1
|
Ma R, van Assen M, Sidorenkov G, Ties D, Jan Pelgrim G, Stillman A, de Cecco C, van der Harst P, Vliegenthart R. Relationships of pericoronary and epicardial fat measurements in male and female patients with and without coronary artery disease. Eur J Radiol 2023; 169:111154. [PMID: 37944331 DOI: 10.1016/j.ejrad.2023.111154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Although pericoronary adipose tissue (PCAT) is a component of the epicardial adipose tissue (EAT) depot, they may have different associations to coronary artery disease (CAD). We explored relationships between pericoronary adipose tissue mean attenuation (PCATMA) and EAT measurements in coronary CT angiography (CCTA) in patients with and without CAD. MATERIAL AND METHODS CCTA scans of 185 non-CAD and 81 CAD patients (86.4% >50% stenosis) were included and retrospectively analyzed. PCATMA and EAT density/volume were measured and analyzed by sex, including associations with age, risk factors and tube voltage using linear regression models. RESULTS In non-CAD and CAD, mean PCATMA and EAT volume were higher in men than in women (non-CAD: -92.5 ± 10.6HU vs -96.2 ± 8.4HU, and 174.4 ± 69.1 cm3 vs 124.1 ± 57.3 cm3; CAD: -92.2 ± 9.0HU vs -97.4 ± 9.7HU, and 193.6 ± 62.5 cm3 vs 148.5 ± 50.5 cm3 (p < 0.05)). EAT density was slightly lower in men than women in non-CAD (-96.4 ± 6.3HU vs -94.4 ± 5.5HU (p < 0.05)), and similar in CAD (-98.2 ± 5.2HU vs 98.2 ± 6.4HU). There was strong correlation between PCATMA and EAT density (non-CAD: r = 0.725, p < 0.001, CAD: r = 0.686, p < 0.001) but no correlation between PCATMA and EAT volume (non-CAD: r = 0.018, p = 0.81, CAD: r = -0.055, p = 0.63). A weak inverse association was found between EAT density and EAT volume (non-CAD: r = -0.244, p < 0.001, CAD: r = -0.263, p = 0.02). In linear regression models, EAT density was significantly associated with PCATMA in both non-CAD and CAD patients independent of risk factors and tube voltage. CONCLUSION In CAD and non-CAD patients, EAT density, but not EAT volume, showed significant associations with PCATMA. Compared to women, men had higher PCATMA and EAT volume independently of disease status, but similar or slightly lower EAT density. Differences in trends and relations of PCATMA and EAT by sex could indicate that personalized interpretation and thresholding is needed.
Collapse
Affiliation(s)
- Runlei Ma
- University of Groningen, University Medical Center Groningen, Department of Radiology, the Netherlands; Affiliated Hospital of Nanjing University of Chinese Medicine, Department of Radiology, China; Jiangsu Province Hospital of Chinese Medicine, Department of Radiology, China
| | - Marly van Assen
- Emory University, School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Grigory Sidorenkov
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, the Netherlands
| | - Daan Ties
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands
| | - Gert Jan Pelgrim
- University of Groningen, University Medical Center Groningen, Department of Radiology, the Netherlands
| | - Arthur Stillman
- Emory University, School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Carlo de Cecco
- Emory University, School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands; University Medical Center Utrecht, Department of Cardiology, Division of Heart and Lungs, the Netherlands
| | - Rozemarijn Vliegenthart
- University of Groningen, University Medical Center Groningen, Department of Radiology, the Netherlands.
| |
Collapse
|
2
|
Figueiredo Neto JAD, Barroso LC, Nunes JKVRS, Nina VJDS. Sex Differences in Mortality After CABG Surgery. Braz J Cardiovasc Surg 2016; 30:610-4. [PMID: 26934399 PMCID: PMC4762551 DOI: 10.5935/1678-9741.20150073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 10/12/2015] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Numerous studies have shown that women undergoing coronary artery bypass
graft surgery present higher mortality rate during hospitalization, and
often complications when compared to men. OBJECTIVE To compare the mortality of men and women undergoing coronary artery bypass
graft surgery and identify factors related to differences occasionally
found. METHODS Retrospective cohort study conducted with 215 consecutive patients who
underwent coronary bypass surgery. RESULTS Women had a higher average age. Low body surface and dyslipidemia were more
prevalent in women (1.65 vs. 1.85, P
<0.001: 53% vs. 30%, P =0.001), whereas
history of smoking and previous myocardial infarction were more prevalent in
men (35% vs.14.7%, P =0.001; 20%
vs. 2.7%, P =0.007). Regarding
complications in the postoperative period, there was a higher rate of blood
transfusions in women. The overall mortality rate was 5.6%, however there
was no statistically significant difference in mortality between men and
women. It was observed that among the patients who died, the average body
surface area was lower than that of patients who did not have this
complication. CONCLUSION There was no difference in mortality between the sexes after coronary artery
bypass graft in this service.
