Day 2 :
San Camillo-Forlanini Hospital, Italy
Keynote: Noncoronary Collateral Myocardial Blood Flow The hyphotesis of enhancement of noncoronary collateral myocardial blood flow and endovascular internal mammary artery occlusion in refractory angina: A new research field
Time : 09:30-10:10
Marco Picichè (MD, Ph.D.) graduated with a degree in medicine from the University of Florence in 1995 and completed his cardiac surgery residency at the Tor Vergata University of Rome in 2000, both summa cum laude. He has worked as an assistant at Saint Luc Hospital, Catholic University of Louvain, Brussels (1999–2001), as a clinic head/hospital assistant at the universities of Clermont-Ferrand (2003–2004) and Montpellier (2004–2007). He held regular teaching appointments at the university of Montpellier school of medicine, obtained certification by the French Board in cardiac surgery (Paris, 2007), earned his research master in surgical science (Paris, 2007). In Canada he authored a research project on ‘‘Noncoronary collateral circulation,’’ which was submitted to the annual research competition at Québec Heart & Lung Institute, Laval University, and received the competition’s highest grant. In September 2011 he received a doctor of philosophy (Ph.D.) in therapeutic innovations from Paris-Sud University. He is the Editor in Chief of the book : « Dawn and evolution of cardiac procedures : research avenues in cardiac surgery and interventional cardiology » (Springer-Verlag publishing house). Currently he is a consultant cardiac surgeon in Italy.
Noncoronary collateral myocardial myocardial blood flow (NCCMBF) or noncoronary collateral circulation (NCCC) is a virtually ignored topic. Few studies have been published to date and we still know little of its nature and almost nothing of its potential benefits in clinical applications. It consists of a micro-vascular network arising from mediastinal, esophageal, bronchial, and intercostal arteries. Blood reaches the myocardium through small channels connected with aortic and pulmonary artery vasa vasorum, and with channels located within the pericardial reflections surrounding the pulmonary and systemic veins. Some phenomena suggest the existence of alternative ways for blood to reach the heart, for no other easy explanation exists. For example, during aortic valve surgery, arterial blood can be seen to flow out from the coronary ostia, while during coronary surgery blood may flow out from the incised coronary artery, despite adequate venting and correct aortic cross-clamping. It is not even rare for patients to show an ejection fraction equal to or greater than 55%, despite occlusion of the right coronary artery and sub-occlusion of the left main artery. It has been demonstrated that collateral branches of the internal thoracic arteries (ITAs) are a source of NCCMBF. In fact, connections exists between ITAs and native coronary arteries both in living patients and cadavers. One study demonstrated these connections by postmortem angiography in 12% of cases. Furthermore, several examples show the potential of the ITAs for developing collateral vessels spontaneously in the presence of an ischemic stimulus. Currently, not all patients suffering from ischemic heart disease benefit from conventional myocardial revascularization techniques; and it is in this context that the concept of ITA occlusion has been promoted again since 2010. May NNCMBF represent a valuable alternative source of myocardial blood supply for no-option patients? Herein, the nature and hypothetical benefits of NCCMBF are discussed.
Vilela Batista Heart Foundation, Brazil
Keynote: SURGICAL TREATMENT OF EISEMENGER
Time : 10:10-10:50
Will be updated soon...
Patients with congenital heart diseases, with left to right shunts, develop pulmonary hyper resistant hypertension, reversing to right to left shunt! Situation called "Eisenmenger"! Patients become cyanotic and the treatment today is heart-lung transplant! In most places this treatment is not done because of 100% mortality! Even at the best Heart Centers the mortality is very high! Consequently these patients are left to die at home with no treatment!
It is written in the textbooks that the reason for this transformation is pulmonary "hyperflow" due to left to right short-circuit! This theory didn’t make sense to me because i’ve done many pneumonectomies and the patients did not develop hyperesistant pulmonary hypertension in the remaining lung with doubled flow. I did then experiments on pigs to prove that what makes the lungs increase resistance was oxygen and not flow!
The treatment of this pathology is based on this new theory - That is: extracting oxygen from the pulmonary artery we can reverse the high resistant pulmonary lesions! I’ve operated 42 Eisenmenger patients who will be presented and discussed during this meeting!
