Heart Attack (cont.)
What is the treatment for heart attack in women?
Thrombolytic (fibrinolytic or clot dissolving) therapy has been shown to reduce
death from heart attacks similarly in men and women; however, the complication
of strokes from the thrombolytic therapy may be slightly higher in women than in
men.
Emergency percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting for acute
heart attack is as effective in women as in men; however women may have a
slightly higher rate of procedure-related complications in their blood vessels
(such as bleeding or clotting at the point of insertion of
the PTCA catheter in the groin) and death. This higher rate of complications has
been attributed to women's older age, smaller artery size, and greater severity
of angina. The long-term outcome of angioplasty or stenting however, is similar
in men and women, and should not be withheld due to gender.
The immediate mortality from coronary artery bypass graft
surgery (CABG) in
women is higher than that for men. The higher immediate mortality rate has been attributed
to women's older age, smaller artery size, and greater severity of angina (the
same as for PTCA). Long term survival, rate of recurrent heart
attack and/or need for reoperation, however, are similar in men and women after
CABG.
What about hormone therapy and heart attack in women?
After menopause, the production of estrogen by the ovaries gradually diminishes
over several years. Along with this reduction, there is an increase in LDL
("bad" cholesterol) and a small decrease in HDL ("good" cholesterol). These
changes in lipid levels are believed to be one of the reasons for the increased
risks of developing CAD after menopause. Women who have had their ovaries
surgically removed (oophorectomy) or experience an early menopause, also have an
accelerated risk of CAD.
Since treatment with estrogen hormone results in higher
HDL and lower LDL cholesterol levels, doctors thought for many years that
estrogen would protect women against CAD (as well protect against
dementia and stroke). Many studies
have found that postmenopausal
women who take estrogen have lower CAD rates than women who do not.
Unfortunately many of the studies were observational studies (studies in which
women are followed over time but decide on their own whether or not they wish to
take estrogen). Observational studies have serious shortcomings because they are
subject to selection bias; for example, women who
choose to take estrogen hormones may be healthier and have a lower risk of heart
attacks than those who do not. In other words, something else in the daily
habits of women who take estrogen (such as exercise or healthier diet) may make
them less likely to develop heart attacks. Therefore, only a randomized trial (a
study in which women agree to be assigned to estrogen or a placebo or sugar pill at random but
are not told which pills they took until the end of the study) can establish the
whether hormone therapy after menopause can prevent CAD.
HERS trial results
The Heart and Estrogen/progestin Replacement Study (HERS), was a randomized
placebo-controlled trial of the effect of the daily use of estrogens plus
medroxyprogesterone (progestin) on the rate of heart attacks in postmenopausal
women who already had CAD. The HERS trial did not find a reduction in heart
attacks in women who took hormone therapy. This lack of benefit in preventing
heart attacks occurred despite an 11% lower LDL and a 10% higher HDL cholesterol
level in the women treated with hormones. The study also found that more women
in the hormone-treated group experienced blood clots in the veins and
gallbladder disease than women in the placebo-treated group. (Blood clots in the
veins are dangerous because these clots can travel to the lungs and cause
pulmonary embolism, a condition
with chest pain, shortness of breath, and even shock and death.) However, the increase in gallbladder disease and blood clots
among healthy users of estrogen who do not have heart disease is very small.
Based on the results of this study, researchers concluded that estrogen is
not effective in preventing coronary artery disease and heart attacks in
postmenopausal women who already have CAD. It should be noted, however, that the
results of the HERS trial only apply to women who have known CAD prior to
starting hormone therapy and not to women without known coronary artery disease.
WHI trial results
The Women's Health Initiative (WHI) was
the first randomized controlled trial designed to determine the long-term
benefits and risks of treatment with estrogens plus medroxyprogesterone
(progestin) in healthy menopausal women (women without CAD). The results were
reported in a series of articles in 2002, 2003, and 2004. The estrogen +
progestin portion of the WHI study had to be stopped earlier than planned, after
just 5.2 years, because the increase in coronary heart disease, stroke, and
pulmonary embolism among women who use
estrogen + progesterone outweighed the benefits of reduced bone fractures and
colon cancer. The estrogen-alone portion of the WHI was stopped because women
who took estrogen alone had no reduction in heart attack risk, yet there was a
significant increase in stroke risk.
The increase in breast cancer became apparent after three to five years, but the
increase in heart disease and pulmonary emboli occurred early on, in the first
year.
Recommendations for the use of estrogens plus medroxyprogesterone (progestin)
in women
Medicinenet Medical Editors believe that:
- Decision regarding use of hormone therapy has to be
individualized, and all women should discuss with their physicians what is
best for her.
- Estrogens plus medroxyprogesterone (progestin) is still the best therapy
for hot flashes. Despite the WHI study, many women remain good candidates
for estrogens plus medroxyprogesterone (progestin) therapy (or estrogen
alone if they have had hysterectomy). This is especially
true if hormone therapy is limited to the shortest duration, optimally less
than five years.
- Estrogens with or without medroxyprogesterone (progestin) should not be
used to prevent or treat either Alzheimer's disease, heart
disease, or stroke.
- While estrogens plus medroxyprogesterone (progestin) are effective in
preventing osteoporosis and related bone fractures, women concerned about
the risk of hormone therapy should discuss with their doctors, the use of
other non-hormonal alternatives to prevent and treat osteoporosis.
Next: What is new in heart attack? »
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