This Article Abstract Full Text (PDF) All Versions of this Article: 105/13/1531    most recent 01.CIR.0000013837.81710.DAv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Koh, K. K. Articles by Cannon, R. O. Search for Related Content PubMed PubMed Citation Articles by Koh, K. K. Articles by Cannon, R. O., III Related Collections Cardiovascular Pharmacology Primary prevention Pathophysiology

(Circulation. 2002;105:1531.)
© 2002 American Heart Association, Inc.

Brief Rapid Communications

Statin Attenuates Increase in C-Reactive Protein During Estrogen Replacement Therapy in Postmenopausal Women

Kwang Kon Koh, MD, PhD; William H. Schenke, BA; Myron A. Waclawiw, PhD; Gyorgy Csako, MD; Richard O. Cannon, III, MD

From the Gachon Medical College, Inchon, South Korea (K.K.K.); and the Cardiovascular Branch (W.H.S., R.O.C.) and Office of Biostatistics Research (M.A.W.), National Heart, Lung, and Blood Institute, and the Department of Laboratory Medicine (G.C.), Clinical Center, National Institutes of Health, Bethesda, Md.

Correspondence to Dr Richard O. Cannon III, National Institutes of Health, Bldg 10, Room 7B15, 10 Center Dr MSC-1650, Bethesda, MD 20892-1650. E-mail cannonr{at}nih.gov

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background— HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular risk, mechanisms of which may include diminished arterial inflammation, as suggested by reduction in levels of C-reactive protein (CRP). Because oral estrogens increase CRP in postmenopausal women, with potential inflammatory and thrombotic consequences that could compromise any benefit to cardiovascular risk, we determined whether the coadministration of a statin might modify the estrogenic effect on CRP.

Methods and Results— In a double-blind, 3-period crossover study, 28 postmenopausal women (average LDL cholesterol 163±36 mg/dL) were randomly assigned to daily conjugated equine estrogens (CEEs) 0.625 mg, simvastatin 10 mg, or their combination for 6 weeks, with each treatment period separated by 6 weeks. CEEs increased median CRP levels from 0.27 to 0.46 mg/dL, simvastatin decreased CRP from 0.29 to 0.28 mg/dL, and the therapies combined increased CRP from 0.28 to 0.36 mg/dL (all P0.02 versus respective baseline values). Post hoc testing showed that the 29% increase in CRP on the combination of CEEs with simvastatin was significantly less than the 70% increase in CRP on CEEs alone (P<0.05). The effect of combination therapy on CRP levels did not correlate with baseline CRP or with baseline or treatment-induced changes in levels of interleukin-6, lipoproteins, or flow-mediated dilation of the brachial artery as a measure of nitric oxide bioactivity.

Conclusions— The combination of statin with estrogen may attenuate the potential harmful effects of estrogen therapy in postmenopausal women and maximize any benefit to cardiovascular risk.

Key Words: hormones • women • inflammation • endothelium • hypercholesterolemia

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Considerable pathological and experimental evidence indicates that inflammation within large arteries contributes importantly to the development, progression, and clinical expression of atherosclerosis.¹ In cohort studies of healthy men and women, serum levels of C-reactive protein (CRP), a marker of inflammation, were positively correlated with cardiovascular risk.^2–4 CRP may be released from the liver on stimulation by cytokines such as interleukin-6 (IL-6)⁵ and from macrophages and smooth muscle cells of atherosclerotic plaques.⁶ In experimental preparations, CRP induces the synthesis of cytokines, cell adhesion molecules, and tissue factor in monocytes and endothelial cells^7,8 and may contribute further to atherogenesis by facilitating uptake of LDL by macrophages, thus accelerating foam-cell formation.⁹

Prospective cohort surveys suggest that hormone replacement therapy decreases the risk of coronary artery disease in postmenopausal women,¹⁰ with potential benefit supported by multiple reports of favorable biological effects of estrogen on lipoproteins, fibrinolysis, and vascular function.¹¹ Several clinical trials, however, have reported an increased incidence of cardiovascular events after initiation of hormone therapy.^12–14 A mechanism for the adverse effects of estrogen may be potentiation of vascular inflammation and thrombosis by increased CRP in serum associated with oral hormone therapy in postmenopausal women.¹⁵ In contrast, HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular risk, the mechanism of which may include diminished arterial inflammation, as suggested by a reduction in levels of CRP in serum that appear to be independent of a reduction in LDL cholesterol levels.^16,17 Because hormone therapy increases CRP in postmenopausal women, which could compromise any benefit to cardiovascular risk, we determined whether the addition of statin might modify the estrogenic effect on CRP.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
Study Population and Design
Twenty-eight healthy postmenopausal women (age 57±1 years) with mild to moderate elevation of LDL cholesterol (average 163±7 mg/dL) participated in a randomized, double-blind, 3-period crossover trial. Data on the primary end point of this study (brachial artery endothelium-dependent reactivity) as well as levels of hormones, lipoproteins, and cell adhesion molecules in blood have been reported previously.¹⁸