- Sessions: Cardiac Remodeling | Heart Transplantation | Cardiac Regeneration | Clinical Cardiology
Regina Celia Spadari
Universidade Federal de Sao Paulo, Brazil
Technische Universitat Ilmenau, Germany
St Hedwig Hospital Berlin, Germany
Katharina is working as a Specialty Registrar in a Department of General Surgery at a teaching hospital of the Charité Berlin in Germany. She has an interest in the perioperative management of surgical patients and is collaborating on interdisciplinary research projects in cardiac and thoracic surgery as well as in intensive care medicine.
Background: Fast track recovery programmes are a major innovation in the care of general surgical patients, reducing perioperative complications, length of stay (LOS) and reducing costs. It is unclear how these relate to the post cardiac surgery population.
Methods: We analysed all databases for studies which evaluated fast track rocovery after cardiac surgery from 1999-2016. A total of 7 studies were identified; 4 studies (3 prospective, 1 retrospective) comparing a fast-track recovery vs. a control group; 3 studies (1 prospective, 2 retrospective) assessing the reasons for failure of fast track recovery programmes.
Results: A total of 792 patients were included comparing fast track recovery. In-hospital mortality was lower in one retrospective cohort study (0.5% vs. 3.3%, p<0.01).
The total length of stay was lower in two studies (p<0.01, 10 (8–12) vs. 11days (9 –14), p=0.02). One study showed lower pain scores on day 1-3 (p<0.01, p<0.05, p<0.01).
Enhanced recovery had lower mean costs í4182±í2284 ($6683±$3650) vs. 4553±í1355 ($7277±$2165), p<0.001).
Three studies with a total of 15,212 patients analysed the failure of enhanced recovery programmes. These described a success rate of 97%, 89% and 84% retrospectively. One study found a readmission to be associated with a prolonged ICU stay (105+/-180.0 vs. 19.2+/-2.4 hours of initial ICU stay) and worse outcomes. Independent risk factors for failure were age, female sex, prolonged surgery, and prolonged cross-clamp time and left ventricular dysfunction.
Conclusion: Small retrospective and prospective studies demonstrate fast track recovery after cardiac surgery as an important management strategy in carefully pre-selected patient groups decreasing the intensive care LOS, total duration of intubation, potentially the LOS and is a cost effective strategy compared to conventional recovery. There is a lack of randomised trail data assessing which components of the fast tracking system contribute most to the outcomes.
Universidade Federal de Sao Paulo, Brazil
Time : 11:30-11:55
Will be updated soon...
Stress affect at least 90% of the world population, as a result of the current lifestyle. In the heart, catecholamines released during the stress response activate beta adrenergic receptors (?-AR), mainly beta
1 (?1-AR) and beta 2 (?2-AR) subtypes. Alterations in the proportion of ?-ARs subtypes, with a role played by ?2-ARs-Gi protein-PI3K-Akt signaling pathways, have been described in several cardiovascular disorders, including heart failure, aging, and in animal models of behavioral stress. This has been the focus of our research group. More recently, it has been shown that sirtuins play a role in several organic processes through the activation of the PI3K-Akt signaling.
Sirtuins are involved in the modulation of the cellular stress response, by activating several downstream molecules, such as those involved in the control of p53, Akt, HIF1-? and NF-?B. SIRT1 and SIRT3 are crucially related to the regulation of cardiomyocyte energy metabolism, production of reactive oxygen species. In the cardiac tissue, SIRT and ?2-ARs-Gi control signaling pathways of cell survival and death, with various roles in the regulation of energy production and oxidative stress, aging, autophagy, energy metabolism, oxidative stress and some diseases. Here, the role played by ?2-ARs and sirtuins during aging, heart fails and in the adaptation to stress is revised and a hypothesis is presented of an interplay between ?2-ARs and sirtuins in the heart.
Kimitsu Chuo Hospital, Japan
Title: Serial Changes on Computed Tomographic Findings of Caseous Calcification of the Mitral Annulus
Time : 11:55-12:20
Will be updated soon...
