Estrogen and C-Reactive Protein?
According to a new study in this week’s issue of Circulation (Circulation. 2002;106:1224–1228), 12 months of treatment with transdermal estradiol resulted in no significant increases in C-reactive protein, whereas orally conjugated equine estrogen, also given for 12 months, did increase levels of C-reactive protein, which has been associated with increased levels of heart disease.
The researchers, led by Andrea Decensi, MD, of the European Institute of Oncology in Milan, Italy, randomized 189 women to receive the estrogen patch and retinoid fenretinide, oral estrogen pills and placebo, oral estrogen pills and fenretinide, or the estrogen patch and placebo. Members of each group also took sequential medroxyprogesterone acetate.
After 6 months, C-reactive protein was increased by 10% in the group with the estrogen patch and by 48% in the group taking the oral estrogen pills. At 12 months, the C-reactive protein levels were 3% in the group on the patch and 64% in the oral estrogen group. The fenretinide had no effect.
In their introduction, the authors proposed that recent studies showed hormone replacement therapy to have no positive effect in preventing heart disease because oral estrogen might increase levels of C-reactive protein. They were attempting to determine the effect of the estrogen patch on levels of the protein.
“Because increased CRP [C-reactive protein] level is among the strongest of the risk factors for CHD [coronary heart disease] in healthy women and because its normalization is associated with a significant improvement in endothelium-dependent vascular reactivity, our findings suggest that transdermal E2 [the estrogen patch] may be associated with a safer effect on CHD during the initial 12 months of ERT [hormone replacement therapy]. However, because the causal association between the changes in CRP induced by oral CEE [estrogen pills] and increased risk of CHD events is still unproved, the clinical effects of transdermal E2 on early and late CHD events remain to be determined,” they wrote.
CKMB Elevation a Marker in PCI Early Mortality?
Patients with increased creatine kinase MB (CKMB) levels after percutaneous intervention are at increased risk of dying after the procedure, and those with CKMB levels ≥5 times higher than normal face the greatest risk. However, the early risk period of death after percutaneous intervention is limited to 3 to 4 months, regardless of the extent of CKMB increase. These findings come from one of the largest evaluations of the meaning of CKMB elevations after percutaneous intervention performed so far. The report of the study, which was led by Stephen Ellis, MD, of The Cleveland Clinic Foundation, appears in this week’s issue of Circulation (Circulation. 2002;106:1205–1210).
Dr Ellis and colleagues monitored the course of 8409 patients who underwent percutaneous intervention with no serious sequelae over an average of 38 months. None of the patients with CKMB levels between normal and 5 times normal died during the first week after percutaneous intervention. Independent predictors of death within 4 months of the procedure included the degree of CKMB elevation, postintervention C-reactive protein levels, increased creatinine levels, low ejection fraction, age, and heart failure. Incomplete revascularization, congestive heart failure, and no statin treatment at discharge were also associated with death.
The authors recommended extending the hospitalization of only those patients with CKMB levels ≥5 times that of normal, particularly those relating to congestive heart failure, inability to restore blood flow to large parts of the heart muscle, advanced age, or kidney failure. Those patients who are at the highest risk of death because of CKMB elevation and other risk factors should be considered strong candidates for statin therapy. They also proposed: “Furthermore, formal testing of the hypothesis that anti-inflammatory medications might reduce the risk of early death in this patient population might well be considered.”
Heart Disease More Debilitating in Women
Heart disease has a more serious effect on the quality of women’s lives than it does on men’s, according to a team of national researchers led by Charles F. Emery, PhD, of Ohio State University. In a presentation given at the American Psychological Association’s annual convention in Chicago, Ill, on August 22, 2002, the authors concluded that a woman’s quality of life with heart disease is significantly worse than that of a man’s, regardless of diagnosis, age, race, or risk factor, and it remains so for ≥12 months after diagnosis or initial treatment.
In their study, the researchers examined 536 patients, 35% of whom were women. Each patient completed a questionnaire and was monitored at 3-month intervals for a year. “For women, lower quality of life was associated with feeling they didn’t have enough support from friends and family,” Dr Emery said. “But levels of social support did not influence psychological functioning among men . . . Women with heart disease need people to talk to and spend time with. Friendship and companionship appears to be extremely important for their well-being.”
Stents Versus Mini-Bypass
Percutaneous intervention with the use of a stent in patients with isolated lesions of the proximal left anterior descending artery worked in the short term with fewer results during the procedure, but minimally invasive bypass surgery provided longer freedom from angina and fewer cases in which reintervention was needed, according to researchers from the University of Leipzig Heart Center in Germany in a report in the August 22, 2002, issue of the New England Journal of Medicine (N Engl J Med. 2002;347:561–566).
In their study of 220 symptomatic patients with appropriate lesions, 110 were sent to surgery and 110 to stenting. A major adverse cardiac event occurred in 31% of patients who underwent stenting versus 15% of those who had the surgery. The biggest difference was that the patients who received stents were more likely to need repeat revascularization of the involved artery because it suffered restenosis. There was no difference in the combined rates of death or heart attack between the two groups. Seventy-nine percent of patients in the surgery group and 62% of patients in the stent group were free from angina 6 months after surgery.
The researchers, led by Anno Diegeler, MD, noted that both methods are safe and effective in this particular form of lesion. “Our study demonstrates that decisions about how to treat an isolated lesion in the proximal left anterior descending artery require an interdisciplinary approach. Patients should be informed about the alternative treatment options and about the rates of success and of periprocedural events among patients with lesions morphologically similar to theirs,” they concluded.