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Menopause and coronary disease
Volume Number
116 6, Part 1
MENOPAUSEANDCORONARYDISEASE To the Editor: We read with great interest the authoritative and comprehensive special report on gender and plasma lipoproteins.’ In a review of such scope, perhaps some errors are inevitable. We wish to correct an important misinterpretation of our recent study of menopause and risk of heart disease.’ Godsland et al., in describins the studv. state that “Estroeen had no effect on CHD risk in women who had undergone a natural menopause.“’ This is not the case; that study did not include an analysis of the effects of estrogen replacement therapy on CHD risk among women with natural menopause. In an earlier paper from the same cohort (The Nurses’ Health Study), we observed a marked protective effect of estrogen on CHD risk.’ Meir J. Stampfer, MD Graham A. Colditz Department of Medicine Brigham and Women’s Hospital and Harvard Medical School 180 Longwood Ave. Boston, MA 02115 REFERENCES 1. Godsland IF, Wynn V, Crook D, Miller NE. Sex, plasma lipoproteins, and atherosclerosis: prevailing assumptions and outstanding auestions. AM HEART J 1987:114:1467-1503. 2. Colditz GASWillett WC, Stampfer MJ, Rdsner B, Speizer FE, Hennekens CH. Menopause and risk of coronary heart disease in women. N Engl J Med 1987:316:1105-10. 3. Stampfer MJ, Willett We, Colditz GA, kosner B. Speizer FE, Hennekens CH. A prospective study of postmenopausal estrogen therapy and coronary heart disease. N Engl J Med 1985;313:1044-9.
REPLY To the Editor: The Boston Nurses’ Health Study is a large and well-planned epidemiologic investigation that has recently provided insight into the relationships between menopausal status, estrogen use, and coronary heart disease (CHD) in women. In their analysis of the effects of menopausal status on CHD risk, the authors showed (1) that naturally postmenopausal women had the same risk of CHD as did premenopausal women, and that this risk was not affected by estrogen usage; and (21 that surgically postmenopausal women had an increased risk of CHD when compared to premenopausal women, and that this risk was eliminated by estrogen usage. Our statement that “Estrogen usage had no effect on CHD risk in women who had undergone A natural menopause” was based on our extrapolation of these two findings. Strictly speaking, we should have said “Compared with premenopausal women, the occurrence of a natural menopause together with estrogen usage did not affect CHD risk.” The Nurses’ Health Study has highlighted some of the complexities that confound this controversial and important field. We are grateful for the opportunity to clarify our understanding of this study. I. F. Godsland V. Wynn D. Crook Cavendish Clinic 21 Wellington Road London, England NW8 95Q
Letters
to the Editor
1649
WARFARIN-RELATED HEMORRHAGE AFTER VALVE REPLACEMENT To the Editor: Czer et al.’ reported a very high linearized event rate for warfarin-related hemorrhage (2.9 “b per patient-year) after valve replacement with the St. Jude Medical prosthesis. The same authors reported much lower rates for the same complication with the same prosthesis in previous publications. In 1984 they found a rate of 0.5% per patient-year: and in 1985 a rate of 1% per patient-year.j Between 1984 and 1987 their patient population increased from 307 to 527 patients, the total number of events increased from 2 to 39, and the follow-up increased from 408 patient-years to 1336 patient-years.” There was apparently no change in the kind of follow-up between the various studies, mostly mailed questionnaires and telephone interviews. The actuarial curve of freedom from hemorrhage can only decrease with time, the total number of patients who bled or the total number of events can only increase with time, but there is no apparent reason for an increase in a linearized rate of the number of events per patient-year. There is no comment about this sixfold increase in the frequency of bleeding compared to the 1984 publication for the same study. In our experience of 49 patients with St. Jude Medical prosthesis in the aortic position, there was a very high incidence of hemorrhage due to anticoagulation (3.26% per patient-year), but there was a major difference in the method of obtaining this information compared with that of Czer et ah we examined 78.9% of our patients in our department at the end of a 7-year study. When the answers to a mailed questionnaire were considered alone, the linearized rate of hemorrhagic complications was only 0.93 % per patient-year. Most of patients forgot to mention these events in answering questionnaires in which we specifically asked if hemorrhagic events had occurred since operation. Clinical interviewing was much more accurate for obtaining this sort of information. Horstkotte et al.4 also reported a rate of 2.577: per patient-year of hemorrhage, and follow-up was also made by consultation in their department; 8O”G of patients were reexamined at the end of their study. The real question is whether the frequency of hemorrhage increases with time as Czer et al. suggest. The apparent increase that they report could be artifactual due to more intensive research methods, especially the use of telephone interviews in their latest publication. However, if the frequency of hemorrhage really does increase with time, it is important to point it out, as it would have clinical implications in the long-term follow-up of patients after valve replacement, and the reasons for this increase would have to be determined. Patient populations may change with time such as the increasing numbers of elderly patients and the occurrence of contraindications in patients receiving anticoagulant therapy. Gil/es Montalescot, MD Daniel Thomas, MD Yves Grosgogeat, MD Department of Cardiology H6pital Piti&Salpbtri6re 47 Bl. de I’h6pitaZ 75013 Paris. France REFERENCES 1. Czer LSC, Matloff ME, Gray RJ. The lism, warfarin-related 1987;114:389.
