Treatment and Role of Hormaonal Replaement Therapy

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1 Treatment and Role of Hormone Replacement Therapy Chung-Ang University Hospital Chee Jeong Kim

4 1998

5 1998

6 Improvement of postmenopausal symptoms Prevention of osteoporosis Prevention of cardiovascular diseases (?)

7 HRT and CHD in Observational Studies -Summary of 23 Studies- Non-user User RR No of patients CVD death 44 6 Age-adjusted rate (10000) Adjusted for age, SBP, smoking 0.37 Education < High school High school > High school Obstet Gynecol 1988;72:23S

8 Effect of HRT on Lipid * * * * * * Kim CJ Arch Intern Med 1996;156:1693

9 Proposed Mechanisms of ERT for Cardioprotective Effect Modification of lipid profiles Reduction of LDL-C and lipoprotein(a) Elevation of HDL-C Improving vasoreactivity Antioxidant Thrombotic & Fibrinolytic mechanism Changes in smooth muscle cell and matrix Angiogenesis

10 2763 postmenopausal women with CHD < 80 years mg of CEE plus 2.5 mg of MPA, Follow-up averaged 4.1 years JAMA. 1998;280:

11 Hypotheses for the HERS Results Inadequate duration of follow-up Subjects who were too old Adverse effect of progesterone

12 HRT and Coronary Events -HERS II- Grady G. JAMA 2002;289:49

13 Effect of Statin CAD Events -HERS- Herrington G. Circulation 2002;105:2962

14 AHA Recommendations We said that hormone treatment should not be used to try to prevent a second heart attack or death among women with established heart disease. We ll incorporate the latest findings from the WHI study into our recommendations for women who have no signs of heart disease.

15 WHI- JAMA 2002;288:

16 Absolute Risk of HRT -WHI Events* MI Stroke PTE Breat CA Colon CA *: Number of events / women-year Hip Fx JAMA 2002;288:

17 RCTs on HRT Women s Atherosclerosis Vitamin/Estrogen Trial (WAVE) - no effect Women s Lipid Lowering Heart Atherosclerosis Trial (WELLHART) - no effect

18 WHI-Estrogen Arm Years Years JAMA. 2004;291:

19 Framingham Study Estrogen Use No Total Death CHD Acutal Expected Acutal Expected < 1 year > 1 year year follow up Ann Intern Med.1978;89:157

20 Discrepancy between Observational Studies and RCTs HRT user in observational studies Healthy More educated Wealthy

21 HRT and CHD in Observational Studies -Meta-analysis of 22 Studies- JAMA 2002;288:

22 HRT and CHD in Observational Studies -Meta-analysis of 23 Studies- Ann Intern Med. 2002;137:

23 1998

24 Overweight and Effect of HRT on Lipid Profiles Percent Change(%) * * * * Control Overweight TC HDL-C LDL-C VLDL-C TG Lp(a)

25 Effect of HRT on Inflammation Author Hormones Study Type CRP(mg/L) p value Control Drug Ridker(1999) HRT CS <0.001 Cushman(1999) HRT CS NS ERT CS <0.001 Cushman(1999) HRT RCT <0.001 (PEPI) ERT RCT <0.001

26 Multiple Outcomes of Raloxifene Evaluation (MORE) 7705 osteoporotic postmenopausal women Selective ER modulator, Raloxifene 60 mg or 120 mg Follow-up averaged 48 months JAMA 2002;287:847

27 AHA Recommendations Selective estrogen receptor modulators (SERMs) aren t the same as HRT. However, like HRT, these should not be used for this purpose until more research is available.

28 Guidelines for CVD Prevention in Women -AHA- Hormone therapy Combined estrogen plus progestin hormone therapy should not be initiated to prevent CVD in postmenopausal women. (Class III, Level A) Combined estrogen plus progestin hormone therapy should not be continued to prevent CVD in postmenopausal women. (Class III, Level C) Other forms of menopausal hormone therapy (eg, unopposed estrogen) should not be initiated or continued to prevent CVD in postmenopausal women pending the results of ongoing trials. (Class III, Level C) Circulation. 2004;109:

29 Future Direction for HRT New female sex hormones Lower dose Early administration of hormones Route of entry

30 Effect of Statin CAD Events -HERS- Herrington G. Circulation 2002;105:2962

31 1998

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$(Microsoft PowerPoint - S13-3_\261\350\273\363\307\366 [\310\243\310\257 \270\360\265\345])$ Cardiovascular Disease in Metabolic Syndrome 김상현 보라매병원내과 서울대학교의과대학내과학교실 Contents Metabolic syndrome and Cardiovascular system CVD Mortality Coronary artery disease Heart failure Atrial fibrillation Management