., M.D.; Kathryn A. Taubert, Ph.D.; and Nanette K. Wenger, M.D.