Additional Therapy to Reduce Risk of MI and Death Class III: No Benefit 1. Estrogen therapy is not recommended in postmeno- pausal women with SIHD with the intent of reducing cardiovascular risk or improving clinical out- comes.811 814 (Level of Evidence: A) 2. Vitamin C, vitamin E, and beta-carotene supplemen- tation are not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD.398,527,815 818 (Level of Evidence: A) 3. Treatment of elevated homocysteine with folate or vitamins B6 and B12 is not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD.819 822 (Level of Evidence: A) 4. Chelation therapy is not recommended with the intent of improving symptoms or reducing cardio- vascular risk in patients with SIHD.823 826 (Level of Evidence: C) 5. Treatment with garlic, coenzyme Q10, selenium, or chromium is not recommended with the intent of reducing cardiovascular risk or improving clin- ical outcomes in patients with SIHD. (Level of Evidence: C) 4.4.2.5.1. Hormone Replacement Therapy. Numerous obser- vational studies have suggested that estrogen therapy might provide protection against the development of IHD in post- menopausal women.827 829 Beneficial effects of exogenous estrogen include an increase in HDL cholesterol, a decrease in LDL cholesterol, and enhanced endothelial function.830 833 In light of the epidemiological data and evidence of salutary physiological effects, postmenopausal estrogen replacement previously was advocated for the primary and secondary prevention of CAD in women. Clinical trials in women with and without established CAD, however, have failed to con- firm a decrease in cardiovascular events with hormone therapy. 