The study participants received conjugated equine estrogens (CEEs) 0.625 mg each morning and placebo each night, placebo each morning and simvastatin 10 mg each night, or a combination of the 2 daily therapies for each of three 6-week treatment periods, with 6 weeks of washout between treatment periods. The National Heart, Lung, and Blood Institute Review Board approved the study, and all participants gave written, informed consent.

Laboratory Assays
CRP and IL-6 assays were performed on serum samples from this study obtained at the beginning and end of each treatment period, coded to maintain blinding, and frozen at -70°C. Samples were processed as 1 batch for CRP using a high-sensitivity (0.01 mg/dL), 2-site chemiluminescent enzyme immunometric assay (Immulite 2000, DPC). The interassay coefficients of variation were 5.1% and 5.7% at mean values of 12.14 and 0.86 mg/dL, respectively, and the intra-assay coefficients of variation were 2.2%, 5.2%, and 8.1% at mean values of 0.66, 0.24, and 0.04 mg/dL, respectively. IL-6 was assayed in triplicate by ELISA (R&D Systems), with an intra-assay coefficient of variation <4%.

Statistical Analysis
Because CRP and IL-6 levels were skewed in our patient population, the Wilcoxon signed-rank test was used to compare median values before and after each treatment and the relative changes in values in response to treatment. The effects of CEEs, simvastatin, and CEEs combined with simvastatin on CRP and on IL-6 were analyzed by a nonparametric repeated-measures ANOVA (Friedman test). Post hoc comparisons between different treatment pairs were made with the Wilcoxon signed-rank test. Spearman’s correlation coefficient was used to determine correlations between data sets when either or both sets showed a skewed distribution.

	Results

Top Abstract Introduction Methods Results Discussion References

 
After 6 weeks of treatment, CEEs increased median CRP levels by 70%, simvastatin decreased CRP by 4%, and the therapies combined increased CRP by 29% (Figure 1), with significant differences in the changes in CRP levels among these therapies (P<0.001 by ANOVA). Post hoc testing showed that the increase in CRP on the combination of CEEs with simvastatin was significantly less than the increase in CRP on CEEs alone (P<0.05). The reduction in CRP levels with simvastatin correlated inversely with the respective baseline CRP values (r=-0.539, P=0.003). The effects of CEEs on CRP did not correlate with respective baseline CRP values, whether administered alone (r=-0.017, P=0.932) or combined with simvastatin (r=0.327, P=0.089). Treatment-induced changes in CRP with CEEs, simvastatin, or CEEs combined with simvastatin did not correlate with changes in LDL cholesterol or HDL cholesterol (all r values between -0.250 and 0.274) or with changes in flow-mediated dilation of the brachial artery as a measure of nitric oxide bioactivity (all r values between 0.046 and 0.272) from respective pretreatment baseline values.

View larger version (17K): [in this window] [in a new window]   Baseline and treatment values of CRP are shown for CEEs, simvastatin (statin), and the treatments combined. Data are presented as 25th percentile, median, and 75th percentile. *P0.02 vs respective baseline values. Brackets with significance figures indicate post hoc comparisons between treatment periods after demonstration of significance among periods by ANOVA (P<0.001).

Modest to weak correlations were present between CRP and IL-6 at baseline before treatment with CEEs (r=0.435, P=0.020), simvastatin (r=0.221, P=0.258), and CEEs combined with simvastatin (r=0.490, P=0.008). Despite increasing CRP, CEEs did not change median levels of IL-6 (from 1.76 pg/mL at baseline to 1.67 pg/mL, P=0.601). Simvastatin decreased median levels of IL-6 from 1.91 to 1.82 pg/mL (P=0.028). The combination of CEEs and simvastatin reduced median levels of IL-6 from 1.81 to 1.58 pg/mL, although this did not achieve statistical significance (P=0.406). There was no correlation between treatment-induced changes in CRP and changes in IL-6 (all r values between -0.197 and 0.165).

