Mulheres Médicas: Burnout durante a Pandemia de COVID-19 no Brasil

Fundamento

A COVID-19 adicionou um fardo enorme sobre os médicos ao redor do mundo, especialmente as mulheres médicas, que são afetadas pelo aumento da carga de trabalho e pela perda da qualidade de vida.

Objetivo

Avaliar os efeitos da pandemia de COVID-19 na qualidade de vida, burnout e espiritualidade de médicas brasileiras que atendem pacientes com COVID-19 direta ou indiretamente.

Método

Estudo prospectivo, observacional realizado de 28 de julho a 27 de setembro de 2020, no Brasil, com mulheres médicas de 47 especialidades, a mais frequente sendo a cardiologia (22,8%), sem restrição de idade. Elas responderam voluntariamente um questionário online com questões sobre características demográficas e socioeconômicas, qualidade de vida (WHOQOL-brief) e espiritualidade (WHOQOL-SRPB) e enunciados do Oldenburg Burnout Inventory. A análise estatística utilizou o software R, regressão beta, árvores de classificação e matriz de correlação policórica, com nível de significância de 5%.

Resultados

Das 769 respondentes, 61,6% relataram sinais de burnout. Cerca de 64% relataram perda salarial de até 50% durante a pandemia. Algumas relataram falta de energia para as tarefas diárias, sentimentos negativos frequentes, insatisfação com a capacidade para o trabalho, e que cuidar de outras pessoas não agregava sentido às suas vidas. Os sentimentos negativos correlacionaram-se negativamente com a satisfação com a vida sexual, a satisfação com as relações pessoais e a energia para as tarefas diárias. A incapacidade de permanecer otimista em tempos de incerteza correlacionou-se positivamente com a sensação de insegurança no dia a dia e com o não reconhecimento de que cuidar de outras pessoas trouxesse sentido à vida.

Conclusão

O presente estudo mostrou uma alta frequência de burnout entre as médicas brasileiras que responderam ao questionário durante a pandemia de COVID-19. Apesar disso, apresentavam uma qualidade de vida relativamente boa e acreditavam que a espiritualidade trazia-lhes conforto e segurança nos momentos difíceis.

Reducing Cardiovascular Disease Risk in Women Beyond Statin Therapy: New Insights 2020

Management of residual and persistent cardiovascular disease (CVD) risk among statin-treated individuals has emerged as an important preventive strategy. The purpose of this article is to review the unique landscape of CVD in women and relevant prior prevention trials, and to discuss how the recent results of the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) might apply to the contemporary management of CVD risk among statin-treated women. Women have unique risk factors that may impact CVD and its prevention. Historically, women have been underrepresented in CVD trials, posing a challenge to development of clinical recommendations for women. Low-density lipoprotein cholesterol-targeting treatments have demonstrated CVD risk reduction, with comparable effects in both sexes. In contrast, triglyceride-lowering treatments (niacin, fenofibrate, and omega-3 fatty acids) have reported mixed findings for CVD risk reduction. Recent clinical trials of combination omega-3 fatty acids (docosahexaenoic acid/eicosapentaenoic acid [EPA]) have not found significant CVD risk reduction. The recently published REDUCE-IT study found that icosapent ethyl, an EPA-only omega-3 fatty acid, in combination with statins, significantly reduced CVD events in high-risk patients. The icosapent ethyl group had a significantly lower occurrence of the primary composite CVD endpoint (17.2%) than the placebo group (22.0%; hazard ratio 0.75; 95% confidence interval 0.68-0.83; p < 0.001). CVD risk reduction with icosapent ethyl treatment was comparable between women and men (p for interaction, 0.33). Data from REDUCE-IT suggest women benefit similarly to men with respect to icosapent ethyl, a novel therapy for prevention of CVD.

Beneficial effects of aggressive low-density lipoprotein cholesterol lowering in women with stable coronary heart disease in the Treating to New Targets (TNT) study

OBJECTIVE

To examine by secondary analysis of the Treating to New Targets (TNT) study whether the benefits of intensive versus standard levels of lipid lowering are equally applicable to women.

METHODS

A total of 10 001 patients (1902 women) with stable coronary heart disease (CHD) were randomised to double-blind treatment with atorvastatin 10 or 80 mg/day for a median follow-up of 4.9 years.