JM, Chaux A, De Robertis M, Stewart St. Jude valve: analysis of thromboembohemorrhage, and survival. AM HEART J
116 6, Part 1
MENOPAUSEANDCORONARYDISEASE To the Editor: We read with great interest the authoritative and comprehensive special report on gender and plasma lipoproteins.’ In a review of such scope, perhaps some errors are inevitable. We wish to correct an important misinterpretation of our recent study of menopause and risk of heart disease.’ Godsland et al., in describins the studv. state that “Estroeen had no effect on CHD risk in women who had undergone a natural menopause.“’ This is not the case; that study did not include an analysis of the effects of estrogen replacement therapy on CHD risk among women with natural menopause. In an earlier paper from the same cohort (The Nurses’ Health Study), we observed a marked protective effect of estrogen on CHD risk.’ Meir J. Stampfer, MD Graham A. Colditz Department of Medicine Brigham and Women’s Hospital and Harvard Medical School 180 Longwood Ave. Boston, MA 02115 REFERENCES 1. Godsland IF, Wynn V, Crook D, Miller NE. Sex, plasma lipoproteins, and atherosclerosis: prevailing assumptions and outstanding auestions. AM HEART J 1987:114:1467-1503. 2. Colditz GASWillett WC, Stampfer MJ, Rdsner B, Speizer FE, Hennekens CH. Menopause and risk of coronary heart disease in women. N Engl J Med 1987:316:1105-10. 3. Stampfer MJ, Willett We, Colditz GA, kosner B. Speizer FE, Hennekens CH. A prospective study of postmenopausal estrogen therapy and coronary heart disease. N Engl J Med 1985;313:1044-9.
REPLY To the Editor: The Boston Nurses’ Health Study is a large and well-planned epidemiologic investigation that has recently provided insight into the relationships between menopausal status, estrogen use, and coronary heart disease (CHD) in women. In their analysis of the effects of menopausal status on CHD risk, the authors showed (1) that naturally postmenopausal women had the same risk of CHD as did premenopausal women, and that this risk was not affected by estrogen usage; and (21 that surgically postmenopausal women had an increased risk of CHD when compared to premenopausal women, and that this risk was eliminated by estrogen usage. Our statement that “Estrogen usage had no effect on CHD risk in women who had undergone A natural menopause” was based on our extrapolation of these two findings. Strictly speaking, we should have said “Compared with premenopausal women, the occurrence of a natural menopause together with estrogen usage did not affect CHD risk.” The Nurses’ Health Study has highlighted some of the complexities that confound this controversial and important field. We are grateful for the opportunity to clarify our understanding of this study. I. F. Godsland V. Wynn D. Crook Cavendish Clinic 21 Wellington Road London, England NW8 95Q
Letters
to the Editor
1649
WARFARIN-RELATED HEMORRHAGE AFTER VALVE REPLACEMENT To the Editor: Czer et al.’ reported a very high linearized event rate for warfarin-related hemorrhage (2.9 “b per patient-year) after valve replacement with the St. Jude Medical prosthesis. The same authors reported much lower rates for the same complication with the same prosthesis in previous publications. In 1984 they found a rate of 0.5% per patient-year: and in 1985 a rate of 1% per patient-year.j Between 1984 and 1987 their patient population increased from 307 to 527 patients, the total number of events increased from 2 to 39, and the follow-up increased from 408 patient-years to 1336 patient-years.” There was apparently no change in the kind of follow-up between the various studies, mostly mailed questionnaires and telephone interviews. The actuarial curve of freedom from hemorrhage can only decrease with time, the total number of patients who bled or the total number of events can only increase with time, but there is no apparent reason for an increase in a linearized rate of the number of events per patient-year. There is no comment about this sixfold increase in the frequency of bleeding compared to the 1984 publication for the same study. In our experience of 49 patients with St. Jude Medical prosthesis in the aortic position, there was a very high incidence of hemorrhage due to anticoagulation (3.26% per patient-year), but there was a major difference in the method of obtaining this information compared with that of Czer et ah we examined 78.9% of our patients in our department at the end of a 7-year study. When the answers to a mailed questionnaire were considered alone, the linearized rate of hemorrhagic complications was only 0.93 % per patient-year. Most of patients forgot to mention these events in answering questionnaires in which we specifically asked if hemorrhagic events had occurred since operation. Clinical interviewing was much more accurate for obtaining this sort of information. Horstkotte et al.4 also reported a rate of 2.577: per patient-year of hemorrhage, and follow-up was also made by consultation in their department; 8O”G of patients were reexamined at the end of their study. The real question is whether the frequency of hemorrhage increases with time as Czer et al. suggest. The apparent increase that they report could be artifactual due to more intensive research methods, especially the use of telephone interviews in their latest publication. However, if the frequency of hemorrhage really does increase with time, it is important to point it out, as it would have clinical implications in the long-term follow-up of patients after valve replacement, and the reasons for this increase would have to be determined. Patient populations may change with time such as the increasing numbers of elderly patients and the occurrence of contraindications in patients receiving anticoagulant therapy. Gil/es Montalescot, MD Daniel Thomas, MD Yves Grosgogeat, MD Department of Cardiology H6pital Piti&Salpbtri6re 47 Bl. de I’h6pitaZ 75013 Paris. France REFERENCES 1. Czer LSC, Matloff ME, Gray RJ. The lism, warfarin-related 1987;114:389.
JM, Chaux A, De Robertis M, Stewart St. Jude valve: analysis of thromboembohemorrhage, and survival. AM HEART J