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
Consistent with data from the Postmenopausal Estrogen/progestin Interventions (PEPI) trial,¹⁵ we found that oral estrogen increases levels of CRP in serum. Although IL-6 has been proposed to be a major cytokine stimulus for CRP synthesis by the liver, ^5,19 we found no correlation between changes in CRP and IL-6 levels in our study cohort. Walsh and coworkers²⁰ similarly reported that the increase in CRP with oral estrogen may be independent of changes in IL-6. In this regard, Herrington et al²¹ found that oral CEEs significantly increased IL-6 levels only in obese women, whereas CRP was significantly increased in both obese and lean women. Instead, increases in CRP with oral estrogen therapy may result in part from a direct stimulatory effect on hepatic CRP synthesis or release during the first pass through the liver, because transdermal application of estrogen does not increase CRP levels.²² Like other studies,^16,17 ours found that a statin preparation reduced CRP levels in postmenopausal women independently of changes in lipoprotein levels. The novel finding in our study is that the addition of statin to estrogen administered to postmenopausal women significantly attenuated the increase in CRP levels observed when estrogen was administered alone. This effect of statin therapy was independent of changes in lipoprotein levels or improvement in brachial artery endothelium-dependent reactivity.

Our findings may have significant implications in the use of hormone therapy in postmenopausal women by reducing the potentially adverse effects on inflammation and thrombosis that may result from increasing CRP to the magnitude observed with estrogen alone. It is possible that if a higher dose of simvastatin or a more potent statin had been used in our study, an even greater attenuation of the estrogenic effect on CRP might have been achieved. Statins are reported to have anti-inflammatory effects in experimental preparations independent of cholesterol lowering^23–25 and thus may be useful as an adjunct to hormone replacement therapy even when cholesterol levels fall within National Cholesterol Education Program guidelines. The potential benefit of this combination therapy, however, should be tested in prospective clinical trials.

Received December 17, 2001; revision received February 4, 2002; accepted February 5, 2002.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med. 1999; 340: 115–126.
   
2. Tracy RP, Lemaitre R, Psaty B, et al. Relationship of C-reactive protein to risk of cardiovascular disease in the elderly: results from the Cardiovascular Health Study and the Rural Health Promotion Project. Arterioscler Thromb Vasc Biol. 1997; 17: 1121–1127.
   
3. Ridker PM, Cushman M, Stampfer MJ, et al. Inflammation, aspirin, and the risk of myocardial infarction in the Physician’s Health Study. N Engl J Med. 1997; 336: 973–979.
   
4. Ridker PM, Buring JE, Shih J, et al. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation. 1998; 98: 731–733.
   
5. Heinrich PC, Castell JV, Andus T. Interleukin-6 and the acute phase response. Biochem J. 1990; 265: 621–636.
   
6. Yasojima K, Schwab C, McGeer EG, et al. Generation of C-reactive protein and complement components in atherosclerotic plaques. Am J Pathol. 2001; 158: 1039–1051.
   
7. Cernak J, Key NS, Bach RR, et al. C-reactive protein induces human peripheral blood monocytes to synthesize tissue factor. Blood. 1993; 82: 513–520.
   
8. Pasceri V, Willerson JT, Yeh ETH. Direct proinflammatory effect of C-reactive protein on human endothelial cells. Circulation. 2000; 102: 2165–2168.
   
9. Zwaka P, Hombach V, Torzewski J. C-reactive protein–mediated low density lipoprotein uptake by macrophages: implications for atherosclerosis. Circulation. 2001; 103: 1194–1197.
   
10. Grodstein F, Manson JE, Stampfer MJ. Postmenopausal hormone use and secondary prevention of coronary events in the Nurses’ Health Study: a prospective, observational study. Ann Intern Med. 2001; 135: 1–8.
    
11. Mendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med. 1999; 340: 1801–1811.
    
12. Hulley S, Grady D, Bush T, et al, for the Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA. 1998; 280: 605–613.
    
13. Alexander KP, Newby IK, Hellkamp AS, et al. Initiation of hormone replacement therapy after acute myocardial infarction is associated with more cardiac events during follow-up. J Am Coll Cardiol. 2001; 38: 1–7.
    