Collapse
|
3
|
Singh-Manoux A, Kivimäki M, Sjösten N, Ferrie JE, Nabi H, Pentti J, Virtanen M, Oksanen T, Vahtera J. Lost work days in the 6 years leading to premature death from cardiovascular disease in men and women. Atherosclerosis 2010; 211:689-93. [PMID: 20444450 DOI: 10.1016/j.atherosclerosis.2010.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 03/02/2010] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is unclear whether individuals experience specific patterns of morbidity prior to premature death from cardiovascular disease (CVD). METHODS We examined morbidity levels in the 6 years leading up to death from CVD in 37,397 men and 113,198 women under 65 years of age from the Finnish Public Sector study, with a particular focus on gender differences. Morbidity was assessed using lost days from work, extracted from register data on sickness leave and disability pension. Data on cause-specific mortality were obtained from national health registers. RESULTS During a median follow-up of 8.5 years, there were 361 CVD deaths (174 from ischaemic heart disease (ICD9 410-414, 427.5; ICD10 I21-I25, I46), 91 from stroke (ICD9 430, 431, 434; ICD10 I60-I60, I61, I63), and 96 from other diseases of circulatory system (ICD9 390-459; ICD10 I00-I99)). Women had lower morbidity than men over the 6 years preceding stroke deaths (RR for mean annual days=0.33 (95% CI 0.14-0.78)). For other causes of CVD mortality, there were no gender differences in morbidity rates prior to death. In men, those who died from CVD had substantially greater morbidity levels than matched controls through the entire 6-year period preceding death (rate ratio=3.59; 95% confidence interval 2.62-4.93). Among women, morbidity days were greater particularly in the year preceding death from stroke. CONCLUSION Our results on working age men and women suggest no gender differences in morbidity prior to death from heart disease and lower morbidity in women prior to death from stroke. These findings challenge the widespread belief that women experience more morbidity symptoms than men.
Collapse
Affiliation(s)
- Archana Singh-Manoux
- INSERM, U1018, Hôpital Paul Brousse, Bât 15/16, 16 Avenue Paul Vaillant Couturier, 94807 Villejuif Cedex, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Abstract
The major goal of medicine in the era of managed care is to control escalating costs and to attain a high level of quality health care. Capitation has limited access to expensive and unnecessary testing, placing an emphasis on the prudent use of available technology. A vast armamentarium of available diagnostic screening tests are available within cardiology. Routine two-dimensional (2-D) echocardiography is a high-quality, low-cost test that provides enhanced portability and real-time test interpretation over other noninvasive test modalities. The echocardiogram may cost up to 50% less than competitive nuclear single-photon emission computed tomography (SPECT) imaging. However, on average 10% of routine and 33% of stress echocardiograms are suboptimal (disproportionately affecting obese patients and those with lung disease). Myocardial contrast echocardiography has been shown to provide enhanced endocardial border delineation and left ventricular opacification, to enhance Doppler signal, and to provide information on myocardial perfusion. In several recent phase II and III studies, the use of a contrast agent has been shown to improve the diagnostic accuracy of echocardiography substantially. Improvements in the diagnostic capabilities of echocardiography have been shown to (1) impact upon downstream repetitive testing in patients with an initially nondiagnostic echocardiogram, (2) potentially increase laboratory throughput, and (3) reduce the rate of false-positive and negative tests as a result of improved image quality. As clinical and cost-effectiveness parallel one another, the use of myocardial contrast echocardiography in selected patient cohorts will result in improved diagnostic accuracy and a cost-effective pattern of care.
Collapse
Affiliation(s)
- L J Shaw
- Cardiovascular Health Services Research, Emory University, Atlanta, Georgia 30322, USA
| |
Collapse
|
5
|
Gender comparison of contractile performance and beta-adrenergic response in isolated rat cardiac trabeculae. J Comp Physiol B 2007; 178:307-13. [PMID: 18030479 DOI: 10.1007/s00360-007-0223-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 10/29/2007] [Accepted: 11/06/2007] [Indexed: 10/22/2022]
Abstract
It is known that gender can affect susceptibility to development of various cardiomyopathies. However, it is unclear whether basic mechanical contractile function of the myocardium differs between genders, whether they respond differently to stressors, or both. To test for a possible gender factor, contractile parameters of healthy, isolated myocardium were investigated under near physiological conditions. Right ventricular ultra-thin trabeculae from young adult LBN-f1 rats were electrically stimulated to isometrically contract at 37 degrees C. No differences were found in developed force or kinetic parameters. In each muscle, the force-frequency relationship was measured at 4, 6, and 8 Hz, encompassing most of the in vivo range. Again, no differences were observed in force-frequency behavior; developed force rose from 21.6 +/- 4.0 at 4 Hz to 30.3 +/- 5.8 mN/mm(2) at 8 Hz in females and from 23.4 +/- 3.4 to 29.8 +/- 3.4 mN/mm(2 )in males. The response to beta-adrenergic stimulation was similar; at 1 microM isoproterenol, developed force increased to 34.5 +/- 6.2 mN/mm(2) in females and 32.3 +/- 3.2 mN/mm(2) in males (female vs. male, not significant). We conclude that basic mechanical performance of healthy isolated myocardium under physiological conditions is not different between males and females, and a different response to stress must underlie gender-based differences in cardiac performance.
Collapse
|
6
|
Affiliation(s)
- Elizabeth Barrett-Connor
- Department of Family and Preventive Medicine, University of California, La Jolla, Calif 92093-0607, USA.
