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CLINICAL STUDY: GENDER ISSUE AND CAD

The effect of estrogen compared to estrogen plus progesterone on the exercise electrocardiogram

^* Division of Cardiology, Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York, USA

Manuscript received December 12, 2001; revised manuscript received June 5, 2002, accepted June 12, 2002.

^* Reprint requests and correspondence: Dr. Sabahat Bokhari, Division of Cardiology, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, PH 9-993B, New York, New York 10032, USA.
sb605{at}columbia.edu

OBJECTIVES: The objective of this study was to evaluate the effect of estrogen compared to estrogen plus progesterone on the stress electrocardiogram (ECG) in relationship to stress-gated myocardial perfusion imaging (MPI) in postmenopausal women.

BACKGROUND: It is generally recognized that estrogen may cause false positive ST depressions on the stress ECG. The effects of estrogen plus progesterone are not known. This study was performed to define the effects of these agents on the stress ECG correlated with results from MPI.

METHODS: We evaluated 140 postmenopausal women—31 not taking any hormone replacement therapy (HRT); 75 taking estrogen alone; and 34 taking estrogen plus progesterone. Women with a history of coronary artery disease (CAD), cardiomyopathy, or an abnormal resting ECG were excluded. All women underwent a symptom-limited treadmill test and MPI.

RESULTS: The overall sensitivity and specificity of the stress ECG compared to MPI in women not taking HRT was 54% and 78%, respectively. In women taking estrogen or estrogen plus progesterone, the sensitivity was unchanged. The power to detect clinically meaningful sensitivity difference (10%) was poor (p = 0.09). The specificity was reduced to 46% (p < 0.01) in women on estrogen therapy. In women taking estrogen plus progesterone, specificity was 80%.

CONCLUSIONS: Our results suggest that estrogen increases the false positive rate of the stress ECG. This decreased specificity is countered by co-administration of progesterone. Nonetheless, because the sensitivity of the stress ECG is only 50% to 57% in postmenopausal women, women at risk should have imaging in conjunction with stress for the optimal detection of CAD.

Abbreviations and Acronyms   CAD   coronary artery disease   ECG   electrocardiogram/electrocardiography   EPRT   estrogen plus progesterone replacement therapy   ERT   estrogen replacement therapy   HRT   hormone replacement therapy   MPI   myocardial perfusion imaging   MVD   multivessel disease   SPECT   single-photon emission computed tomographic imaging   SVD   single-vessel disease   Tl-201   thallium-201

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