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Interventions for acute coronary syndrome in young women and oral contraceptives

The risk of acute coronary syndromes increases with age in postmenopausal women, particularly and in those patients with diabetes and other risk factors for atherosclerotic disease. However, the occurrence of myocardial infarction in young, premenopausal women is not uncommon as demonstrated by this study. Yet, their events cannot be easily explained by the same traditional risk factors seen in older women. Thus, there is an interest in identifying potentially modifiable risk factors for acute coronary syndromes in these women. One of these risk factors may still be the use of oral contraceptives, despite the modifications made in more recent formulations. The increased risk of both venous and arterial thrombosis with the use of oral contraceptives has been well described since the 1970s. Attempts have been made to modify the content of OCPs to reduce these risks. While the continued risk of venous thromboembolism with newer generation OCPs has been well demonstrated, the risk of arterial thrombosis, particularly myocardial infarctions, has been less well established. A study by Tanis et al. demonstrates an increased risk of myocardial infarction with the use of second generation OCPs while the effect of third generation OCPs on myocardial infarction risk was inconclusive [1]. However, a study by Lidegaard et al. published more recently demonstrated an increased risk of myocardial infarction for all combination estrogen–progesterone OCPs studied, including the more recent “fourth generation” OCPs which uses low dose ethinyl estradiol and the progesterone compound drospirenone [2]. This is in spite of the finding that the newer OCPs raise HDL and lower blood pressure, which would be expected to protect against myocardial infarction. In this issue of CCI, Karabay et al. [3] retrospectively compared the outcomes and lesion characteristics of patients on Yasmin, a fourth generation OCP, who experienced a STEMI as compared with those women not on oral contraceptives. This was a single center study which analyzed 1,851 patients who underwent primary PCI for acute STEMI during the study period, 440 of whom were women, 101 of whom were younger than age 50, and 12 of whom were taking Yasmin for at least four months preceeding their event. Their study showed that, compared to women of the same age group who were not taking Yasmin, women taking Yasmin had a higher angiographic thrombus burden as determined by both TIMI and Yip classification and were more likely to have multivessel thrombosis. Furthermore, the incidence of final TIMI 3 flow and complete resolution of ST segment elevation was lower, and the incidence of congestive heart failure and systolic dysfunction was greater in those women taking Yasmin. Of note, those women taking Yasmin were less likely to have traditional risk factors for atherosclerotic disease. This observation suggests an alternative etiology for their acute coronary syndrome which is thrombotic in origin as opposed to atherosclerosis. Potential limitations of this study include its retrospective nature and the need to rely on accurate charting. In addition, only 12 women were taking Yasmin at the time of their event, which is a small number from which to draw definitive conclusions. Furthermore, there were a significantly greater proportion of smokers in the group of women taking Yasmin, which could be a potential confounding factor as smoking is known to be prothrombotic, increase endothelial dysfunction, and be a significant risk factor for coronary artery disease. In spite of the limitations, potential mechanisms exist to explain the findings of this study. Historically three major areas are thought to increase the risk for thrombosis in vessels. As described years ago, Virchow’s triad of endothelial injury, hypercoagulability, and stasis, continues to be at the center of acute