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW There are some striking sex differences regarding presentation, symptoms and sign, diagnosis, and treatment of coronary artery disease. Historically, healthcare delivery to women has been plagued with treatment bias favoring men. This review will present relevant cardiovascular physiologic sex differences, current treatment options for coronary artery disease both surgical and medical, and clinical outcomes of such treatments. RECENT FINDINGS In the past, pharmacologic and interventional studies generally excluded women from their subjects. As a result, women have been traditionally treated based on the findings in their male counterparts. Recent studies examining sex differences in the treatment of coronary artery disease have given new insight into the hormonal and behavioral influences associated with coronary artery disease. Finally, these studies have drawn attention to possibly inadvertent discrepancies in the way men and women are treated for coronary artery disease. SUMMARY Despite significant advances in medical and surgical approaches to treat coronary artery disease, it remains and will continue to be the most important healthcare challenge of the 21st century. Whereas efforts are underway to encourage inclusion of more women in therapeutic trials, the educational process, particularly in medical school, needs to broadly address sex specific pathophysiology and treatment, rather than relying on sub-subspecialty training for optimizing healthcare delivery in women.
Collapse
Affiliation(s)
- Terry Ann Chambers
- Department of Anesthesiology, Weill Medical College of Cornell University New York, NY 10021, USA
| | | | | |
Collapse
|
8
|
Helgeson VS. Cognitive adaptation, psychological adjustment, and disease progression among angioplasty patients: 4 years later. Health Psychol 2003; 22:30-8. [PMID: 12558199 DOI: 10.1037/0278-6133.22.1.30] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The long-term effects of the Cognitive Adaptation Theory Index (CATI) on psychological and physical health outcomes among men (n = 199) and women (n = 99) treated for coronary artery disease with percutaneous transluminal coronary angioplasty were examined. The CATI reflects a positive view of the self, a positive view of one's future, and a sense of personal control over daily life. This index was created from questionnaires administered during hospitalization for the initial angioplasty. Four years later, the CATI predicted positive adjustment to disease, even when initial adjustment was taken into consideration. In addition, the CATI predicted a reduced likelihood of sustaining a subsequent cardiac event over 4 years. This association was more robust for men.
Collapse
Affiliation(s)
- Vicki S Helgeson
- Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, USA.
| |
Collapse
|
9
|
Affiliation(s)
- Paul R.J. Falger
- Department of Medical Psychology, University Hospital Maastricht, Director, Cardiac Behavior Modification Program, P.O. Box 5800, 6202, AZ Maastricht, The Netherlands
| |
Collapse
|
10
|
Califf RM, DeLong ER, Ostbye T, Muhlbaier LH, Chen A, LaPointe NA, Hammill BG, McCants CB, Kramer JM. Underuse of aspirin in a referral population with documented coronary artery disease. Am J Cardiol 2002; 89:653-61. [PMID: 11897205 DOI: 10.1016/s0002-9149(01)02335-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite substantial evidence that antiplatelet therapy saves lives and reduces adverse events in patients with coronary artery disease (CAD), use of the most widely available and lowest cost antiplatelet agent, aspirin, continues to be disappointingly low. In a large database of patients with known CAD, we (1) explored trends in the use of aspirin over time, (2) characterized patients most likely to take aspirin regularly, and (3) estimated the effectiveness of aspirin use by examining long-term outcomes. Using patients entered in the Duke Databank for Cardiovascular Diseases, we explored the use of aspirin from 1969 to 1999. More than 25,000 patients were sent a questionnaire that included several questions about medication use, including 1 question specifically about aspirin. Patients who failed to respond to the questionnaire received a follow-up telephone call. Aspirin use increased substantially over the most recent 4 years in the study, from 59% in 1995 to 81% in 1999. Predictors of aspirin use included younger age, male sex, being a nonsmoker, and having had a myocardial infarction or revascularization procedure. Patients who never took aspirin had a risk ratio for death of 1.85 compared with patients who regularly took aspirin. Despite the well-known beneficial effects of aspirin, too many patients without contraindications to aspirin fail to take it regularly. The health care system currently lacks effective methods to ensure that patients who have CAD have adequate follow-up concerning aspirin use.
Collapse
Affiliation(s)
- Robert M Califf
- Centers for Education & Research on Therapeutics (CERTs), Duke Clinical Research Institute, Durham, North Carolina 27715, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Miller TD, Roger VL, Hodge DO, Hopfenspirger MR, Bailey KR, Gibbons RJ. Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease. J Am Coll Cardiol 2001; 38:690-7. [PMID: 11527619 DOI: 10.1016/s0735-1097(01)01413-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study examined gender differences and temporal changes in the clinical characteristics of patients referred for nuclear stress imaging, their imaging results and subsequent utilization of coronary angiography and revascularization. BACKGROUND Gender bias may influence resource utilization in patients with coronary artery disease (CAD). No study has analyzed gender differences and time trends in patients referred for noninvasive testing and subsequent use of invasive procedures. METHODS Between January 1986 and December 1995, 14,499 patients (5,910 women and 8,589 men) without established CAD underwent stress myocardial perfusion imaging. The clinical characteristics, imaging results, coronary angiograms and revascularization outcomes were compared in women and men over time. RESULTS The mean pretest probability of CAD was lower in women (45%) than in men (70%) (p < 0.001). More women (69%) than men (42%) had normal nuclear images (p < 0.001). Men (17%) were more likely than women (8%) to undergo coronary angiography (p < 0.001). Male gender was independently associated with referral for coronary angiography (multivariate model: chi-square = 16, p < 0.001) but was considerably weaker than the imaging variables (summed reversibility score: chi-square = 273, p < 0.001). Revascularization was performed in more men (46% of the population undergoing angiography) than women (39%) (p = 0.01), but gender was not independently associated with referral to revascularization. There were no significant differences in clinical, imaging or invasive variables between the genders over time. CONCLUSIONS There was little evidence for a bias against women in this study. Women were somewhat less likely to undergo coronary angiography but were referred for stress perfusion imaging more liberally. Practice patterns remained constant over this 10-year period.
