Discontinuation of hormone replacement therapy after myocardial infarction and short term risk of adverse cardiovascular events: nationwide cohort study

Abstract

Objective To assess the risk of adverse cardiovascular events in women who discontinue hormone replacement therapy after myocardial infarction compared with those who continue.Design Nationwide register based cohort study.Setting All hospitals in Denmark.Population All 3322 women aged 40 years or over who survived 30 days after a myocardial infarction and were prescribed hormone replacement therapy at the time of myocardial infarction in the period 1997 to 2008.Main outcome measures Reinfarction, cardiovascular mortality, and all cause mortality 30 to 360 days after discharge.Results A total of 282 (8.5%) women had a reinfarction, 218 (6.6%) died of cardiovascular causes, and 357 (10.7%) died of any cause during follow-up. Women who discontinued overall hormone replacement therapy in the first year after myocardial infarction did not have a significantly different risk of reinfarction (hazard ratio 0.90, 95% confidence interval 0.68 to 1.19), cardiovascular mortality (1.21, 0.90 to 1.62), or all cause mortality (1.22, 0.97 to 1.53) than women who continued use. However, discontinuation of vaginal oestrogen was associated with a lower risk of reinfarction (hazard ratio 0.54, 0.34 to 0.86).Conclusion No certain conclusions can be drawn regarding increased or decreased risk of adverse cardiovascular events with continuing hormone replacement therapy after myocardial infarction. The results rule out neither a modest benefit nor a worrisome increase in risk. These figures may be valuable when a possible cardiovascular risk of hormone replacement therapy needs to be balanced with menopausal symptoms for the individual patient.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy

“…According to our current guidelines, HT use should be discontinued after MI or stroke, although this was not generally the case prior to the Women's Health Initiative publication in 2002 (5). We have no data on whether women continued or discontinued HT in this study after a nonfatal MI or stroke, but in another Nordic study, 80% of women continued the use of HT after a MI (33).…”

“…However, these findings were not confirmed in placebo-controlled trials, like in the HERS (3) and in the WHI (4). Furthermore, an increased risk of cardiovascular events has been associated with HT initiation, particularly in the secondary prevention trials, (3) although after a myocardial infarction (MI) the continuation of HT did not increase the risk of reinfarction (5). Thus, the current guidelines recommend that HT should be used only in recently menopausal women for moderate-to-severe vasomotor symptoms for the shortest possible time (6).…”

HRT in women with cardiovascular disease: Can we start, should we stop?

“…Recently, a nationwide register of 3322 women aged 40 years or over who survived 30 days after a myocardial infarction and were prescribed HRT showed no certain increased or a decreased risk of re-infarction or death with continuing HRT. 14 Their results ruled out a worrisome increase in risk in women with IHD using HRT.…”

Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long?

“…In general, HT is contraindicated in women with known CHD, including history of MI or peripheral artery disease. 13 Although discontinuation of HT after acute MI is advised, a meta-analysis of 10 trials of HT in 5766 secondary prevention patients suggest that, in this setting, the absolute risk of death, MI, angina, or revascularization is low 79 (Table 7).…”