Hormonal contraception and myocardial infarction
ESC Congress Library. Stevenson J. 05/05/16; 133821; CS06.3 Disclosure(s): Grants/Research Support: Abbott Speakers Bureau/Honoraria: Abbott, Bayer and Pfizer Consulting Fees: Abbott, Pfizer
Dr. John Stevenson
Dr. John Stevenson
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Abstract
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Hormone replacement therapy (HRT), when used appropriately in postmenopausal women, reduces coronary heart disease (CHD) risk. HRT uses natural estrogen, either estradiol 17-β or conjugated equine estrogens combined with a progestogen when indicated. Oral contraceptive (OC) preparations predominantly combine ethinylestradiol with various different progestogens. Certain synthetic estrogen-progestogen combinations have adverse effects on lipids and lipoproteins, glucose and insulin, and coagulation, thereby increasing the risk of myocardial infarction (MI). Most combinations increase triglyceride levels, but effects on HDL and LDL cholesterol vary according to the type and dose of the progestogen. Progestogen-only OCs have little metabolic impact. OCs containing second generation levonorgestrel have the worst lipid profile and are associated with a greater degree of insulin resistance and a larger insulin response to a glucose challenge A meta-analysis in 2003 showed that overall current OC use increased the risk for MI with an odds ratio (OR) of 2.48 (CI 1.91-3.22) compared with never use. However, sub-group analyses demonstrated some important differences. The type of progestogen had an impact, with a significant increased risk for MI being seen with the use of first and second generation progestogens but nit with third generation. Ethinylestradiol showed a dose-response relationship with MI risk, with a significantly increased risk seen with doses of 30 µg or above, but not with 20 µg. Women using OCs with pre-existing coronary risk factors such as smoking, hypertension and hypercholesterolemia had greatly increased risk of MI. The use of progestogen-only OCs was not associated with an increased risk for MI. In contrast, the risk of venous thrombo-embolism (VTE), whilst increased with all OCs, appears slightly higher with those containing third generation progestogens. Newer progestogens such as drospirenone are now used in OCs, and drospirenone has the benefits of lowering blood pressure and preventing or limiting weight gain. This could be expected to give less cardiovascular risk, but preliminary data suggest that the risk of arterial thrombosis with OC containing drospirenone is slightly higher than with those containing first and second generation progestogens, whereas the risk from transdermal or vaginal ring OCs is not. It is not known if estradiol-containing OCs carry less risk for MI, although their metabolic profile might be more favourable. The increased risk for MI from any OC is very low. However, care should be taken in selecting the appropriate OC preparation for women with CHD risk factors.
Hormone replacement therapy (HRT), when used appropriately in postmenopausal women, reduces coronary heart disease (CHD) risk. HRT uses natural estrogen, either estradiol 17-β or conjugated equine estrogens combined with a progestogen when indicated. Oral contraceptive (OC) preparations predominantly combine ethinylestradiol with various different progestogens. Certain synthetic estrogen-progestogen combinations have adverse effects on lipids and lipoproteins, glucose and insulin, and coagulation, thereby increasing the risk of myocardial infarction (MI). Most combinations increase triglyceride levels, but effects on HDL and LDL cholesterol vary according to the type and dose of the progestogen. Progestogen-only OCs have little metabolic impact. OCs containing second generation levonorgestrel have the worst lipid profile and are associated with a greater degree of insulin resistance and a larger insulin response to a glucose challenge A meta-analysis in 2003 showed that overall current OC use increased the risk for MI with an odds ratio (OR) of 2.48 (CI 1.91-3.22) compared with never use. However, sub-group analyses demonstrated some important differences. The type of progestogen had an impact, with a significant increased risk for MI being seen with the use of first and second generation progestogens but nit with third generation. Ethinylestradiol showed a dose-response relationship with MI risk, with a significantly increased risk seen with doses of 30 µg or above, but not with 20 µg. Women using OCs with pre-existing coronary risk factors such as smoking, hypertension and hypercholesterolemia had greatly increased risk of MI. The use of progestogen-only OCs was not associated with an increased risk for MI. In contrast, the risk of venous thrombo-embolism (VTE), whilst increased with all OCs, appears slightly higher with those containing third generation progestogens. Newer progestogens such as drospirenone are now used in OCs, and drospirenone has the benefits of lowering blood pressure and preventing or limiting weight gain. This could be expected to give less cardiovascular risk, but preliminary data suggest that the risk of arterial thrombosis with OC containing drospirenone is slightly higher than with those containing first and second generation progestogens, whereas the risk from transdermal or vaginal ring OCs is not. It is not known if estradiol-containing OCs carry less risk for MI, although their metabolic profile might be more favourable. The increased risk for MI from any OC is very low. However, care should be taken in selecting the appropriate OC preparation for women with CHD risk factors.
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