Collapse
Affiliation(s)
- T D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | | | | | |
Collapse
|
12
|
McPherson R, Angus C, Murray P, Genest J. Efficacy of atorvastatin in achieving National Cholesterol Education Program low-density lipoprotein targets in women with severe dyslipidemia and cardiovascular disease or risk factors for cardiovascular disease: The Women's Atorvastatin Trial on Cholesterol (WATCH). Am Heart J 2001; 141:949-56. [PMID: 11376309 DOI: 10.1067/mhj.2001.115588] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Recent studies have demonstrated that women at high risk for cardiovascular disease (CVD) benefit from cholesterol lowering to an extent similar to that of men. The ability to achieve established treatment goals for low-density lipoprotein cholesterol (LDL-C) in women with clearly defined risk factors has not been examined in detail. METHODS AND RESULTS We have determined the efficacy and frequency of achieving target levels for LDL-C with atorvastatin on the basis of National Cholesterol Education Program Adult Treatment Panel II recommendations in 318 women according to the presence of CVD (198 women) or risk factors for CVD (120 women) and the presence of mixed dyslipidemia with obesity with or without CVD (72 women). Mean baseline LDL-C concentrations for women with established CVD were in the upper 10% of the distribution for age-matched North American women and, for those without CVD, were also extremely elevated and were in the top 5% of the LDL-C distribution for age-matched women in this population. The majority of participants without CVD (63%) reached LDL-C targets (LDL-C <or=160 mg/dL [4.1 mmol/L] if <2 CHD risk factors and LDL-C <or=130 mg/dL [3.4 mmol/L] if >or=2 CVD risk factors) with 10 mg atorvastatin and 79% reached targets with up to 20 mg of atorvastatin. For women with established CVD, 34% achieved an LDL-C <or=100 mg/dL (2.6 mmol/L) with 10 mg and 60% reached this target with up to 20 mg of atorvastatin. With maximal titration to the LDL-C target, up to and including 80 mg atorvastatin, 87% of women without CVD and 80% of women with established CVD achieved LDL-C targets. The presence of mixed dyslipidemia with obesity did not affect the frequency of achieving LDL-C targets. CONCLUSION Atorvastatin is very effective in achieving National Cholesterol Education Program Adult Treatment Panel II target concentrations for LDL-C in the majority of women with established CVD or CVD risk factors.
Collapse
Affiliation(s)
- R McPherson
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | | | | | | |
Collapse
|
13
|
Castanho VS, Oliveira LS, Pinheiro HP, Oliveira HCF, de Faria EC. Sex differences in risk factors for coronary heart disease: a study in a Brazilian population. BMC Public Health 2001; 1:3. [PMID: 11305930 PMCID: PMC31435 DOI: 10.1186/1471-2458-1-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2000] [Accepted: 04/03/2001] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In Brazil coronary heart disease (CHD) constitutes the most important cause of death in both sexes in all the regions of the country and interestingly, the difference between the sexes in the CHD mortality rates is one of the smallest in the world because of high rates among women. Since a question has been raised about whether or how the incidence of several CHD risk factors differs between the sexes in Brazil the prevalence of various risk factors for CHD such as high blood cholesterol, diabetes mellitus, hypertension, obesity, sedentary lifestyle and cigarette smoking was compared between the sexes in a Brazilian population; also the relationships between blood cholesterol and the other risk factors were evaluated. RESULTS The population presented high frequencies of all the risk factors evaluated. High blood cholesterol (CHOL) and hypertension were more prevalent among women as compared to men. Hypertension, diabetes and smoking showed equal or higher prevalence in women in pre-menopausal ages as compared to men. Obesity and physical inactivity were equally prevalent in both sexes respectively in the postmenopausal age group and at all ages. CHOL was associated with BMI, sex, age, hypertension and physical inactivity. CONCLUSIONS In this population the high prevalence of the CHD risk factors indicated that there is an urgent need for its control; the higher or equal prevalences of several risk factors in women could in part explain the high rates of mortality from CHD in females as compared to males.
