Risk Factors and Secondary Prevention in Women with Heart Disease: The Heart and Estrogen/progestin Replacement Study

  1. Eric Vittinghoff, PhD;
  2. Michael G. Shlipak, MD, MPH;
  3. Paul D. Varosy, MD;
  4. Curt D. Furberg, MD, PhD;
  5. Christine C. Ireland, MPH;
  6. Steven S. Khan, MD;
  7. Roger Blumenthal, MD;
  8. Elizabeth Barrett-Connor, MD;
  9. Stephen Hulley, MD, MPH; and
  10. for the Heart and Estrogen/progestin Replacement Study Research Group
  1. From the University of California, San Francisco, and Veterans Affairs Medical Center, San Francisco, California; Wake Forest University School of Medicine, Winston-Salem, North Carolina; University of California, Los Angeles, Los Angeles, California; Johns Hopkins University, Baltimore, Maryland; and University of California, San Diego, San Diego, California.

    Abstract

    Background: Risk factors for coronary heart disease events have most commonly been evaluated in healthy men.

    Objective: To assess risk factors, event rates, and use of secondary prevention treatments in women with preexisting coronary disease.

    Design: A prospective cohort of clinical trial participants.

    Setting: 20 U.S. clinical centers.

    Participants: 2763 postmenopausal women with known coronary disease in the Heart and Estrogen/progestin Replacement Study (HERS).

    Measurements: Myocardial infarction or death from coronary heart disease.

    Results: On multivariable analysis, the researchers found 11 risk factors: 6 noted by history (nonwhite ethnicity, lack of exercise, treated diabetes, angina, congestive heart failure, and more than one previous myocardial infarction) and 5 that were measured (blood pressure, low-density lipoprotein cholesterol level, high-density lipoprotein cholesterol level, lipoprotein[a] level, and creatinine clearance). The annual rate of coronary events was 1.3% (95% CI, 0.7% to 2.5%) in women with no risk factors and 8.7% (CI, 7.1% to 10.8%) in women with five or more risk factors (a sixfold increase). At entry into HERS, 83% of participants were receiving aspirin or other antiplatelet agents, 33% were receiving β-blockers, 18% were receiving angiotensin-converting enzyme inhibitors, and 53% were receiving lipid-lowering drugs. Women with more risk factors were less likely to be taking aspirin (P < 0.001) and lipid-lowering drugs (P = 0.006).

    Conclusions: Women with coronary disease are at high risk for myocardial infarction or death from coronary heart disease even in the absence of other risk factors, and their risk increases up to sixfold when many risk factors are present. Established drugs for secondary prevention, including aspirin, β-blockers, and lipid-lowering agents, are underused in these women, especially those at highest risk.

    Article and Author Information

    • Grant Support: By Wyeth-Ayerst Laboratories. Dr. Shlipak is funded by a Research Career Development Award from the Health Services Research and Development Service of the Veterans Affairs Administration.

    • Potential Financial Conflicts of Interest:Consultancies: C.D. Furberg; Honoraria: M.G. Shlipak, C.D. Furberg, S.S. Khan; Grants received: E. Vittinghoff, M.G. Shlipak, C.D. Furberg, C.C. Ireland, S.S. Khan, R. Blumenthal, E. Barrett-Connor, S. Hulley.

    • Requests for Single Reprints: Eric Vittinghoff, PhD, University of California, San Francisco, 74 New Montgomery, Suite 600, San Francisco, CA 94105.

    • Current Author Addresses: Dr. Vittinghoff, Ms. Ireland, and Dr. Hulley: University of California, San Francisco, 74 New Montgomery, Suite 600, San Francisco, CA 94105.

    • Drs. Shlipak and Varosy: Veterans Affairs Medical Center, 4150 Clement Street (111A1), San Francisco, CA 94121.

    • Dr. Furberg: Wake Forest University School of Medicine, One Medical Center Boulevard, Winston-Salem, NC 27157-1066.

    • Dr. Khan: Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 6215, Los Angeles, CA 90048-1804.

    • Dr. Blumenthal: Johns Hopkins University Hospital, 600 North Wolfe Street, Carnegie Room 538, Baltimore, MD 21287.

    • Dr. Barrett-Connor: University of California, San Diego, Stein Clinical Research Building 0607, CA 92093-0607.

    • Author Contributions: Conception and design: E. Vittinghoff, M.G. Shlipak, S. Hulley.

    • Analysis and interpretation of the data: E. Vittinghoff, M.G. Shlipak, P.D. Varosy, C.D. Furberg, S.S. Khan, S. Hulley.

    • Drafting of the article: E. Vittinghoff, M.G. Shlipak, P.D. Varosy, S.S. Khan, S. Hulley.

    • Critical revision of the article for important intellectual content: E. Vittinghoff, M.G. Shlipak, P.D. Varosy, C.D. Furberg, S.S. Khan, R. Blumenthal, E. Barrett-Connor, S. Hulley.

    • Final approval of the article: E. Vittinghoff, M.G. Shlipak, P.D. Varosy, C.D. Furberg, C.C. Ireland, S.S. Khan, R. Blumenthal, E. Barrett-Connor, S. Hulley.

    • Provision of study materials or patients: S.S. Khan, E. Barrett-Connor.

    • Statistical expertise: E. Vittinghoff, P.D. Varosy.

    • Obtaining of funding: E. Barrett-Connor, S. Hulley.

    • Administrative, technical, or logistic support: C.D. Furberg, C.C. Ireland, S.S. Khan, S. Hulley.

    • Collection and assembly of data: S.S. Khan.

    Summary for Patients

    • Summaries for Patients:Risk Factors and Treatment in Women with Coronary Artery Disease Ann Intern Med January 21, 2003 138:I-10
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    1. Ann Intern Med January 21, 2003 vol. 138 no. 2 81-89
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