[Is primary, secondary or tertiary prevention of coronary heart disease possible by means of oestrogens or gestagens?].

Clinical trials in primary prevention of coronary atherosclerosis have demonstrated that estrogen application in postmenopausal women may reduce the relative risk by approximately 50 % when initiated at the time of decreasing endogenous estradiol production. Multifactorial estrogen actions (i. e. vasodilatation, inhibition of vascular smooth muscle cell proliferation) could explain these observations. Based on some investigations in secondary and tertiary prevention of coronary atherosclerosis in postmenopausal women it may be concluded that oestrogens alone or in combination with certain progestins may have a protective effect in reducing the rate of reinfarctions. From an epidemiological point of view it was emphasized that these studies were not randomised and therefore not suitable for drawing conclusions generally valid in all postmenopausal women. The HERS-study was initiated in order to get reliable informations. However, the results of this study are not comparable with any other investigation as in the HERS-study for the first time a continuous combined oestrogen/progestin application was chosen. The authors pointed out that several positive oestrogen actions may be antagonised by progestins as the oestrogen receptor density could be down regulated by progestins. The HERS study shows indeed no increase in reinfarctions and a decrease in total mortality after long term treatment. Consequently, the study shows that there is a demand to strongly emphasise the significance of primary prevention.