Lipid Lowering Agents

Although the U.S. National Cholesterol Education Program (NCEP) guidelines recommend an LDL cholesterol goal of less than 100 mg/dL for men and women with documented coronary heart disease, the Heart Estrogen/Progestin Replacement Study (HERS) trial of postmenopausal women with atherosclerotic coronary artery disease revealed that only 47% of women were taking lipid-lowering medication, and LDL cholesterol was above target in 91% of the study group. In fact, only 33% of women with LDL cholesterol >160 mg/dL were receiving lipid lowering therapy (51). To address this issue, the Women's Atorvastatin Trial on Cholesterol (WATCH) aggressively treated women and importantly demonstrated that 87% of women with 2 or more coronary artery disease risk factors and 80% of women with documented coronary heart disease treated with atorvastatin reached their LDL cholesterol goal (52).

Studies of cholesterol-lowering agents for primary prevention of coronary heart disease that included women were underpowered to detect absolute decreases in mortality; however, the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/ TexCAPS) revealed that after an average of 5.2 yr follow-up, the risk of a first major acute coronary event was reduced in both men and women with a decrease in relative risk of 46% in women (53).

The Scandinavian Simvastatin Survival Study was a trial of simvastatin therapy for secondary prevention of coronary heart disease that enrolled 3617 men and 827 women with angina or a prior myocardial infarction. At a median follow-up of 5.4 yr, simvastatin therapy achieved a 37.4% reduction of LDL cholesterol in women resulting in a 49% decrease in the need for percutaneous or surgical revascularization procedures. In contrast to what was observed in men, women did not experience a significant reduc-

Fig. 6. Hormone replacement therapy and coronary artery disease. In women treated with estrogen or a combination of estrogen and medroxyprogestin (MPA), there was a reduction in LDL cholesterol and an increase in HDL cholesterol; however, this improvement in lipid profile did not translate into a regression of coronary artery disease at angiography, nor did it lead to a significant reduction in clinical events. LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; MI, myocardial infarction (60).

Fig. 6. Hormone replacement therapy and coronary artery disease. In women treated with estrogen or a combination of estrogen and medroxyprogestin (MPA), there was a reduction in LDL cholesterol and an increase in HDL cholesterol; however, this improvement in lipid profile did not translate into a regression of coronary artery disease at angiography, nor did it lead to a significant reduction in clinical events. LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; MI, myocardial infarction (60).

tion in cardiovascular or all-cause mortality. One potential explanation for these results is that women who participated in the study were more likely to have angina as the entry criteria to the study than men (37 vs 17%), and, therefore, may not have had significant epicardial coronary artery disease (54). Similarly, in the Cholesterol and Recurrent Events (CARE) trial, 3583 men and 576 postmenopausal women with a history of myocardial infarction and elevated LDL cholesterol were randomized to pravastatin or placebo, and, at 5-yr follow-up, the reduction of risk of cardiovascular death in women treated with pravastatin was twice that seen in men (43 vs 21%). In addition, women had a greater reduction in nonfatal myocardial infarction than men (51 vs 15%) and a 56% decrease in stroke (55).

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