Collapse
Affiliation(s)
- Vera S Castanho
- Dept. of Clinical Pathology, School of Medicine; Center for Experimental Medicine and Surgery, University of Campinas São Paulo, Brazil
| | - Letícia S Oliveira
- Dept. of Clinical Pathology, School of Medicine; Center for Experimental Medicine and Surgery, University of Campinas São Paulo, Brazil
| | - Hildete P Pinheiro
- Department of Statistics, Institute of Mathematics and Statistics, University of Campinas, São Paulo, Brazil
| | - Helena CF Oliveira
- Department of Physiology and Biophysics, Institute of Biology, University of Campinas, São Paulo, Brazil
| | - Eliana C de Faria
- Dept. of Clinical Pathology, School of Medicine; Center for Experimental Medicine and Surgery, University of Campinas São Paulo, Brazil
| |
Collapse
|
14
|
Deaton C, Kunik CL, Hachamovitch R, Redberg RF, Shaw LJ. Diagnostic strategies for women with suspected coronary artery disease. J Cardiovasc Nurs 2001; 15:39-53. [PMID: 12968770 DOI: 10.1097/00005082-200104000-00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The clinician evaluating a woman with symptoms potentially indicative of coronary heart disease faces the challenge of choosing the appropriate diagnostic test. The use of noninvasive testing in women has been controversial due to a perception of diminished accuracy, limited female representation, and technical limitations that compromise efficacy. Recent meta-analyses and large observational series report marked improvements in accuracy for women undergoing exercise treadmill, echocardiography, and nuclear testing. Electron beam computed tomography is a relatively new technique, and the body of evidence is still developing. An adequate body of evidence supports the use of noninvasive testing for intermediate risk, symptomatic women and may result in improved diagnostic and therapeutic decision making.
Collapse
Affiliation(s)
- C Deaton
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia 30322, USA.
| | | | | | | | | |
Collapse
|
15
|
McFetridge J, Hanley J, Allen DM, Cheek A, Kelly A, Cheek DJ. WOMEN AND CARDIOVASCULAR DISEASE. Nurs Clin North Am 2000. [DOI: 10.1016/s0029-6465(22)02641-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
16
|
Blackburn GG, Foody JM, Sprecher DL, Park E, Apperson-Hansen C, Pashkow FJ. Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias. JOURNAL OF CARDIOPULMONARY REHABILITATION 2000; 20:189-95. [PMID: 10860201 DOI: 10.1097/00008483-200005000-00007] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical practice guidelines have been published for cardiac rehabilitation, directing programs to address secondary risk-reduction issues. The role of risk factor profiles in the referral of patients to cardiac rehabilitation programs has not been evaluated. METHODS Patients from the Cardiovascular Information Registry at the Cleveland Clinic Foundation (CCF) who entered the CCF hospital-based cardiac rehabilitation program (n = 371) were compared with those who did not participate in the CCF program (n = 2960) with respect to gender, demographics, and risk factor profile for CAD. A random subset of those who did not participate in the CCF program (n = 100) was interviewed by phone to determine participation patterns in other rehabilitation programs. RESULTS Only 11% of patients participated in CCF-based program. Standard risk factors were similar between participants and nonparticipants. Rehabilitation patients were younger (63 +/- 10 versus 66 +/- 10, P < 0.01) and as a group had better left ventricular function (moderate-severe left ventricle: 16% versus 23%, P < 0.01) than nonparticipants. Women were underrepresented in the CCF rehabilitation population (20% versus 30%, P < 0.01). Of the phone survey sample, 21% of patients entered other community-based rehabilitation programs. Similar trends with respect to risk factors, younger age, and better left ventricular function were noted for the community subset. However, women accounted for a greater percentage of the participants in the community programs than the CCF-based program (42.8% versus 19.7%, P < 0.03). CONCLUSIONS Conclusions based on institution-specific programs likely underestimate overall participation in cardiac rehabilitation. Traditional risk factors apparently are not considered when referring patients to cardiac rehabilitation programs. Younger patients with lower mortality risks preferentially participate in rehabilitation programs. Women are more likely to participate in community-based programs. Overall use of cardiac rehabilitation programs remains low.
Collapse
Affiliation(s)
- G G Blackburn
- Department of Cardiology, Cleveland Clinic Foundation, Ohio, USA.
| | | | | | | | | | | |
Collapse
|
17
|
Rieves D, Wright G, Gupta G, Shacter E. Clinical trial (GUSTO-1 and INJECT) evidence of earlier death for men than women after acute myocardial infarction. Am J Cardiol 2000; 85:147-53. [PMID: 10955368 DOI: 10.1016/s0002-9149(99)00652-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Epidemiologic studies of acute myocardial infarction (AMI) have described gender differences in the time of death after infarction, with greater numbers of men dying before hospitalization than women. However, in controlled, hospital-based clinical trials, women die at higher rates than men. We hypothesized that evidence of a gender difference in the time of death following AMI may be found in controlled studies of hospitalized AMI patients. We performed a retrospective analysis of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) and International Joint Efficacy Comparison of Thrombolytics (INJECT) trial databases using logistic regression modeling and time-to-death analyses. The age-adjusted female-to-male odds ratio for mortality was 1.4 (95% confidence interval 1.3 to 1.5) in GUSTO-1 and 1.5 (95% confidence interval 1.3 to 1.8) in INJECT. GUSTO-1 showed that among patients dying during the first 24 hours after symptom onset, men died an average of 1.7 hours earlier than women (p<0.001). This difference was due to earlier deaths among men < or =65 years of age. Furthermore, in GUSTO-1, the analysis of time to death in hour increments demonstrated that greater proportions of men died at earlier time points than women and a disproportionate number of early deaths occurred among younger men than among women of any age or older men. In INJECT, where time to death could only be analyzed in 1-day increments, no gender differences were evident. These results raise the possibility that the pattern of earlier death for men in thrombolytic clinical trials represents the continuation of a gender-specific mortality pattern that began before hospitalization. The death of a disproportionate number of men before hospitalization may represent an inherent gender bias for clinical studies enrolling only hospitalized patients. More high-risk men would be excluded from these studies than women because of death before hospitalization. Hence, gender comparisons of in-hospital mortality rates may artificially inflate values for women.
