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(Circulation. 2000;101:e223.)
© 2000 American Heart Association, Inc.

Circulation Electronic Pages

Hormone Replacement Therapy and Cardiac Prevention

Beth L. Abramson, MD, FRCPC

Director of Women’s Cardiovascular Health and the Cardiac Prevention and Rehabilitation Center Assistant Professor of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

	Introduction

 
To the Editor:

The consensus statement by Mosca et al¹ that was recently published in Circulation should be applauded because it shows that researchers finally realize that women have unique cardiovascular needs. Despite this praise, I do have concerns regarding their overgeneralization of the Heart and Estrogen/Progestin Replacement Study (HERS) trial² and their stance on hormone replacement therapy (HRT) for the prevention of coronary disease. I was disappointed that the position on HRT was not stronger.

After a critical review of the literature, there are several reasons why I think this should be the case. First, one must delineate primary versus secondary prevention when addressing the HRT issue because the pathophysiology is likely different. In women with established coronary disease, events occur from antecedent atherosclerotic plaque rupture and thrombus formation. In those without established coronary disease, however, the turning point in disease progression is the development (rather than the rupture, or thrombosis) of the atherosclerotic plaque. This plaque development is multifactorial and partially related to endothelial dysfunction and the establishment of lipids within the arterial wall. Although the data are nonrandomized, much exists³ that suggests a benefit of HRT in women without established coronary disease via a reduction in cardiac events and death due to coronary heart disease (enough to support a class B recommendation according to the Canadian Task Force on Preventative Health Care grading system).

Additionally, one must be cautious when extrapolating results from the HERS trial to all women with established coronary disease. Although the authors were . . . [Full Text of this Article]

Lori Mosca, MD, PhD; Scott M. Grundy, MD, PhD; Debra Judelson, MD; Kathleen King, PhD, RN; Marian Limacher, MD; Suzanne Oparil, MD; Richard Pasternak, MD; Thomas A. Pearson, MD, PhD; Rita F. Redberg, MD; Sidney C. Smith, MD; Mary Winston, EdD, RD; Stanley Zinberg, MD

Preventative Cardiology Program, New York Presbyterian Hospital, 622 West 168th Street, New York, NY 10032