RESULTS

In women and men, intensive treatment with atorvastatin 80 mg significantly reduced the rate of major cardiovascular events compared with atorvastatin 10 mg. Among women, the relative and absolute reductions were 27% and 2.7%, respectively (hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.54 to 1.00, p = 0.049). In men, the corresponding rate reductions were 21% and 2.2% (HR = 0.79, 95% CI 0.69 to 0.91, p = 0.001). The number needed to treat value (to prevent one cardiovascular event over 4.9 years compared with patients treated with atorvastatin 10 mg) for atorvastatin 80 mg was 29 for women and 30 for men. Rates of death of non-cardiovascular origin in the atorvastatin 80 mg and atorvastatin 10 mg were 3.6% and 1.6%, respectively (p = 0.004) among women, and 2.8% and 3.1% (p = 0.47) among men.

CONCLUSION

Intensive lipid-lowering treatment with atorvastatin 80 mg produced significant reductions in relative risk for major cardiovascular events compared with atorvastatin 10 mg in both women and men with stable CHD.

Coronary heart disease in women: update 2008

Coronary heart disease (CHD) remains the leading cause of mortality for US women, responsible for almost 250,000 deaths annually. Preventive heart-health behavioral changes by women and aggressive coronary risk reduction can decrease the number of women disabled and killed by CHD. Angina is the predominant initial and subsequent presentation of CHD in women; categorization of chest pain and risk stratification of women assume pivotal roles. A robust evidence-based algorithm can guide cardiovascular imaging techniques to evaluate women with suspected myocardial ischemia to detect those with worsened survival. Restricted functional capacity (<5 METs) is a consistent marker of worsened prognosis. Younger women have substantially higher mortality rates than men following myocardial infarction and coronary bypass surgery. Although these women have more comorbidity and risk factors, other issues including biological differences, treatment differences, and psychosocial factors require management strategies tailored to the unique needs of women.

Coronary heart disease in women: battle is won, but the war remains

According to the most recent report of the US National Heart, Lung, and Blood Institute, mortality from coronary heart disease has declined in women from one in three to one in four. Due to massive campaigning efforts in educating the medical community and the general public, coronary heart disease has become increasingly recognized as a woman's disease. Indeed, it is the number one killer in women, exceeding cancer and infectious diseases. Numerous observational studies, clinical trials, and reports have indicated that there are gender-specific differences in the presentation, diagnosis, treatment, and outcomes of coronary heart disease. One common theme, not only in United States, but world-wide is the underutilization of known and validated medical and interventional therapies in women compared to men. Even though previously conducted large, randomized controlled trials had limited numbers of women, recent large scale cardiac trials in women have enabled the development of evidence-based guidelines for coronary heart disease diagnosis and management in women. Importantly, menopausal hormone therapy and antioxidant vitamin therapy do not protect post-menopausal women from coronary heart disease. Aggressive life-style and pharmacologic management of known coronary risk factors in women should be a top priority to improve coronary heart disease morbidity and mortality. Research data continue to emerge to fill the gaps of how gender affects atherosclerosis; in the meantime, continued patient and physician education to increase awareness of coronary heart disease may help to eliminate some of the gender-based disparities in the delivery of coronary care to women.

Cardiovascular disease in the elderly

Cardiovascular disease is the major cause of death and disability in the elderly. Atherosclerotic coronary heart disease is the most prevalent problem, followed by hypertensive cardiovascular disease. Calcific aortic stenosis is the most common haemodynamically important valvular lesion; surgical correction significantly improves the prognosis. Pulmonary embolism occurs frequently, related to immobilization and co-morbidity. Congestive heart failure is both under-diagnosed and over-diagnosed. Complete heart block and sick sinus syndrome increase with age; appropriate pacemaker therapy can improve the length and quality of life. Clinical evaluation of elderly patients is often hampered by multiple co-existing disease involving other organ systems, problems in reporting symptoms, and associated functional and structural changes of ageing that may mimic or mask cardiovascular disease. Presentations of cardiac illness often differ from those in a younger population. Most of the available data on therapy and prognosis do not apply to contemporary practice, so that clinical decisions are often extrapolated from information acquired in younger patients. Elderly patients are at high risk of complications of most diagnostic and therapeutic procedures, more related to co-morbidity than to age; they have more frequent and serious adverse drug reactions, due both to co-morbidity and to multiple medications. Age as such should not constitute a barrier to cardiac care; in the USA at least one-third of all cardiovascular procedures are performed in elderly patients. The goals of therapy are improvement in function and postponement of debilitating illness, enabling an extended active independent lifestyle.

