CLINICAL STUDY
Initiation of hormone replacement therapy after acute myocardial infarction is associated with more cardiac events during follow-up
Karen P. Alexander, MD, FACCa,
L. Kristin Newby, MD, FACC ,
Anne S. Hellkamp, MS,
Robert A. Harrington, MD, FACC,
Eric D. Peterson, MD, MPH, FACCa,
Steve Kopecky, MD, FACC ,
Antoly Langer, MD, FACC ,
Patrick O’Gara, MD, FACC||,
Christopher M. O’Connor, MD, FACC,
Robert N. Daly, MS, PhD¶,
Robert M. Califf, MD, FACC,
Steven Khan, MD, FACC# and
Valentin Fuster, MD, FACC**
a Outcomes Research and Assessment Group, The Duke Clinical Research Institute, Durham, North Carolina, USA
The Duke Clinical Research Institute, Durham, North Carolina, USA
Mayo Clinic, Rochester, Minnesota, USA
St. Michael’s Hospital, Toronto, Canada
|| Brigham and Women’s Hospital, Boston, Massachusetts, USA
¶ Dupont Pharmaceuticals, Wilmington, Delaware, USA
# Cedars-Sinai Medical Center, Los Angeles, California, USA
** Mount Sinai Medical Center, New York, New York, USA
Manuscript received July 24, 2000;
revised manuscript received February 2, 2001,
accepted March 28, 2001.
Reprint requests and correspondence: Dr. Karen P. Alexander, Duke University Medical Center, Box 3411, Durham, North Carolina 27710
alexa019{at}mc.duke.edu
OBJECTIVES
This study explored the association between the initiation of hormone replacement therapy (HRT) and early cardiac events (<1 year) in women with a recent myocardial infarction (MI).
BACKGROUND
Observational studies have linked postmenopausal hormone use with a reduced risk of death from heart disease. However, a recent randomized trial of HRT found no long-term benefit, primarily due to an increase in cardiac events in the first year.
METHODS
The Coumadin Aspirin Reinfarction Study (CARS) database contains information on HRT use and menopausal status for women with a recent MI. We classified the 1,857 postmenopausal women in CARS as prior/current HRT users if they took HRT before enrollment, new users if they began HRT during the study period or never users. We assessed the incidence of cardiac events (death, MI, unstable angina [UA]) during follow-up.
RESULTS
In our cohort, 28% (n = 524) used HRT at some point. Of these, 21% (n = 111) began HRT after their MI. New users had a higher incidence of death/MI/UA (41% vs. 28%, p = 0.001) during follow-up than never users, largely due to a higher incidence of UA (39% vs. 20%, p = 0.001). After adjustment, new users still had a significantly higher risk of death/MI/UA than never users during follow-up (relative risk [RR] = 1.44 [1.05–1.99]). Prior/current users had no excess risk of the composite end point after adjustment. Users of estrogen/progestin had a lower incidence of death/MI/UA during follow-up than users of estrogen only (RR = 0.56 [0.37–0.85]).
CONCLUSIONS
Postmenopausal women who initiated HRT after a recent MI had an increased risk of cardiac events largely due to excess UA during follow-up.
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Abbreviations and Acronyms
| | BP | = blood pressure | | CARS | = Coumadin Aspirin Reinfarction Study | | CI | = confidence interval | | ECG | = electrocardiographic or electrocardiogram | | EF | = ejection fraction | | ERA | = Estrogen Replacement and Atherosclerosis trial | | HERS | = Heart and Estrogen/progestin Replacement Study | | HRT | = hormone replacement therapy | | MI | = myocardial infarction | | PEPI | = Postmenopausal Estrogen/Progestin Intervention trial | | PTCA | = percutaneous transluminal coronary angioplasty | | PVD | = peripheral vascular disease | | RR | = relative risk | | TIA | = transient ischemic attack | | UA | = unstable angina |
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