Collapse
Affiliation(s)
- D Rieves
- Food and Drug Administration, Center for Biologic Evaluation and Research, Rockville, Maryland, USA
| | | | | | | |
Collapse
|
18
|
Shaw LJ, Heller GV, Travin MI, Lauer M, Marwick T, Hachamovitch R, Berman DS, Miller DD. Cost analysis of diagnostic testing for coronary artery disease in women with stable chest pain. Economics of Noninvasive Diagnosis (END) Study Group. J Nucl Cardiol 1999; 6:559-69. [PMID: 10608582 DOI: 10.1016/s1071-3581(99)90091-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Seven clinical sites compiled data from 4638 women who were referred directly to coronary angiography (catheterization-first strategy; n = 3375) or who underwent stress myocardial perfusion imaging (MPI) first (n = 1263) followed by coronary angiography if at least one reversible myocardial perfusion abnormality was detected. The study examines the cost minimization potential of these available invasive and noninvasive diagnostic strategies in women with chest pain. METHODS AND RESULTS Women in both groups were subclassified by the core laboratory as being at low (<0.15), intermediate (0.15 to 0.60), or high (>0.60) pretest likelihood for coronary artery disease (CAD). Among the catheterization-first patients, at least one coronary stenosis >70% was present in 13% of low likelihood patients, 29% of intermediate likelihood patients, and 52% of patients with high CAD likelihood. Perfusion abnormality rates in the MPI-first group were 23% in low likelihood patients, 27% in intermediate likelihood patients, and 34% in high CAD likelihood patients. Of the MPI-first subset, 50%, 55%, and 76%, respectively, underwent catheterization in at least one coronary stenosis >70%. Cardiac death rates ranged from 0.5% to 2.2% in patients with CAD and did not differ from the 2 testing strategies (P = not significant). The composite cost per patient of diagnostic testing plus follow-up medical care over a period of 2.5 +/- 1.5 years (calculated for both strategies from inflation-corrected Medicare charges, adjusted for institutional cost-charge ratios) ranged from $2490 for patients with low likelihood to $3687 for patients with high likelihood with the catheterization-first strategy and from $1587 to $2585 for patients undergoing MPI first (P < .01 between risk subsets and strategies). CONCLUSIONS In women referred for diagnostic evaluation of stable chest pain, MPI followed by selective coronary angiography in patients with at least 1 perfusion abnormality minimizes the near-term composite cost per patient compared with a direct catheterization-first strategy, regardless of pretest CAD likelihood.
Collapse
Affiliation(s)
- L J Shaw
- Emory University, Atlanta, Ga, USA
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Lin CL, Chiang CW, Shaw CK, Chu PH, Chang CJ, Ko YL. Gender differences in the presentation of adult obstructive hypertrophic cardiomyopathy with resting gradient: a study of 122 patients. JAPANESE CIRCULATION JOURNAL 1999; 63:859-64. [PMID: 10598891 DOI: 10.1253/jcj.63.859] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The present study investigated gender differences among adult patients with obstructive hypertrophic cardiomyopathy (OHCM) and resting gradient. Using outflow gradients >10 mmHg and the presence of asymmetrical septal hypertrophy of the left ventricle as inclusion criteria, 122 patients were identified among patients referred for echocardiographic examinations between May 1990 and October 1996. Clinical, echocardiographical and follow-up data were compared between male and female patients. The female patients were significantly older than male patients (mean age +/-SD 66.7+/-10.5 vs 54.8+/-12.5 years). The female patients had a smaller interventricular septal wall thickness, less frequent systolic anterior movement of the mitral valve, more frequent association with hypertension, and less frequent association with ischemic heart disease (IHD) and giant T wave inversion. In this study population, adult female patients presented with OHCM 12 years later than males. Whether this represents female patients' reluctance to seek medical attention early, a different disease process that affects predominantly elderly females, or a gender-specific end organ response to aging, hypertension, IHD and other processes, or the protective effects of estrogen remains to be determined.