Evidence-based management of coronary artery disease in the elderly--current perspectives

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. The clinical trial data available to guide therapy in this growing population subset are relatively limited. This review will focus on treatment approaches and recommendations obtained from subgroup analyses of elderly patients from major clinical trials for the management of chronic stable angina, acute coronary syndromes (unstable angina and non-ST-segment elevation myocardial infarction), and coronary revascularization. Recent advances in the treatment of stable angina have shown that use of angiotensin-converting enzyme inhibitors and lipid-lowering therapy as adjunctive measures show benefit in the elderly by reducing the occurrence of death, nonfatal myocardial infarction, and unstable angina. However, if patients experience disabling or unstable anginal symptoms despite effective medical therapy, coronary revascularization must be considered. Several clinical trials have shown a significant reduction in major adverse cardiac events when using intravenous glycoprotein receptor antagonists periprocedurally during percutaneous revascularization approaches in elderly patients with unstable angina or non-ST-segment elevation myocardial infarction, especially when these measures are performed as soon as possible. However, the success of myocardial revascularization by a percutaneous or surgical approach is highly dependent on the patient's associated comorbidities, especially in patients over age 80 years.

Evidence-based management of acute myocardial infarction in the elderly--current perspectives

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. Despite several, large cardiovascular clinical trials, data to guide therapy in this growing population subset are relatively limited. This review focuses on treatment approaches and recommendations for the management of elderly patients with acute myocardial infarction (MI) obtained from subgroup analyses from major clinical trials.Treatment options for acute MI in the elderly have changed dramatically since the 1990s. Reperfusion therapy by primary percutaneous coronary intervention has superseded the use of thrombolytic therapy for the treatment of acute ST-elevation myocardial infarction (STEMI). Clinical trial data have demonstrated that even transferring patients to facilities that have primary angioplasty capabilities is better than thrombolytic therapy, if the anticipated transfer time is of acceptable duration. Additionally, adjunctive use of the intravenous glycoprotein (GP) receptor antagonist, abciximab, during primary angioplasty affords a reduction in the composite primary end point of death, reinfarction, and target vessel revascularization, with much of the benefit derived from the latter. Thrombolytic therapy, barring any contraindication, must be used when mechanical revascularization is not available; however, the risk for complications in the elderly is higher, especially for those 75 years and older. Studies investigating the use of thrombolytics plus GP receptor antagonists with and without percutaneous coronary intervention show questionable benefit in the elderly.

Women in cardiology: the US experience

"You are not required to complete the work, but neither are you at liberty to abstain from it.."-Rabbi Tarfon, Pirke Avot 2:16.

Baseline characteristics of participants in the Raloxifene Use for The Heart (RUTH) trial

The Raloxifene Use for The Heart (RUTH) trial is a randomized, placebo-controlled, double-blind trial designed to determine whether raloxifene 60 mg/day compared with placebo lowers the risk of coronary events (coronary death, nonfatal myocardial infarction [MI], or hospitalized acute coronary syndromes other than MI) and reduces the risk of invasive breast cancer in women at risk for a major coronary event. Raloxifene is a selective estrogen receptor modulator that improves cardiovascular risk factors, reduces the risk of vertebral fracture, and is associated with a reduced incidence of invasive breast cancer in postmenopausal women with osteoporosis. Between June 1998 and August 2000, 10,101 women were enrolled at 187 sites in 26 countries. Approximately half of the women had documented coronary heart disease (CHD) (n = 5,031); the remainder had multiple CHD risk factors that increased their risk for a CHD event (n = 5,070). The mean age of participants was 68 years (39% were >70 years old), and did not differ between those with documented CHD and those at increased CHD risk. Most women were Caucasian (84%); 60% had a body mass index >/=27 kg/m(2), 46% had diabetes mellitus, 78% had systemic hypertension, and 14% had low-density lipoprotein cholesterol >160 mg/dl. Compared with women at increased CHD risk, women with documented CHD had higher cardiovascular risk scores, a higher prevalence of abnormal electrocardiograms, greater use of cardiovascular medications, were more likely to have had cardiac rehabilitation, and were more likely to have previously used estrogen or oral contraceptives, but had a slightly lower prevalence of CHD risk factors such as smoking, obesity, diabetes mellitus, and systemic hypertension, and had lower serum levels of total and low-density lipoprotein cholesterol. The RUTH cohort is the largest group of postmenopausal women at increased risk of CHD events ever assembled in a clinical trial, and is the first trial designed to determine the effect of a selective estrogen receptor modulator on the risk of CHD events.

