JACC Advances · Jan 23, 2026

Hormone Replacement Therapy and Cardiovascular Outcomes by Race and Ethnicity: MESA (Multi-Ethnic Study of Atherosclerosis)

By Flynn S, Haidar A, Liang I et al.

BACKGROUND: There is mixed data regarding hormone replacement therapy (HRT) and cardiovascular disease (CVD), particularly on how timing of HRT initiation close to menopause may affect outcomes, and there is little data among different race/ethnicity groups. OBJECTIVES: The purpose of this study was to how HRT use and cardiovascular outcomes differ by race/ethnicity. METHODS: The Multi-Ethnic Study of Atherosclerosis is a prospective epidemiologic study of participants without CVD at enrollment. Outcomes were (1) all-cause mortality and (2) major adverse cardiovascular events (MACEs). Cox models were developed, focusing on the timing of HRT initiation and differences by race/ethnicity (White, Black, Hispanic, and Chinese). RESULTS: There were 2,427 postmenopausal women with data on HRT and outcomes, followed up for a median of 14 years. HRT use within 5 years of menopause was associated with decreased MACE and all-cause mortality (HR: 0.72 [95% CI: 0.55-0.96] and HR 0.62 [95% CI: 0.48-0.80], respectively). These findings differed by racial/ethnic groups, with Chinese participants on HRT having increased MACE and a trend towards increased mortality (HR: 2.27 [95% CI: 1.06-4.87] and HR: 1.34 [95% CI: 0.73-2.47], respectively). These findings were only seen in Chinese participants who had the metabolic syndrome or elevated triglyceride levels. CONCLUSIONS: We found relative benefit with early initiation of HRT in all race/ethnic groups except Chinese, adding to the complex literature on HRT use in CVD primary prevention. However, Chinese women with the metabolic syndrome or elevated triglycerides may have increased risk of adverse cardiovascular outcomes with HRT, suggesting further research is needed on racial and metabolic differences in the cardiovascular impact of HRT use.

doi.org/10.1016/j.jacadv.2025.102561 Open access PubMed 41579828 Interventions