14. Statement from Claude Lenfant, MD, NHLBI Director, on Preliminary Trends in the Women’s Health Initiative. NHLBI Communications Office, April 3, 2000.
    
15. Cushman M, Legault C, Barrett-Conner E, et al. Effect of postmenopausal hormones on inflammation-sensitive proteins: the Postmenopausal Estrogen Progestin Interventions (PEPI) study. Circulation. 1999; 99: 354–360.
    
16. Ridker PM, Rifai N, Clearfield M, et al. Measurement of C-reactive protein for the targeting of statin therapy in the primary prevention of acute coronary events. N Engl J Med. 2001; 344: 1959–1965.
    
17. Jialal I, Stein D, Balis D, et al. Effect of hydroxymethyl glutaryl CoA reductase inhibitor therapy on high sensitive C-reactive protein levels. Circulation. 2001; 103: 1933–1935.
    
18. Koh KK, Cardillo C, Bui MN, et al. Vascular effects of estrogen and cholesterol-lowering therapies in hypercholesterolemic postmenopausal women. Circulation. 1999; 99: 354–360.
    
19. Yudkin JS, Stehouwer CDA, Emeiss JJ, et al. C-reactive protein in healthy subjects: associations with obesity, insulin resistance, and endothelial dysfunction: a potential role for cytokines originating from adipose tissue? Arterioscler Thromb Vasc Biol. 1999; 19: 972–978.
    
20. Walsh BW, Cox DA, Sashegyi A, et al. Role of tumor necrosis factor- and interleukin-6 in the effects of hormone replacement therapy and raloxifene on C-reactive protein in postmenopausal women. Am J Cardiol. 2001; 88: 825–828.
    
21. Herrington DM, Brosnihan KB, Pusser BE, et al. Differential effects of E and droloxifene on C-reactive protein and other markers of inflammation in healthy postmenopausal women. J Clin Endocrinol Metab. 2001; 86: 4216–4222.
    
22. Vehkavaara S, Silveira A, Hakala-Ala-Pietila T, et al. Effects of oral and transdermal estrogen replacement therapy on markers of coagulation, fibrinolysis, inflammation and serum lipids and lipoproteins in postmenopausal women, Thromb Haemost. 2001; 85: 619–625.
    
23. Weber C, Erl W, Weber KSC. HMG-CoA reductase inhibitors decrease CD11b expression and CD11b-dependent adhesion of monocytes to endothelium and reduce increased adhesiveness of monocytes isolated from patients with hypercholesterolemia. J Am Coll Cardiol. 1997; 30: 1212–1217.
    
24. Pasceri V, Chang J, Willerson JT, et al. Modulation of C-reactive protein–mediated monocyte chemoattractant protein-1 induction in human endothelial cells by anti-atherosclerosis drugs. Circulation. 2001; 103: 2531–2534.
    
25. Sparrow CP, Burton CA, Hernandez M, et al. Simvastatin has anti-inflammatory and antiatherosclerotic activities independent of plasma cholesterol lowering. Arterioscler Thromb Vasc Biol. 2001; 21: 115–121.
    

This article has been cited by other articles:

				E. Wong, M. Freiberg, R. Tracy, and L. Kuller Epidemiology of Cytokines: The Women On the Move through Activity and Nutrition (WOMAN) Study Am. J. Epidemiol., June 25, 2008; (2008) kwn132v1. [Abstract] [Full Text] [PDF]

				K. K. Koh and B.-K. Yoon Controversies regarding hormone therapy: Insights from inflammation and hemostasis Cardiovasc Res, April 1, 2006; 70(1): 22 - 30. [Abstract] [Full Text] [PDF]

				K. K. Koh, S. H. Han, and M. J. Quon Inflammatory Markers and the Metabolic Syndrome: Insights From Therapeutic Interventions J. Am. Coll. Cardiol., December 6, 2005; 46(11): 1978 - 1985. [Abstract] [Full Text] [PDF]

				S.-H. Juan, J.-J. Chen, C.-H. Chen, H. Lin, C.-F. Cheng, J.-C. Liu, M.-H. Hsieh, Y.-L. Chen, H.-H. Chao, T.-H. Chen, et al. 17{beta}-Estradiol inhibits cyclic strain-induced endothelin-1 gene expression within vascular endothelial cells Am J Physiol Heart Circ Physiol, September 1, 2004; 287(3): H1254 - H1261. [Abstract] [Full Text] [PDF]