Managing ambulatory anticoagulation

This overview of the management of ambulatory oral anticoagulant therapy addresses the importance of patient education and highlights tested educational techniques; describes issues of documentation of the patient encounter in the medical record; and reviews drug dosage adjustments, the management of patients with high International Normalized Ratio (INR) values, and the recommended changes of oral anticoagulation for patients who undergo invasive procedures.

Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease

OBJECTIVES

This study sought to determine the independent association of renal insufficiency with cardiovascular risk among women with known coronary heart disease (CHD).

BACKGROUND

Although patients with end-stage renal disease and proteinuria are at high risk for cardiovascular events, little is known about the cardiovascular risk associated with moderate renal insufficiency.

METHODS

The Heart and Estrogen/progestin Replacement Study (HERS) was a clinical trial among 2,763 women with coronary disease who were randomized to conjugated estrogen plus progestins or identical placebo and followed for a mean of 4.1 years. Women were categorized as having normal renal function (creatinine < 1.2 mg/dl; n = 2,012), mild renal insufficiency (1.2 mg/dl to 1.4 mg/dl; n = 567) and moderate renal insufficiency (>1.4 mg/dl; n = 182). We examined the independent association of renal function with incident cardiovascular events including CHD death, nonfatal myocardial infarction, hospitalization for unstable angina, stroke and transient ischemic attacks.

RESULTS

Compared with women with normal renal function, those with mild and moderate renal insufficiency were older, more likely to be black, have a history of hypertension and diabetes and have higher serum levels of triglycerides and lipoprotein(a). After multivariate adjustment, both mild (relative hazards [RH] = 1.24; 95% confidence interval [CI]: 1.0 to 1.5) and moderate renal insufficiency (RH = 1.57; 95% CI: 1.2 to 2.1) were independently associated with increased risk for cardiovascular events compared with women with normal renal function.

CONCLUSIONS

Renal insufficiency is an independent risk factor for cardiovascular events in postmenopausal women with known coronary artery disease. Renal function may add helpful information to CHD risk stratification.

Design and methods of the Raloxifene Use for The Heart (RUTH) study

Raloxifene is a selective estrogen receptor modulator that lowers total and low-density lipoprotein (LDL) cholesterol, reduces the risk of vertebral fracture, and is associated with a reduced incidence of invasive breast cancer in postmenopausal women with osteoporosis. The Raloxifene Use for The Heart (RUTH) trial is designed to determine whether raloxifene 60 mg/day compared with placebo: (1) lowers the risk of the coronary events (coronary death, nonfatal myocardial infarction [MI], or hospitalized acute coronary syndromes other than MI); and (2) reduces the risk of invasive breast cancer in women at risk for a major coronary event. RUTH is a double-blind, placebo-controlled, randomized clinical trial of 10,101 postmenopausal women aged > or =55 years from 26 countries. Women are eligible for randomization if they are postmenopausal and have documented coronary heart disease (CHD), peripheral arterial disease, or multiple risk factors for CHD. Use of estrogen within the previous 6 months is an exclusion factor. The study will be terminated after a minimum of 1,670 participants experience a primary coronary end point. Secondary end points include cardiovascular death, myocardial revascularization, noncoronary arterial revascularization, stroke, all-cause hospitalization, all-cause mortality, all breast cancers, clinical fractures, and venous thromboembolic events, in addition to the individual components of the composite primary coronary end point. RUTH will provide important information about the risk-benefit ratio of raloxifene in preventing acute coronary events and invasive breast cancer, as well as information about the natural history of CHD in women at risk of major coronary events.