A 74-year-old female with interstitial pneumonia and old myocardial infarction was admitted with stroke because of calcific emboli. Caseous calcification of the mitral annulus was detected using computed tomography (CT) and transthoracic echocardiography during the follow-up of the interstitial pneumonia and myocardial infarction, respectively. On recent examination, echocardiography showed caseous calcification of the mitral annulus. CT revealed an oval calcification with a homogeneous density in and a scattered calcification under the posterior mitral annulus, which was detected for the first time and could not be detected by echocardiography. Rupture of the caseous calcification was suspected. Surgical treatment was postponed because the interstitial pneumonia worsened. CT performed during treatment of pneumonia showed changes in the shape and density of caseous calcification; however, scattered calcification under the mitral annulus persisted. Operative findings were consistent with signs on CT, i.e., a white, soft, plaster-like content and a similar scattered material around the chordae of the posterior leaflet. The sequences of changes of caseous calcification of the mitral annulus obtained by CT suggest its importance as a follow-up tool and indicate the necessity and timing of surgery.
University of Debrecen, Hungary
Time : 12:20-12:45
Béla Nagy Jr. graduated as an MD at University of Debrecen in 2004 and completed his PhD from the same University in 2010. He worked as a postdoctoral fellow at Temple University School of Medicine in Philadelphia, PA for two years. Currently, he is an assistant professor at Department of Laboratory Medicine, University of Debrecen. He has published more than 30 peer-reviewed international papers, especially in platelet physiology in metabolic and cardiovascular diseases. He is the advisor of two full-time PhD students focusing on the analysis of platelet and plasma microRNAs in diabetes mellitus and septic conditions.
MiRNAs play a prominent role in the regulation of vasculature in coronary artery disease via controlling critical signaling pathways. Previous studies described that miR-223 suppressed ICAM-1 in endothelial cells (EC), while vascular inflammation via NF-κB was regulated by miR-181b. Non-coding small RNAs promoted vascular inflammation and remodeling after stent injury, as in-stent restenosis (ISR) was prevented by genetic ablation of miR-21 attenuating neointimal formation after stenting in pigs. Few data are available, which miRNAs are involved in EC activation after stent implantation. Our group recently published higher levels of soluble E-selectin and VCAM-1 after bare-metal (BMS) versus drug-eluting stenting (DES) in stable angina patients. One fifth of BMS subjects displayed ISR, while no DES individuals had complication. We compared plasma miRNAs in patients with or without ISR, and miRNA alterations were analyzed in cultured human coronary artery and umbilical vein endothelial cells challenged with recombinant TNF-α in the presence or absence of externally added everolimus. We found that there were 36 significantly decreased and 21 upregulated circulating miRNAs in BMS with ISR vs. those BMS without complication and all DES patients. Among in vitro conditions, TNF-α enhanced miR-146a, miR-155 and miR-185 expression in both EC cultures indicating cellular inflammatory response and dysfunction. Decreased miR-424, miR-223 and miR-181b were found with elevated E-selectin, ICAM-1 and VCAM-1 mRNA levels. In contrast, everolimus raised these miRNAs causing significantly depressed mRNAs and protein concentration of these adhesion proteins. In conclusion, everolimus suppressed EC activation in case of DES via modulating circulating and cellular miRNAs.
Ravi Ghatnatti is a young cardiac surgeon from India and presently working as Assistant Professor in Cradiothoracic and Vascular Surgery department of KLE’s Dr Prabhakar Kore Hospital, Belgaum,India. He is expertise in coronary artery bypasses grafting and total arterial revascularization. He has International and National publications to his credit. His work on “Renal Dysfunction and Hemodilution- What is the threshold hematocrit acceptable on cardiopulmonary bypass?” was presented in 51st Society of Thoracic Surgeons meeting 2015 held at San Diego, California USA.
Coronary endarterectomy assures complete revascularization of the myocardium in case of diffusely diseased vessels and prevents residual ischemia. Recently cardiac surgeons are performing increasing number of coronary endarterectomy and it has evolved as an important adjuvant procedure in coronary artery bypass grafting. There are controversies regarding the efficiency of coronary endarterectomy. Higher rates of mortality and morbidity are the frequent points of criticism. At present the available evidence supports coronary endarterectomy in off-pump coronary artery bypass surgery and along with valvular procedures. Graft patency is better with open technique. Post-operative anticoagulation regimen although not uniform, the overall outcome remains the same. Therefore it is important to focus on the current results to accept coronary endarterectomy as a routine procedure like coronary artery bypass surgery.
