Gender differences in pain characteristics of chronic stable angina and perceived physical limitation in patients with coronary artery disease

The role of sex and gender in somatic complaints among patients with coronary heart disease: A longitudinal study on acute and long-term changes

BACKGROUND

Somatic complaints are persistently reported in patients with coronary heart disease (CHD). Sex and gender influence health and well-being in a variety of ways, but it is unknown how they affect somatic complaints over time after percutaneous coronary intervention (PCI). Therefore, we examined the association between sex and gender on somatic health complaints during the first month (acute) and the first two years (recovery) after PCI.

METHODS

514 patients (Mage = 64.2 ± 8.9, 84.2% male) completed the somatic scale of the Health Complaints Scale (including the subscales: cardiopulmonary complaints, fatigue, sleep problems) at baseline, one, 12-, and 24-months post-PCI. In a follow-up study, they filled in additional questionnaires to gauge gender norms, traits, and identity. Linear mixed modeling analyses were used to assess the influence of sex, gender, their interaction, and covariates on somatic complaints for the acute and recovery phases separately.

RESULTS

A general decline in somatic complaints over time was observed during the acute phase, followed by a stabilization in the recovery phase. Females and individuals with more feminine traits, norms, and identities reported increased somatic complaints. Males with more pronounced feminine norms and females with more masculine norms likewise reported more somatic, cardiopulmonary, and fatigue complaints. Furthermore, age, cardiac history, and comorbid diseases partly explained the associations with somatic complaints.

CONCLUSION

While somatic complaints improve post-PCI, there are still conspicuous sex and gender differences that need to be considered. Future research should further elaborate upon these discrepancies and incorporate sex and gender in prevention and develop tailored interventions to diminish somatic complaints.

Feasibility and preliminary efficacy of acupuncture for angina in an underserved diverse population

PURPOSE

Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL).

METHODS

Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire-7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis.

RESULTS

The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = -2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001).

CONCLUSIONS AND IMPLICATIONS

Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT.

TRIAL REGISTRATION NUMBER

NCT02914834 (ClinicalTrials.gov).

Health-related qualify of life, angina type and coronary artery disease in patients with stable chest pain

BACKGROUND

Health-related quality of life (HRQoL) is impaired in patients with stable angina but patients often present with other forms of chest pain. The aim of this study was to compare the pre-diagnostic HRQoL in patients with suspected coronary artery disease (CAD) according to angina type, gender, and presence of obstructive CAD.

METHODS

From the pilot study for the European DISCHARGE trial, we analysed data from 24 sites including 1263 patients (45.9% women, 61.1 ± 11.3 years) who were clinically referred for invasive coronary angiography (ICA; 617 patients) or coronary computed tomography angiography (CTA; 646 patients). Prior to the procedures, patients completed HRQoL questionnaires: the Short Form (SF)-12v2, the EuroQoL (EQ-5D-3 L) and the Hospital Anxiety and Depression Scale.

RESULTS

Fifty-five percent of ICA and 35% of CTA patients had typical angina, 23 and 33% had atypical angina, 18 and 28% had non-anginal chest discomfort and 5 and 5% had other chest discomfort, respectively. Patients with typical angina had the poorest physical functioning compared to the other angina groups (SF-12 physical component score; 41.2 ± 8.8, 43.3 ± 9.1, 46.2 ± 9.0, 46.4 ± 11.4, respectively, all age and gender-adjusted p < 0.01), and highest anxiety levels (8.3 ± 4.1, 7.5 ± 4.1, 6.5 ± 4.0, 4.7 ± 4.5, respectively, all adjusted p < 0.01). On all other measures, patients with typical or atypical angina had lower HRQoL compared to the two other groups (all adjusted p < 0.05). HRQoL did not differ between patients with and without obstructive CAD while women had worse HRQoL compared with men, irrespective of age and angina type.

CONCLUSIONS

Prior to a diagnostic procedure for stable chest pain, HRQoL is associated with chest pain characteristics, but not with obstructive CAD, and is significantly lower in women.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02400229.

Chest Pain Characteristics in Cardiac Syndrome X Compared to Coronary Artery Disease

AIM

This study aimed to assess if clinical remarks gained by analysis of the present and past medical history of patients undergoing elective coronary angiography (ECA) due to typical chest pain can help to predict the outcome of ECA.

MATERIAL AND METHODS

One hundred and fifty-four ECA candidates with a history of typical chest were seen on the same day intended for ECA in the cardiac centre of AlShaab Teaching Hospital, Khartoum, Sudan. The details of the present complaints, characteristics of chest pain, past medical and socioeconomic history were recorded from each subject guided by a questionnaire. ECA confirmed CAD in 112 of the studied patients and were considered as the test group. The remaining patients (N = 42) were diagnosed as CSX after exclusion of significant narrowing of the coronary vessels and were considered as the control group.

RESULTS

Univariate analysis of pain characteristics among patients undergoing coronary angiography revealed that pain is less likely to radiate to the neck (OR = 0.44, 95% CI = 0.21 - 0.91, P = 0.027) and the back (OR = 0.48, 95% CI = 0.23 - 1.00, P = 0.049) in patients with CAD. Presence of shortness of breathing and/or dizziness significantly decrease the odds of having abnormal coronary angiography (OR = 0.30 and 0.48, 95% CI = 0.12 - 0.77 and 0.22 - 0.92, P = 0.013 and 0.030 respectively). Past history of diabetes mellitus significantly increases the odds of having abnormal coronary angiography (OR = 3.96, 95% CI = 1.68 - 9.30, P = 0.002). In contrast, past medical history of migraine decreases the odds of having positive finding in ECA (OR = 0.31, 95% CI = 0.13 - 0.72, P = 0.006).

