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Michael G. Shlipak, MD, MPH; Joel A. Simon, MD, MPH; Eric Vittinghoff, PhD; Feng Lin, MS; Elizabeth Barrett-Connor, MD; Robert H. Knopp, MD; Robert I. Levy, MD; Stephen B. Hulley, MD, MPH

JAMA. 2000;283:1845-1852.

Context  Lipoprotein(a) [Lp(a)] has been identified as an independent risk factor for coronary heart disease (CHD) events. However, few data exist on the clinical importance of Lp(a) lowering for CHD prevention. Hormone therapy with estrogen has been found to lower Lp(a) levels in women.

Objective  To determine the relationships among treatment with estrogen and progestin, serum Lp(a) levels, and subsequent CHD events in postmenopausal women.

Design and Setting  The Heart and Estrogen/progestin Replacement Study (HERS), a randomized, blinded, placebo-controlled secondary prevention trial conducted from January 1993 through July 1998 with a mean follow-up of 4.1 years at 20 centers.

Participants  A total of 2763 postmenopausal women younger than 80 years with coronary artery disease and an intact uterus. Mean age was 66.7 years.

Intervention  Participants were randomly assigned to receive either conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in 1 tablet daily (n = 1380), or identical placebo (n = 1383).

Main Outcome Measures  Lipoprotein(a) levels and CHD events (nonfatal myocardial infarction and CHD death).

Results  Increased baseline Lp(a) levels were associated with subsequent CHD events among women in the placebo arm. After multivariate adjustment, women in the second, third, and fourth quartiles of baseline Lp(a) level had relative hazards (RHs) (compared with the first quartile) of 1.01 (95% confidence interval [CI], 0.64-1.59), 1.31 (95% CI, 0.85-2.04), and 1.54 (95% CI, 0.99-2.39), respectively, compared with women in the lowest quartile (P for trend = .03). Treatment with estrogen and progestin reduced mean (SD) Lp(a) levels significantly (–5.8 [15] mg/dL) (-0.20 [0.53] µmol/L)compared with placebo (0.3 [17] mg/dL) (0.01 [0.60] µmol/L) (P<.001). In a randomized subgroup comparison, women with low baseline Lp(a) levels had less benefit from estrogen and progestin than women with high Lp(a) levels; the RH for women assigned to estrogen and progestin compared with placebo were 1.49 (95% CI, 0.97-2.26) in the lowest quartile and 1.05 (95% CI, 0.67-1.65), 0.78 (0.52-1.18), and 0.85 (0.58-1.25) in the second, third, and fourth quartiles, respectively (P for interaction trend = .03).

Conclusions  Our data suggest that Lp(a) is an independent risk factor for recurrent CHD in postmenopausal women and that treatment with estrogen and progestin lowers Lp(a) levels. Estrogen and progestin therapy appears to have a more favorable effect (relative to placebo) in women with high initial Lp(a) levels than in women with low levels. This apparent interaction needs confirmation in other trials.

Author Affiliations: Departments of Medicine (Drs Shlipak and Simon), and Epidemiology and Biostatistics (Drs Simon, Vittinghoff, and Hulley and Ms Lin), University of California, San Francisco; General Internal Medicine Section, Veterans Affairs Medical Center, San Francisco (Drs Shlipak and Simon); Department of Family and Preventive Medicine, University of California, San Diego (Dr Barrett-Connor); Northwest Lipid Research Clinic and the University of Washington, Seattle (Dr Knopp); and American Home Products, Madison, NJ (Dr Levy).

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