Technische Universität Ilmenau, Germany
Title: Episodic occurrence of atrial fibrillation as result of interacting sources and small conduction pathways
Time : 16:10-16:35
Claudia Lenk studied technical physics but started early to use her physics background to study physiological mechanisms. Her focus lies on the study of mechanisms underlying observations like the synchronization between heartbeat and breathing or the generation and episodic occurrence of atrial fibrillation. Therefore, she combines computational modeling with experiments. She obtained her PhD at the Technische Universität Ilmenau, Germany, for her modeling studies and experiments on AF mechanisms.
A major risk of stroke is atrial fibrillation (AF), the most common cardiac arrhythmia in clinical practice in the industrial countries . Paroxysmal AF, characterized by the alternation of fibrillation episodes with normal sinus rhythm, complicates AF detection and thus stroke prevention.
A proposed mechanism for the intermittent occurrence is the interaction of excitation waves from two different sources, called pacemaker, located in separate regions . The primary pacemaker represents the sinus node in the right atrium while the secondary one represents a self-excitatory source in the left atrium such as an ectopic focus or reentrant wave. The pacemaker’s waves can only get in contact through a small bridge resembling conducting pathways between the atria. Results from the CONFIRM trial  support the hypotheses of a perturbing source as generating mechanism of AF.
In this talk we present results from modeling studies based on two different electrophysiological models  and relate them to experimental results. The FitzHugh-Nagumo (FHN) model is a generic model with unphysiological action potential shape and restitution properties. More realistic is the model of Bueno-Orovio, Cherry and Fenton (BOCF-model), which we adapted to atrial electrophysiology.
Three different types of irregular patterns are observed in the FHN model whereas in the BOCF model only one type was present . However, for a reduced excitability in the BOCF model corresponding to a reduced sodium channel conductance not only the three types of fibrillatory-like patterns are recovered but also another type is observed. This one is caused by a partial conduction block of the waves at the bridge as was described for experiments on rapid pacing of Bachmanns Bundle . Furthermore, the strength of irregularity is increased compared to the other types.
Which type of fibrillatory-like pattern occurs is determined by the pacemakers frequencies. Thus, these studies propose an explanation for the episodic occurrence of paroxysmal AF which does not require any tissue heterogeneities. Changes in the frequency can trigger AF episodes, which might explain why AF episodes occur for some patients when they are resting and for others while they are active or stressed.
Will be updated soon...
Statement of the problem:
In India 2.78 million death are due to Cardiovascular diseases of which 50 % are due to CAD.
Peculiarities of CAD patterns in Indian patients- Younger age at presentation, high incidence of DVD and TVD, diffuse involvement, distal disease and significant LV dysfunction at presentation
Diffuse CAD: Length of significant stenosis > 20 mm, multiple significant stenosis (> 70% narrowing) in the same artery separated by segment of apparently normal vessel and significant narrowing involving the whole length of coronary artery.
Methodology: We in our institute, perform OP CAB and use LIMA and veins as conduits to perform the surgery.
Once the conduits are harvested, we heparinize with I.V. Heparin 3 mg/Kg given to achieve an ACT >300.Using the octopus as stabilizer, we perform an endartrectomy of the LAD first and then use a vein patch to cover the defect. LIMA is then used to anastomose the LAD on the vein patch. Veins are used to bypass the LCX and RCA, as deemed appropriate. The proximal ends of the vein grafts are anastomosed to Ascending Aorta with side clamp and heart beating. Intra op we start Lomodex infusion 20ml/hr which is continued for 24 hours and the inotropes used are Adrenaline and Dobutamine as and when necessary. Postoperatively aspirin 75mg is given and Heparin infusion started after 6hours to maintain ACT of around 150 for 24 hours. Patients are usually extubated after 4 hours provided they are hemodynamically stable. Anticoagulation by Acitrom is commenced orally from day 1 to maintain an INR of 2 for 3 months.
Result: Out of the 20 patients in last 18months outcomes have been excellent with no in-hospital mortality or cerebrovascular incidents.
Conclusion: Off pump CABG with coronary end-arterectomy offers a good solution to the problem of diffuse coronary artery disease.
Cardiac Surgeon, Greece
Title: The evolution of cardiovascular surgery in elderly patients: Science and technology contribution
Time : 17:00-17:25
D. Protogeros is a cardiac surgeon specialized in full arterial coronary revascularization on a beating heart and stem cell transplantation for ischemic heart failure. He is also an active participant and organizer of international collaborative projects.