Collapse
Affiliation(s)
- C L Lin
- Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taiwan, Republic of China
| | | | | | | | | | | |
Collapse
|
20
|
Helgeson VS, Fritz HL. Cognitive adaptation as a predictor of new coronary events after percutaneous transluminal coronary angioplasty. Psychosom Med 1999; 61:488-95. [PMID: 10443757 DOI: 10.1097/00006842-199907000-00013] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We tested whether the psychological components of cognitive adaptation theory would predict new coronary events after a first percutaneous transluminal coronary angioplasty (PTCA). METHODS A consecutive sample of patients treated successfully with PTCA were enrolled in the study. Of 343 patients approached, 303 (88%) agreed to participate and were interviewed shortly before hospital discharge. We measured the components of cognitive adaptation theory (optimism, self-esteem, and mastery) during the interview. Five patients were excluded from the analysis because of early, in-hospital reocclusion. New cardiac events (coronary artery bypass grafting, PTCA, myocardial infarction, or disease progression) were examined within 6 months of the first PTCA. We obtained 6-month follow-up data on 98% of patients. RESULTS The cognitive adaptation index predicted new cardiac events, even when demographic variables and medical variables thought to predict restenosis were statistically controlled (p = .02). CONCLUSIONS These results suggest that persons who respond to their illness by perceiving control over their futures, by having positive expectations about their futures, and by holding a positive view of themselves seem to be at less risk for a new cardiac event after a first PTCA.
Collapse
Affiliation(s)
- V S Helgeson
- Psychology Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA. vh2e+@andrew.cmu.edu
| | | |
Collapse
|
21
|
Hussain KM, Kogan A, Estrada AQ, Kostandy G, Foschi A, Dadkhah S. Referral pattern and outcome in men and women undergoing coronary artery bypass surgery--a critical review. Angiology 1998; 49:243-50. [PMID: 9555926 DOI: 10.1177/000331979804900401] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Women with coronary artery disease are less likely to undergo coronary artery bypass surgery, and this may represent a potential referral bias in favor of men. A higher in-hospital mortality rate in women compared with men has been reported earlier. Accumulating evidence currently suggests, however, that variables other than gender, such as advanced age, late referral, angina classification, diabetes mellitus, concurrent medical conditions, the number of diseased vessels, the caliber of coronary arteries, and the decreased body surface area in women may have accounted for this difference. In fact, when these variables are taken into account, female gender is no longer a statistically significant predictor of operative mortality. Women appear to have comparable immediate and late survival rates. Recurrent angina, perioperative myocardial infarction, congestive heart failure, incomplete revascularization, and early and late graft reocclusion following surgery are, however, more prevalent in women. Men and women show differences in recovery experiences after discharge following bypass surgery. When coronary bypass surgery is offered to women, the decision should be individualized, based on the patients' perioperative baseline clinical risk factors and coronary anatomy. Coronary artery bypass surgery should not be withheld in women who are considered to be appropriate candidates for fear of a reduced success rate.
Collapse
Affiliation(s)
- K M Hussain
- Department of Cardiology, St. Francis Hospital of Evanston, Illinois 60202, USA
| | | | | | | | | | | |
Collapse
|
22
|
|
23
|
Hussain KM, Estrada AQ, Kogan A, Dadkhah S, Foschi A. Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease. Am Heart J 1997; 134:719-27. [PMID: 9351740 DOI: 10.1016/s0002-8703(97)70056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.
Collapse
Affiliation(s)
- K M Hussain
- Department of Cardiology, St. Francis Hospital of Evanston, Ill., USA
| | | | | | | | | |
Collapse
|
24
|
Abstract
Dobutamine echocardiography (DE) has been shown to be safe, feasible, and accurate for identification of coronary artery disease (CAD) in mixed populations. The purpose of this study was to examine gender differences in physiologic response and accuracy of DE. We studied 2,886 consecutive DEs, performed in 2,748 patients, 1,209 of whom (44%) were women. A standard incremental protocol (5 to 40 microg/kg/min in 3-minute stages) was followed by atropine and/or an additional stage with 50 microg/kg/min, if the heart rate response was inadequate. Hemodynamic and echocardiographic findings were recorded at each stage. Three hundred sixty-nine patients without previous cardiac intervention (including 135 women) also underwent cardiac catheterization within 1 year of DE. Significant coronary stenoses (defined angiographically as >50% diameter) were present in 67% of women and 65% of men, of whom 55% and 65%, respectively, had multivessel disease. Women had a higher baseline heart rate (76 +/- 13 vs 73 +/- 14 beats/min, p <0.0001), and showed a more rapid increase in heart rate at low dose, with a higher age-predicted maximum heart rate at peak. This led to test termination at target heart rate but a submaximum dose in 22% of women versus 15% of men (p <0.0001) and less frequent administration of atropine (29% vs 34%, p <0.01). Dose-limiting side effects (8% vs 7%) and submaximum heart rate responses (14% vs 17%) were comparable in men and women. Even after the exclusion of negative DE at submaximal heart rate responses, the overall sensitivity was significantly lower in women than men (78% vs 88%, p <0.05), both for single (72% vs 78%, p <0.05) and for multivessel disease (82% vs 93%, p <0.05). The low specificity in both genders (55% vs 46%) probably reflected post-test referral bias. Thus, physiologic responses to dobutamine stress are comparable in men and women, except for a more rapid heart rate response in women, but the accuracy of DE for diagnosis of CAD in women is less than in men.