Mutations in the genes regulating methylene tetrahydrofolate reductase (MTHFR C-->T677) and cystathione beta-synthase (CBS G-->A919, CBS T-->c833) are not associated with myocardial infarction in African Americans

Moderate hyperhomocysteinemia is a putative risk factor for cardiovascular disease. Molecular studies have demonstrated increased plasma homocysteine levels in the presence of DNA mutations in either the methylenetetrahydrofolate reductase (MTHFR) enzyme found in the remethylation pathway or the enzyme cystathione beta-synthase (CBS) of the transsulfuration pathway. To determine whether the mutation C-->T677 in the MTHFR gene or the T-->C833/844ins68 and G-->A919 mutations in the CBS gene are associated with myocardial infarction (MI) in African Americans, DNA was analyzed from samples obtained from a case-control study conducted at a large, inner-city hospital. One-hundred ten African American subjects with a diagnosis of MI and 185 race- and age-matched controls were recruited. Our results demonstrated that 15% of the MI cases were heterozygous for the C-->T677 (MTHFR) mutation, while 1.8% were homozygous. When compared to the controls in which 15% were heterozygous and 2.1% were homozygous, no significant association with MI was observed. In addition, 34% of the cases were heterozygous for the T-->C833 (CBS) mutation while 6% were homozygous. This is compared to 32% and 5% of the controls having the heterozygous and homozygous genotype, respectively. No significant association was observed for the T-->C833 (CBS) mutation among the cases and controls. Although this mutation has no significant association with MI, the prevalence of the heterozygous state was higher than what has been reported for whites (12%). No mutations for G-->A919 (CBS) were detected in the cases or controls. The racial differences of the CBS T-->C833 polymorphism suggest that further investigation into the other areas of the CBS gene is needed.

Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart disease: an ancillary study of volunteers for hers

Postmenopausal women with coronary heart disease (CHD) who volunteered for the Heart and Estrogen/Progestin Replacement Study (HERS) randomized clinical trial had high rates of gynecological abnormalities. We examined compliance with gynecological cancer screening and factors affecting this behavior. Women who met inclusion criteria for HERS and were seen for screening by the study gynecologist were considered eligible for this study. Data were abstracted from study records, and additional information was obtained by telephone questionnaire. Adherence to mammography, breast examination, pelvic examination, and Pap smear recommendations was assessed. Provider behavior and its effect on compliance were assessed. Compliance rates were 59.1% for monthly breast self-examination (BSE), 67.2% for yearly mammography, 73% for yearly Pap smear and pelvic examination, and 75.7% for provider breast examination. Over 50% of patients had most of their screening tests done within the last year. Provider behavior was significantly related to patient screening compliance for mammography, breast examination, Pap smear, and pelvic examination. Provider gender was not significantly related to adherence. There were no significant differences in compliance rates based on the type of most recent coronary event. Compliance rates did not differ significantly between patients with and without gynecological abnormalities, except for mammography (78.3% versus 48.3%, p = 0.02). The majority of patients were compliant with gynecological screening. Among patients with gynecological abnormalities, mammography compliance was significantly lower. Provider behavior was an important factor in influencing women to obtain preventive screening. There were no significant differences in compliance based on provider gender or type of coronary event preceding HERS enrollment.

Coronary heart disease in African Americans

African Americans have the highest overall mortality rate from coronary heart disease (CHD) of any ethnic group in the United States, particularly out-of-hospital deaths, and especially at younger ages. Although all of the reasons for the excess CHD mortality among African Americans have not been elucidated, it is clear that there is a high prevalence of certain coronary risk factors, delay in the recognition and treatment of high-risk individuals, and limited access to cardiovascular care. The clinical spectrum of acute and chronic CHD in African Americans is similar to that in whites. However, African Americans have a higher risk of sudden cardiac death and present more often with unstable angina and non-Q-wave myocardial infarction than whites. African Americans have less obstructive coronary artery disease on angiography, but may have a similar or greater total burden of coronary atherosclerosis. Ethnic differences in the clinical manifestations of CHD may be explained largely by the inherent heterogeneity of the coronary syndromes, and the disproportionately high prevalence and severity of hypertension and type 2 diabetes in African Americans. Identification of high-risk individuals for vigorous risk factor modification-especially control of hypertension, regression of left ventricular hypertrophy, control of diabetes, treatment of dyslipidemia, and smoking cessation--is key for successful risk reduction.