Protogeros operated on over 5,000 adult heart patients between 1998 to present covering the entire range of cardio incidents including but not limited to coronary artery disease, heart valves, aneurysms, etc
Moreover, Protogeros has established a protocol for the heart team specialized on coronary artery bypass and implantation of mononuclear autologous pluripotent cells in patients suffering from ischemic heart failure.
Protogeros was trained by Prof. A. M. Calafiore and at present is Deputy Director of the 2nd Cardiac Surgery Clinic, “HENRY DUNANT Hospital Center”, Athens, Greece
Due to the increase of average life expectancy and the higher incidence rate of cardiovascular disease with advancing age, more elderly patients are in need of cardiac surgery nowadays. Advances in pre- and post-operative care have made it possible that an increasing number of elderly patients can be operated safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is acceptable, only in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.
We describe a combined cardiac surgery procedure , aortic valve replacement and double coronary bypass, on a 91-year old lady with hypertension, diabetes mellitus, renal insufficiency and cerebrovascular disease known as the oldest patient worldwide who has undergone this type of procedure.
Time : 17:25-17:50
Rajani Singh has completed her MS (Anatomy) at the age of 33 years from MLN medical College University of Allahabad. She worked as Additional Professor Anatomy in Premier medical Institute of India wef july 2012 till date. She alsoworked as Lecturer for 4 years, Assistant Professor for 4 years and Associate Professor for one year in highly reputed King George Medical College Lucknow UP India She has published more than 60 papers in reputed journals. She is member of AAA, AACA, AS, HAPS, ASI, ASI Upand SOCA. She has been on the editorial board of OA case Reports London, Clinical Anatomy USA, Archives of Anatomy and Physiology, Scientific pages Anatomy and Physiology, USA and Anatomy and Physiology open access, USA.
Rate of fatal coronary artery diseases is increasing by leaps and bounds in modern times. The anatomy of coronary artery has recently been reemphasized in association with the use of coronary arteriography. The variant vascular anatomy in general and coronary arterial anatomy in particular plays very crucial role in the arterial disease process, their diagnosis and treatment. Therefore, thorough understanding of variant and normal anatomy of coronary artery is imperative. The major coronary artery diseases are hardening and narrowing of these arteries due to atherosclerosis and arteriosclerosis. The advances made in coronary arterial bypass surgeries and modern methods of myocardial revascularization also make sound and detailed knowledge of the variant anatomy of coronary artery indispensable. Therefore, description of 3 cases of aberrant configuration of right/left, accessory and new arteries along with touching mechanism of atherosclerosis has been brought in this work. The right coronary artery in one case had high anomalous origin about 3 cm above the root of ascending aorta and accessory coronary artery arises at the level of right coronary artery irrigating left ventricle. Also right coronary artery had extended course up to left border of heart in second case. In third case, a new artery arises from anterior interventricular artery entering into the infundibulum and supplied septal papillary muscle. The variations in configuration of these arteries coupled with arising of new and accessory arteries not only alter irrigation pattern but also complicate imagery interpretation and surgical manipulations. Hope these results will aid the future cardiac health.
- Workshop on "Sex and Stress in the ICU"
This paper will discuss comparisons from complaint free or pre-cardiac disposition risk factor period until post and chronic heart failure stage.
Method- Scope review of past 5 years using key search words: gender, cardiac/heart, symptom expression, risk factors, & complications. . Evidence-based guidelines for the prevention of CVD in adult women are presented.
There is an abundance of published works describing significant differences in cardiac disease comparing genders. The range of differences span expression of symptoms, timing of first complaint, reaction of health care teams to women cardiac patients and differences in post cardiac episode rehabilitation to name a few.
Men have higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. Women experience lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care. Women were more likely (64%) to be depressed than men (44%). Depressed female patients scored significantly worse than non-depressed patients on all components of QOL. However, they did not differ in ejection fraction or treatment, except that
depressed patients were significantly less likely to be receiving beta-blockers. In advanced age, the increase in the rate of hypertension is steeper in women than in men, leading to a prevalence of hypertension of 69% in men and 72% in women at age 65 to 75 years.
Increased knowledge of gender-specific risks for Cardiac Disease has led to national campaigns to educate women. Future gender-related clinical and research activities should focus on the identification of sex- and gender-specific criteria for risk management in female cardiac patients.