Collapse
Affiliation(s)
- M A Secknus
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
| | | |
Collapse
|
25
|
Onat A, Dursunoğlu D, Sansoy V. Relatively high coronary death and event rates in Turkish women. Relation to three major risk factors in five-year follow-up of cohort. Int J Cardiol 1997; 61:69-77. [PMID: 9292335 DOI: 10.1016/s0167-5273(97)00121-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The study describes rates of coronary heart disease death and nonfatal coronary events over five years in a cohort of random sample population and relates them to levels of three major risk factors. It is based on a longitudinal follow-up of survey conducted initially in 1990 in all geographic regions of Turkey. Two-thirds of the original cohort aged 20 years or over 2259 adults comprising 1146 women was followed up by physical examination and an ECG recording at rest. New coronary events were defined to include myocardial infarction and stable angina with or without associated myocardial ischemia developed during the follow-up period. Overall annual death rate was nine per 1000 adults. Coronary deaths numbered 55 (of which 26 were women) representing 4.1 per year and were found high in women. New coronary events were registered in 37 men and 32 women (annual rates 7.2 and 5.8 per 1000, respectively). Among male participants aged initially 40 years or over, high systolic blood pressure (> or = 130 mmHg) at baseline significantly predicted coronary death (age-adjusted risk ratio (RR) 3.3) while high cholesterol concentrations (> or = 5.2 mmol l-1) predicted new coronary events alone (RR almost 2). In women systolic pressure again strongly predicted coronary death (age-adjusted RR 3.9), whereas abnormal cholesterol levels discriminated for coronary death and new coronary events (RR around 2.3 for each). High diastolic pressure (> or = 85 mmHg) was of predictive value for the combined outcome of coronary death and events in women (RR 1.9) but not in men. Multivariate analysis by logistic regression identified systolic blood pressure in men as significant independent predictor of coronary death, while total cholesterol concentration in both genders and systolic blood pressure in men were independent predictors of the combined outcome of coronary death or nonfatal coronary events. It was concluded that known major risk factors act in similar magnitudes commensurate with the specific risk increments also in populations with essentially low cholesterol levels. The relatively high coronary morbidity and mortality in Turkish women approaching that in men may be accounted for by an inherent greater risk burden.
Collapse
Affiliation(s)
- A Onat
- Turkish Society of Cardiology, Istanbul, Turkey
| | | | | |
Collapse
|
26
|
Heupler S, Mehta R, Lobo A, Leung D, Marwick TH. Prognostic implications of exercise echocardiography in women with known or suspected coronary artery disease. J Am Coll Cardiol 1997; 30:414-20. [PMID: 9247513 DOI: 10.1016/s0735-1097(97)00167-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to define the value of exercise echocardiography as an independent predictor of cardiac events in women with known or suspected coronary artery disease (CAD), incremental to the data provided by clinical evaluation and exercise testing. BACKGROUND Exercise echocardiography is more accurate than exercise electrocardiography for the identification of CAD in women. However, the prognostic implications of exercise echocardiography, especially relative to exercise electrocardiography, are undefined. METHODS Symptom-limited exercise echocardiography was performed in 549 consecutive women between 1989 and 1993. Echocardiography and electrocardiography were performed before and after treadmill exercise; an abnormal result on exercise electrocardiography was defined by ST segment depression > 0.1 mV, ischemia by exercise echocardiography as a new or worse wall motion abnormality after exercise and scar by akinesia or dyskinesia at rest. After exclusion of six patients with uninterpretable studies (1%) and 35 (6%) lost to follow-up, 508 women (mean [+/-SD] age 55 +/- 11 years) were followed up for 41 +/- 10 months for cardiac-related death, infarction or late revascularization. RESULTS The group attained 92 +/- 10% of age-predicted maximal heart rate, with an exercise capacity of 7 +/- 2 metabolic equivalents. Of 420 women with an interpretable electrocardiogram, significant ST segment changes were present in 68 (16%). Results of exercise echocardiography were normal in 413 (81%) women, positive for ischemia in 66 (13%) and scar only in 29 (6%). No events occurred in 444 patients (89%), and 19 underwent primary revascularization (within 3 months of exercise test). Cardiac events occurred in 36 women (7%), including 17 who died of cardia causes and 19 who had a myocardial infarction or required late revascularization for progressive symptoms. On univariate analysis, the variables associated with cardiac mortality and total cardiac events were a history of CAD, diabetes, left ventricular hypertrophy, exercise capacity and echocardiographic evidence of myocardial ischemia and infarction. A Cox proportional hazards model showed the independent predictors of outcome to be known CAD (odds ratio [OR] 6.6, 95% confidence interval [CI] 3.2 to 13.7, p < 0.00001) and echocardiographic ischemia (OR 4.3, 95% CI 2.1 to 8.7, p < 0.0001). The prognostic value of exercise echocardiography incremental to clinical and exercise variables was demonstrated using sequential Cox models. CONCLUSIONS In this large cohort of women, exercise echocardiography provided key prognostic information incremental to clinical and exercise testing data.
Collapse
Affiliation(s)
- S Heupler
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
| | | | | | | | | |
Collapse
|
27
|
|
28
|
Alexander KP, Mark DB. Effect of gender on angioplasty outcome: are we closer to the answer? Mayo Clin Proc 1997; 72:89-91. [PMID: 9005294 DOI: 10.4065/72.1.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|