				K. K. Koh and I. Sakuma Should Progestins Be Blamed for the Failure of Hormone Replacement Therapy to Reduce Cardiovascular Events in Randomized Controlled Trials? Arterioscler. Thromb. Vasc. Biol., July 1, 2004; 24(7): 1171 - 1179. [Abstract] [Full Text] [PDF]

				C. Kluft Identifying patients at risk of coronary vascular disease: the potential role of inflammatory markers Eur. Heart J. Suppl., July 1, 2004; 6(suppl_C): C21 - C27. [Abstract] [Full Text] [PDF]

				J. M Backes, P. A Howard, and P. M Moriarty Role of C-Reactive Protein in Cardiovascular Disease Ann. Pharmacother., January 1, 2004; 38(1): 110 - 118. [Abstract] [Full Text] [PDF]

				E. Nikander, M. Metsa-Heikkila, A. Tiitinen, and O. Ylikorkala Evidence of a Lack of Effect of a Phytoestrogen Regimen on the Levels of C-Reactive Protein, E-Selectin, and Nitrate in Postmenopausal Women J. Clin. Endocrinol. Metab., November 1, 2003; 88(11): 5180 - 5185. [Abstract] [Full Text] [PDF]

				K. K. Koh, J. Y. Ahn, D. K. Jin, B.-K. Yoon, H. S. Kim, D. S. Kim, W. C. Kang, S. H. Han, I. S. Choi, and E. K. Shin Significant Differential Effects of Hormone Therapy or Tibolone on Markers of Cardiovascular Disease in Postmenopausal Women: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study Arterioscler. Thromb. Vasc. Biol., October 1, 2003; 23(10): 1889 - 1894. [Abstract] [Full Text] [PDF]

				A. Silvestri, O. Gebara, C. Vitale, M. Wajngarten, F. Leonardo, J. A.F. Ramires, M. Fini, G. Mercuro, and G. M.C. Rosano Increased Levels of C-Reactive Protein After Oral Hormone Replacement Therapy May Not Be Related to an Increased Inflammatory Response Circulation, July 1, 2003; 107(25): 3165 - 3169. [Abstract] [Full Text] [PDF]

				S. Davison and S. R. Davis New Markers for Cardiovascular Disease Risk in Women: Impact of Endogenous Estrogen Status and Exogenous Postmenopausal Hormone Therapy J. Clin. Endocrinol. Metab., June 1, 2003; 88(6): 2470 - 2478. [Abstract] [Full Text] [PDF]

				P. O. Bonetti, L. O. Lerman, and A. Lerman Endothelial Dysfunction: A Marker of Atherosclerotic Risk Arterioscler. Thromb. Vasc. Biol., February 1, 2003; 23(2): 168 - 175. [Abstract] [Full Text] [PDF]

				A. Wakatsuki, Y. Okatani, T. Fukaya, K. K. Koh, W. H. Schenke, R. O. Cannon III, M. A. Waclawiw, and G. Csako Statin Attenuates Increase in C-Reactive Protein During Estrogen Replacement Therapy in Postmenopausal Women * Response Circulation, December 10, 2002; 106 (24): e198 - e199. [Full Text] [PDF]

				P. Garnero, C. Jamin, C.-L. Benhamou, C. Pelissier, and C. Roux Effects of tibolone and combined 17{beta}-estradiol and norethisterone acetate on serum C-reactive protein in healthy post-menopausal women: a randomized trial Hum. Reprod., October 1, 2002; 17(10): 2748 - 2753. [Abstract] [Full Text] [PDF]

				K. K. Koh Effects of estrogen on the vascular wall: vasomotor function and inflammation Cardiovasc Res, September 1, 2002; 55(4): 714 - 726. [Full Text] [PDF]

				D. M. Herrington, E. Vittinghoff, F. Lin, J. Fong, F. Harris, D. Hunninghake, V. Bittner, H. G. Schrott, R. S. Blumenthal, R. Levy, et al. Statin Therapy, Cardiovascular Events, and Total Mortality in the Heart and Estrogen/Progestin Replacement Study (HERS) Circulation, June 25, 2002; 105(25): 2962 - 2967. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: 105/13/1531    most recent 01.CIR.0000013837.81710.DAv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Koh, K. K. Articles by Cannon, R. O. Search for Related Content PubMed PubMed Citation Articles by Koh, K. K. Articles by Cannon, R. O., III Related Collections Cardiovascular Pharmacology Primary prevention Pathophysiology