The aim of this presentatin is to increase ICU nurses' awareness and knowledge regarding differences in gender and response to stress. According to 2011 survey by American Psychological Association more women reported a great deal of stress in their lives, compared with 20% of men. In terms of stress perception, women tend to report stress related to financial and economic issues, whereas men more often cite stress around work-related issues. Women actually have greater functional connective density in their brains, as measured by functional MRI studies. Not just that, but the way Female brains are connected looks different from how male brains are connected. Women tend to have more interhemispheric connectomes, which actually allow for more connectivity between analytical and intuitive processes, whereas men tend to have more intrahemispheric connections—on the same side of the brain—which facilitates more connectivity between kinesthetic tasks and motor skills. More women feel that stress strongly affects their health. In terms of dealing with stress, women are more motivated than men to act on their stress. Does that lead to more action on behalf of women? The answer is no. Both men and women have a fairly high thought/action gap in stress management. To manage stress, it has been shown that women tend to engage in such activities as reading and spending time with family. Men engage more in physical activities, playing sports, and working out. Many studies have found that women are more predisposed to mental stress-induced myocardial ischemia compared with men. Moreover, women are more likely to have a lingering effect of negative emotions, which worsens outcomes as well.
the stress management program] is a great step forward. It's a huge opportunity for us to intervene at the right time to prevent this as much as possible.
Israeli Cardiology and Critical Care Nursing Society, Rambam Health Care Campus, Israel
Increase ICU nurses' awareness regarding the topic of gender differences in cardiac rehabilitation post cardiac infarction. Published study show that women participate significantly less than men in cardiac rehabilitation programs. The factors contributing to their lack of involvement in cardiac rehabilitation programs is their older age, less robust physical baseline status, and physicians tendency to send fewer women to rehabilitation programs. Many papers found that women find exercise tiring and painful, dislike public or mixed-gender exercise, and perceive unmet emotional needs in Cardiac rehabilitation. The growing acknowledgement of gender-specific cardiovascular health needs highlights the need for effective risk reduction interventions for women. Investigators have called for strategies addressing underserved rehabilitation populations, such as women, who are least likely to avail themselves of these services. Gender-specific programs, tailored to individual readiness to change may be more effective than traditional programs in meeting women's unique needs. Future studies need to address many research questions. First, to what extent is attendance in women influenced by a motivationally enhanced, gender-tailored rehabilitation programs compared to that of women attending traditional programs, and second, what are the useful baseline sociodemographic and clinical predictors of attendance of the exercise and education components of cardiac rehabilitation? Nurses need to initiate and emphasize the importance of cardiac rehabilitation participation. Gender specific instructions to female and male patients differently based on evidence presented.
Israeli Cardiology and Critical Care Nursing Society, Rambam Health Care Campus, Israel
The following information based on the latest available evidence can be used to provide guidance to use of Hormone replacement therapy and alternatives. Premenopausal women have a lower risk and incidence of hypertension and cardiovascular disease (CVD) compared to age-matched men and this sex advantage for women gradually disappears after menopause, suggesting that sexual hormones play a cardio protective role in women. However, randomized prospective primary or secondary prevention trials failed to confirm that hormone replacement therapy (HRT) affords cardio protection. This review highlights the factors that may contribute to this divergent outcome and could reveal why young or premenopausal women are protected from CVD and yet postmenopausal women do not benefit from HRT. Observational studies also show that postmenopausal women who receive hormone replacement therapy (HRT) have a lower rate of CVD and cardiac death than those not receiving HRT. However, two randomized prospective primary or secondary prevention trials, the Women’s Health Initiative (WHI) and the Heart and Estrogen/Progestin Replacement Study (HERS I and II)], showed that HRT may actually increase the risk and events of CVD in postmenopausal women. The reasons for this paradoxical characterization of HRT as both beneficial and detrimental remain unclear. Overall, the use of HRT has become one of the most controversial topics related to women’s health, making it all the more urgent to clarify whether estrogens (and/or HRT) prevent or promote CVD, as well as the mechanism(s) involved. HRT has become one of the most controversial topics related to women’s health. Future studies are necessary if we are to understand the divergent published findings regarding HRT and develop new therapeutic strategies to improve the quality of life for women.