Estrogens and SERMs in coronary heart disease

Estrogen combines beneficial and harmful actions by affecting many intracellular pathways in a large number of target organs related to the cardiovascular system. In observational studies and large outcome trials, an improvement of serum lipid profile and reduction of cardiovascular event rate were reported, whereas thrombembolic complications and stroke rate increased. Recognition of the diversity and tissue selectivity of estrogen's effects prompted the development of selective estrogen receptor modulators (SERMs), which were subsequently used to dissect the different mechanisms of action. SERMs are estrogen receptor (ER) ligands that exert partial agonist or antagonist actions on the ER in a tissue-, pathway- or isoform-specific manner. As ER ligands, they trigger a large variety of effects, including extranuclear ER actions, which can be further modulated by coactivators, corepressors and potential novel estrogen-binding proteins/receptors. Thus, SERMs can display tissue- or pathway-specific effects, or a combination of these. Pharmacological and clinical data are available for the classical SERM prototypes raloxifene and tamoxifene, as well as for new SERMs in different stages of development, isotype-specific agonists and pathway-selective ligands. These compounds exert many different effects, including vasodilatation in coronary arteries, altered responses to ischemic damage, hypertrophy of the myocardium, and improvement in serum cholesterol and lipid profile. The development of future SERMs will focus on different indications, including hormone therapy or cardiovascular disease. However, they all should antagonize estrogen action in female reproductive organs, yet protect from bone loss and not interfere with the beneficial effects of estrogen in the brain.