ischaemic heart disease and HRT

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NICE state with respect to HRT and cardiovascular disease (1):

  • HRT:
    • does not increase cardiovascular disease risk when started in women aged under 60 years
    • does not affect the risk of dying from cardiovascular disease

  • the presence of cardiovascular risk factors is not a contraindication to HRT as long as they are optimally managed

  • the baseline risk of coronary heart disease and stroke for women around menopausal age varies from one woman to another according to the presence of cardiovascular risk factors

  • HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease

  • HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease.

Data shows taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke. Also explain that the baseline population risk of stroke in women aged under 60 years is very low

  • Table 1: Absolute rates of coronary heart disease for different types of HRT compared with no HRT (or placebo), different durations of HRT use and time since stopping HRT for menopausal women
    • table shows the difference in coronary heart disease incidence per 1000 menopausal women over 7.5 years (95% confifidence interval) (baseline population risk in the UK over 7.5 years: 26.3 per 1000)
  •     Current HRT users Treatment duration <5 years Treatment duration 5-10 years >5 years since stopping treatment
    Women on oestrogen alone RCT estimate 6 fewer (-10 to 1) No available data No available data 6 fewer (-9 to -2)
    Women on oestrogen alone Observational estimate 6 fewer (-9 to -3) No available data No available data No available data
    Women on oestrogen + progestogen RCT estimate 5 more (-3 to 18) No available data No available data 4 more (-1 to 11)
    Women on oestrogen + progestogen Observational estimate No available data No available data No available data No available data

A joint societies statement has noted with repect to HRT and cardiovascular disease (2):

Key points summary

- The timing MHT (menopausal hormone therapy) is initiated, referred to as the ‘timing hypothesis’ and ‘the cardiovascular window of opportunity’, can have a significant impact on the risk of CVD with MHT intake

- Cochrane data-analysis shows that MHT initiated within 10 years of the menopause is likely to be associated with a reduction in coronary heart disease and cardiovascular mortality.

- Evidence from the Cochrane data-analysis and that from the long-term follow-up data of the WHI showed no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated MHT more than 10 years after the menopause

 

Reference:

Last edited 10/2020 and last reviewed 09/2021

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