Venous thrombosis in relation to fibrinogen and factor VII genes among African-Americans

We evaluated the relation between venous thrombosis and plasma fibrinogen levels, the HaeIII and BcI polymorphisms of the beta fibrinogen gene, and the MspI polymorphisms of the factor VII gene in a case-control study of African-Americans. The study included 91 venous thrombosis cases and 185 control subjects obtained from a hospital in Atlanta, Georgia. High plasma fibrinogen was associated with increased risk of venous thrombosis, but the finding was not statistically significant. There was little association between the HaeIII polymorphisms and the BclI polymorphisms and the risk of venous thrombosis. The prevalence of the M2/M2 genotype of the factor VII gene was higher among cases than controls, but the difference was not statistically significant. The prevalence of the HaeIII H2 allele and the BclI B2 allele of the beta fibrinogen gene, both of which have been associated with slightly higher levels of plasma fibrinogen in most studies, is considerably lower among African-Americans in this study than it is among Whites in the United States and among Northern Europeans. The study is limited by its small size. However, despite this limitation, it supports the belief that increased plasma fibrinogen levels are associated with increased venous thrombosis risk. The study also indicated that the HaeIII and the BclI polymorphisms of the beta fibrinogen gene and the MspI polymorphisms of the factor VII gene are not strong determinants of venous thrombosis.

The role of the t-PA I/D and PAI-1 4G/5G polymorphisms in African-American adults with a diagnosis of myocardial infarction or venous thromboembolism

To determine whether or not the PAI-1 4G/5G and t-PA I/D polymorphisms in African-Americans were linked to cardiovascular disease, the association of these polymorphisms to disease expression was analyzed in a recently completed case-control study of myocardial infarction or venous thromboembolism among African-Americans. All African-Americans patients with a history of venous thromboembolism attending an anticoagulant clinic, and patients with a history of a MI attending a cardiology clinic at a large local urban public hospital were eligible for inclusion as cases in the study. In this study it was observed that there was a statistically significant association between the D allele of the t-PA I/D polymorphism and venous thromboembolism and a nonsignificant association between the D allele and myocardial infarction among African-Americans. t-PA antigen levels were statistically significantly higher among both myocardial infarction and venous thromboembolism cases compared with control subjects. The genotypes were unrelated to t-PA plasma levels. There was no association between either myocardial infarction or venous thromboembolism and the 4G/5G PAI-1 genotype. It was also found that genotype frequencies for both PAI-1 4G/5G and t-PA I/D polymorphisms in African-American adults were different from those reported for both U.S. Causcians and Europeans.

Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study

BACKGROUND

Oral contraceptive use increases risk for venous thromboembolism, but data on the effect of postmenopausal hormone therapy are limited.

OBJECTIVE

To determine the effect of therapy with estrogen plus progestin on risk for venous thromboembolic events in postmenopausal women.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

20 clinical centers in the United States.

PARTICIPANTS

2763 postmenopausal women younger than 80 years of age (mean age, 67 years) who had coronary heart disease but no previous venous thromboembolism and had not had a hysterectomy.

INTERVENTION

Conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in one tablet (n = 1380) or placebo that was identical in appearance (n = 1383).

MEASUREMENTS

Documented deep venous thrombosis or pulmonary embolism.

RESULTS

During an average of 4.1 years of follow-up, 34 women in the hormone therapy group and 13 in the placebo group experienced venous thromboembolic events (relative hazard, 2.7 [95% CI, 1.4 to 5.0] [P = 0.003]; excess risk, 3.9 per 1000 woman-years [CI, 1.4 to 6.4 per 1000 woman-years]; number needed to treat for harm, 256 [CI, 157 to 692]). In multivariate analysis, the risk for venous thromboembolism was increased among women who had lower-extremity fractures (relative hazard, 18.1 [CI, 5.4 to 60.4]) or cancer (relative hazard, 3.9 [CI, 1.6 to 9.4]) and for 90 days after inpatient surgery (relative hazard, 4.9 [CI, 2.4 to 9.8]) or nonsurgical hospitalization (relative hazard, 5.7 [CI, 3.0 to 10.8]). Risk was decreased with aspirin (relative hazard, 0.5 [CI, 0.2 to 0.8]) or statin use (relative hazard, 0.5 [CI, 0.2 to 0.9]).

CONCLUSIONS

Postmenopausal therapy with estrogen plus progestin increases risk for venous thromboembolism in women with coronary heart disease. This risk should be considered when the risks and benefits of therapy are being weighed.

Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study

BACKGROUND

Oral contraceptive use increases risk for venous thromboembolism, but data on the effect of postmenopausal hormone therapy are limited.

OBJECTIVE

To determine the effect of therapy with estrogen plus progestin on risk for venous thromboembolic events in postmenopausal women.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

20 clinical centers in the United States.

