[The current state of hormonal prevention of coronary heart disease in menopausal women].

The increased incidence and prevalence of coronary heart disease among older women, coupled with the less favorable prognosis for women who sustain coronary events than for men, has resulted in the medical community's attention to the potential beneficial effects of hormone therapy in menopausal women. Much biological evidence supports a protective mechanism of estrogen; nevertheless, some aspects are contradictory. Although observational studies have shown a clear cardiovascular benefit associated with hormone therapy, the significant skew inherent in these data has resulted in overestimation of benefits and underestimation of risks. Recent reanalysis of these observational data controlling for confounding variables failed to show cardiovascular benefit. Several randomized, double-blind, placebo-controlled studies have failed to show improvement in clinical cardiovascular outcomes with menopausal hormone therapy both in healthy women and in women with established coronary heart disease. Current research has also focused on pharmacologic agents that selectively modulate estrogen receptors, such as raloxifene, which are useful for the prevention and treatment of osteoporosis without increasing the risk of breast cancer. A clinical trial is now underway to evaluate the effects of raloxifene on coronary events and on the incidence of invasive breast cancer in menopausal women both with established coronary heart disease and at increased risk for coronary events. Current recommendations do not advocate the initiation of menopausal hormone therapy for the primary or secondary prevention of coronary events. The proven lifestyle interventions of smoking cessation, heart healthy diet, weight control, and physical activity should be undertaken, with statin use for control of elevated LDL cholesterol levels and pharmacologic blood pressure control when appropriate.