Estrogen Therapy and Coronary-Artery Calcification

Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.
New England Journal of Medicine (Impact Factor: 55.87). 07/2007; 356(25):2591-602. DOI: 10.1056/NEJMoa071513
Source: PubMed


Calcified plaque in the coronary arteries is a marker for atheromatous-plaque burden and is predictive of future risk of cardiovascular events. We examined the relationship between estrogen therapy and coronary-artery calcium in the context of a randomized clinical trial.
In our ancillary substudy of the Women's Health Initiative trial of conjugated equine estrogens (0.625 mg per day) as compared with placebo in women who had undergone hysterectomy, we performed computed tomography of the heart in 1064 women aged 50 to 59 years at randomization. Imaging was conducted at 28 of 40 centers after a mean of 7.4 years of treatment and 1.3 years after the trial was completed (8.7 years after randomization). Coronary-artery calcium (or Agatston) scores were measured at a central reading center without knowledge of randomization status.
The mean coronary-artery calcium score after trial completion was lower among women receiving estrogen (83.1) than among those receiving placebo (123.1) (P=0.02 by rank test). After adjustment for coronary risk factors, the multivariate odds ratios for coronary-artery calcium scores of more than 0, 10 or more, and 100 or more in the group receiving estrogen as compared with placebo were 0.78 (95% confidence interval, 0.58 to 1.04), 0.74 (0.55 to 0.99), and 0.69 (0.48 to 0.98), respectively. The corresponding odds ratios among women with at least 80% adherence to the study estrogen or placebo were 0.64 (P=0.01), 0.55 (P<0.001), and 0.46 (P=0.001). For coronary-artery calcium scores of more than 300 (vs. <10), the multivariate odds ratio was 0.58 (P=0.03) in an intention-to-treat analysis and 0.39 (P=0.004) among women with at least 80% adherence.
Among women 50 to 59 years old at enrollment, the calcified-plaque burden in the coronary arteries after trial completion was lower in women assigned to estrogen than in those assigned to placebo. However, estrogen has complex biologic effects and may influence the risk of cardiovascular events and other outcomes through multiple pathways. ( number, NCT00000611.)

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    • "If E2 protects the kidney from diabetic damage by interfering with TGF-β1 signaling, an obvious extension of these studies would be to administer E2 to diabetic patients, to prevent or ameliorate diabetic kidney damage. Since exogenous estrogen’s protection against the development and progression of cardiovascular disease has been questioned,91–94 a clear answer to the possible protective role of E2 on kidney function should come from large-scale, randomized trials (which are not planned, so far). There are several theoretical limitations within the concept that E2 might be directly responsible for the observed sex difference in diabetic nephropathy. "
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    • "The menopausal transition is associated with CVD [13] and hormone replacement therapy (HRT) in form of estrogen and progesterone application increases the risk of CVD [14]. But HRT has been reported to have an initially protective effect on the calcification of the coronary arteries [15]. "
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    • "Duration of lactation has been associated with lower prevalence of the metabolic syndrome in midlife, making the BAC-lactation relationship somewhat paradoxical [70]. A significant inverse association has been reported between menopausal hormonal therapy and BAC in 4 studies [55, 71–73]. These data underscore a resemblance between BAC and coronary atherosclerosis, since increased duration of hormonal therapy has been shown to be associated with lower prevalence of CAC [74]. "
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