PARTICIPANTS

2763 postmenopausal women younger than 80 years of age (mean age, 67 years) who had coronary heart disease but no previous venous thromboembolism and had not had a hysterectomy.

INTERVENTION

Conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in one tablet (n = 1380) or placebo that was identical in appearance (n = 1383).

MEASUREMENTS

Documented deep venous thrombosis or pulmonary embolism.

RESULTS

During an average of 4.1 years of follow-up, 34 women in the hormone therapy group and 13 in the placebo group experienced venous thromboembolic events (relative hazard, 2.7 [95% CI, 1.4 to 5.0] [P = 0.003]; excess risk, 3.9 per 1000 woman-years [CI, 1.4 to 6.4 per 1000 woman-years]; number needed to treat for harm, 256 [CI, 157 to 692]). In multivariate analysis, the risk for venous thromboembolism was increased among women who had lower-extremity fractures (relative hazard, 18.1 [CI, 5.4 to 60.4]) or cancer (relative hazard, 3.9 [CI, 1.6 to 9.4]) and for 90 days after inpatient surgery (relative hazard, 4.9 [CI, 2.4 to 9.8]) or nonsurgical hospitalization (relative hazard, 5.7 [CI, 3.0 to 10.8]). Risk was decreased with aspirin (relative hazard, 0.5 [CI, 0.2 to 0.8]) or statin use (relative hazard, 0.5 [CI, 0.2 to 0.9]).

CONCLUSIONS

Postmenopausal therapy with estrogen plus progestin increases risk for venous thromboembolism in women with coronary heart disease. This risk should be considered when the risks and benefits of therapy are being weighed.

Lipid management and control of other coronary risk factors in the postmenopausal woman

This review identifies coronary heart disease (CHD) as the leading cause of mortality among postmenopausal women and highlights the well-documented problem of underrecognition and undertreatment of women who are at risk for or who already have CHD. This undertreatment encompasses both preventive care (i.e., drug treatment for lipid management) and more invasive treatments (e.g., revascularization procedures). Preventive interventions to reduce dyslipidemia and control other coronary risk factors can lessen CHD mortality and morbidity in the postmenopausal woman.

The relationship between polymorphisms in the endothelial cell nitric oxide synthase gene and the platelet GPIIIa gene with myocardial infarction and venous thromboembolism in African Americans

STUDY OBJECTIVES

To determine whether the polymorphic dinucleotide repeats found in intron 4 of the endothelial cell nitric oxide synthase (ecNOS) gene and the platelet GPIIIa PLA(1)/A(2) polymorphism are associated with myocardial infarction (MI) and venous thromboembolism (VTE) in African Americans. Because these two genes may interact physiologically, the third objective was to determine if there was a relationship between the polymorphisms with respect to MI and VTE.

DESIGN

A hospital-based case-control study. After informed consent was obtained, blood used for DNA extraction was drawn from the subjects.

SETTING

The study was conducted in the Anticoagulant Clinic and the Cardiology Clinic at Grady Memorial Hospital in Atlanta Georgia.

PATIENTS

Subjects were recruited from African-American patients with a reported history of MI (n = 110) or VTE (n = 91). Control subjects (n = 185) without a history of cardiovascular or venous disease were recruited from an outpatient clinic.

MEASUREMENTS AND RESULTS

The 393 ecNOS allele was more common among MI cases (36%; p = 0.01) and VTE cases (35%; p = 0.04) than among control subjects (26%). There was no association between the GPIIIa genotypes and either MI or VTE. However, among the MI subjects, there was a strong association between the ecNOS 393/393 genotype and the Pl(A2) allele. It was also found that the frequency of the 393 allele was higher in African-American persons (0.26) compared with what has been reported for Australian Caucasians (0. 14) and Japanese (0.10).

CONCLUSIONS

The 393 allele but not the Pl(A2) allele was significantly associated with both MI and VTE in African Americans. Homozygosity for the 393 allele was significantly associated to the diagnosis of MI prior to the age of 45. The combination of the 393 allele and a Pl(A2) allele was also highly associated with MI. The frequency of the 393 allele was significantly higher in African Americans than what has been reported for other populations. This study furthers not only extends the association of the 393 allele to VTE but has demonstrated an interaction with the Pl(A2) allele with respect to MI.