BMS consensus statement

Summary

Coronary heart disease (CHD) is a leading cause of death in women. Observational studies have consistently shown estrogen to help prevent CHD in postmenopausal women. The large randomized controlled Women’s Health Initiative (WHI) trial initially did not confirm these observational findings. However, further analyses of the WHI study as well as meta-analyses of randomised clinical trials of hormone replacement therapy (HRT) and of the observational Nurses’ Health Study have now found that the timing of onset of HRT use is important and that estrogen may have an important protective role in CHD, particularly in women initiating treatment below age 60 years. This BMS Consensus Statement will examine the evidence regarding HRT and non-estrogen therapies (lipid lowering agents, aspirin, antihypertensives, antidiabetic medications, SERMs) as well as diet, lifestyle and smoking cessation in the primary prevention of CHD in women.

Summary practice points

• Estrogen may have a protective role in CHD prevention especially if initiated in women below age 60 years or within 10 years of onset of menopause.
• Healthcare professionals should consider the potential benefits of estrogen for the reduction of all-cause mortality and prevention of CHD in their decision making when initiating HRT in healthy postmenopausal women below age 60 years or within 10 years of menopause onset. Use of HRT solely for primary prevention of CHD is off label.
• Women with POI or early menopause should take estrogen to reduce the risk of CHD.
• Lipid-lowering agents are probably beneficial in primary prevention.
• Aspirin cannot be recommended for primary prevention of CHD, but may protect against stroke.
• Treating hypertension reduces the risk of CHD.
• In diabetics, prevention of CHD is based on management of established cardiovascular risk factors through both lifestyle measures and pharmacotherapy.
• In metabolic syndrome, prevention of CHD is based on management of established cardiovascular risk factors through both lifestyle measures and pharmacotherapy.
• Stopping smoking, reducing obesity, improving diet and undertaking regular exercise are key lifestyle measures to reduce coronary heart disease.