126 Hormone replacement therapy (HRT) in women after myocardial infarction (MI)/ischaemic heart disease

Abstract

Introduction Women with diagnosed menopause suffer from symptoms that are often debilitating and impair their quality of life. Post menopausal symptoms are commonly managed with hormone replacement therapy (HRT) to provide relief and improvement in quality of life. However, given the complex role of HRT in cardiovascular risk, its use in post-menopausal women after a myocardial infarction remains controversial.

Furthermore, the European Society of Cardiology, NICE, American Heart Association and British Menopause Society do not provide an agreed guidelines regarding initiation, continuation, cessation or modification of HRT post myocardial infarction (MI.) This results in inconsistent decision making with a clear need to standardise post MI management of HRT in hospitals.

Oestrogen affects remodelling and thrombogenesis in a dose dependent risk therefore higher doses may cause adverse effects whereas lower doses and non-oral routes are known to be neutral or even be beneficial. The consensus from the British Menopause Society (BMS) is that there are no absolute contraindications for the use of HRT post MI with the current data also suggesting the prioritisation of symptom management with the lowest possible dose using a non-oral form of HRT.1 Additionally, the synergistic effect of combining HRT and statins yields greater improvement in Lipid profile than either therapy alone.2

The aim of this quality improvement project was to assess local practice, educate regarding current evidence and guidance available as well as develop local guidelines to provide a safe approach backed with current data on HRT prescribing post MI.

Methods Retrospectively, data of all patients presenting with ACS at our local trust over the past 1 year were reviewed.

Post menopausal women with confirmed STEMI/NSTEMI were included, whereas women of pre-menopausal age or non-MI diagnosis were excluded from our review.

For each eligible patient, GP records as well as admission medication charts were examined to determine if HRT was started, continued, changed or discontinued following MI admission.

Furthermore, a survey involving clinicians was conducted in our local cardiology department. The aim of the survey was to assess confidence when dealing with HRT in MI patients, awareness of BMS guidance and their usual practice.

We used the results of these to guide a change within our department. With the help of gynaecology team and pharmacists, we formed a local guidance to inform clinicians of the current BMS recommendation, including suggested preferential routes/dosing of HRT post-MI.

Results A total of 178 patients were screened, of whom 14 were taking HRT. 3 of these patients were not prescribed pre-existing HRT on admission, 6 had HRT continued as previously prescribed, and 5 patients had their HRT discontinued (table 1). There were no adjustments made to any existing HRT routes or dosages.

From our departmental survey, we established that 88.89% of clinicians were not aware of BMS guidance on HRT prescribing in MI patients and similarly >66% did not feel confident managing HRT post MI (table 2).

Conclusions This project identified that HRT prescribing in women following MI is inconsistently and often poorly managed, largely due to clinician uncertainty and outdated perceptions regarding cardiovascular risk.

Consequently, many women are left without appropriate symptom control. This highlights a broader and well recognised issue within healthcare where women’s health concerns are frequently misjudged.

Given that cardiovascular disease remains the leading cause of mortality in women, addressing gender-specific health needs should be an integral part of post MI care.

The results from both our audit and survey showed a significant lack of confidence and avoidance when dealing with HRT.

Consequently, we established local guidelines; the goals of which were to provide clear, evidence-informed, safe, and pragmatic recommendations for assessment, initiation, and ongoing prescribing of HRT in women who have sustained a MI. The guidelines are in keeping with British Menopause Society guidance, and local Cardiology and Gynaecology teams’ input. It also included a flowchart to aid clinicians further (appendix 1).

These received excellent feedback from the local teams with reports of improved confidence and knowledge in managing women’s health post myocardial infarction.

The development and implementation of clear, evidence-based guidance outlining how HRT can be safely prescribed in this patient group represents an important initial step towards improving clinical practice. It provides a practical framework to support clinician decision making and empower shared discussions with patients. Ultimately, sustained change will require on-going education, cultural shifts in prioritising women’s health with more evidence and multi-disciplinary collaboration to ensure that symptom burden, quality of life and CV outcomes are addressed in parallel.