CONCLUSION

Characteristics of chest pain are comparable in CAD and CSX. However, pain is less likely to radiate to the neck and/or the back in the first group. Presence of dyspnea and dizziness during angina attacks as well as the history of migraine significantly decreases the odds of having abnormal coronary angiography.

Acupuncture to Improve Symptoms for Stable Angina: Protocol for a Randomized Controlled Trial

Background

Acupuncture has demonstrated physiologic analgesic effects in Chinese patients with stable angina. One proposed mechanism of action for these analgesic effects is the downregulation of M1 macrophages, interleukin 1 beta, interleukin-6, interleukin-18, and tumor necrosis factor alpha.

Objective

This study aims to test a 10-session, 5-week acupuncture treatment protocol as a complementary therapy for symptoms of stable angina for American patients, who vary from Chinese patients in health care systems and other salient variables.

Methods

We are conducting a randomized controlled trial (RCT) of 69 adults (35 assigned to initial acupuncture and 34 to an attention control condition) with a medically confirmed diagnosis of stable angina, whose pain and associated symptoms have not been controlled to their satisfaction with guideline-directed medical management. Participants in the experimental group will receive a standardized traditional Chinese medicine point prescription. The attention control group will view non–pain-related health education videos over 5 weeks equal to the 10 hours of treatment for the acupuncture group. Participants will complete the McGill Pain Questionnaire and the Seattle Angina Questionnaire-7, as well as have inflammatory cytokines measured at baseline and study completion. The primary outcomes are anginal pain and quality of life.

Results

This study has been funded over 2 years by the National Institutes of Health, National Institute for Nursing Research. We are currently recruiting and expect to have initial results by December 2020.

Conclusions

We will generate data on feasibility, acceptability, effect sizes, and protocol revisions for a future fully powered RCT of the protocol. Findings will help determine if patients with persistent ischemic symptoms experience a proinflammatory state and hyperalgesia caused by multiple neural and immune processes not always relieved with medication.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14705

Positive and Negative Affect Is Related to Experiencing Chest Pain During Exercise-Induced Myocardial Ischemia

OBJECTIVE

Silent myocardial ischemia is thought to be associated with worse cardiovascular outcomes due to a lack of perception of pain cues that initiate treatment seeking. Negative affect (NA) has been associated with increased pain reporting and positive affect (PA) with decreased pain reporting, but these psychological factors have not been examined within the context of myocardial ischemia. This study evaluated the associations between PA, NA, and chest pain reporting in patients with and without ischemia during exercise testing.

METHODS

A total of 246 patients referred for myocardial perfusion single-photon emission computed tomography exercise stress testing completed the positive and negative affect schedule-expanded version, a measure of PA and NA. Presence of chest pain and myocardial ischemia were evaluated using standardized protocols.

RESULTS

Logistic regression analyses revealed that for every 1-point increase in NA, there was a 13% higher chance for ischemic patients (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and an 11% higher chance in nonischemic patients (OR = 1.11; 95% CI = 1.03 to 1.19) to report chest pain. A significant interaction of PA and NA on chest pain reporting (β = 0.02; 95% CI = 0.002 to 0.031) was also observed; nonischemic patients with high NA and PA reported more chest pain (57%) versus patients with low NA and low PA (13%), with high NA and low PA (17%), and with high PA and low NA (7%).

CONCLUSIONS

Patients who experience higher NA are more likely to report experiencing chest pain. In patients without ischemia, high NA and PA was also associated with a higher likelihood of reporting chest pain. Results suggest that high levels of PA as well as NA may increase the experience and/or reporting of chest pain.

Ideal Cardiovascular Health and Incident Cardiovascular Events: The Jackson Heart Study

INTRODUCTION

The epidemiology of American Heart Association ideal cardiovascular health (CVH) metrics has not been fully examined in African Americans. This study examines the associations of CVH metrics with incident cardiovascular disease (CVD) in the Jackson Heart Study, a longitudinal cohort study of CVD in African Americans.

METHODS

Jackson Heart Study participants without CVD (n=4,702) were followed prospectively between 2000 and 2011. Incidence rates and Cox proportional hazard ratios estimated risks for incident CVD (myocardial infarction, stroke, cardiac procedures, and CVD mortality) associated with seven CVH metrics by sex. Analyses were performed in 2015.

RESULTS

Participants were followed for a median of 8.3 years; none had ideal health on all seven CVH metrics. The prevalence of ideal health was low for nutrition, physical activity, BMI, and blood pressure metrics. The age-adjusted CVD incidence rate (IR) per 1,000 person years was highest for individuals with the least ideal health metrics: zero to one (IR=12.5, 95% CI=9.7, 16.1), two (IR=8.2, 95% CI=6.5, 10.4), three (IR=5.7, 95% CI=4.2, 7.6), and four or more (IR=3.4, 95% CI=2.0, 5.9). Adjusting for covariates, individuals with four or more ideal CVH metrics had lower risks of incident CVD compared with those with zero or one ideal CVH metric (hazard ratio, 0.29; 95% CI=0.17, 0.52; p<0.001).

CONCLUSIONS

African Americans with more ideal CVH metrics have lower risks of incident CVD. Comprehensive preventive behavioral and clinical supports should be intensified to improve CVD risk for African Americans with few ideal CVH metrics.

Description of Unexplained Chest Pain and Its Influence on Daily Life In Men and Women

Background: Patients with unexplained chest pain have seldom organic pathology. Although both physical and psychological factors have been studied and suggested as causes of chest pain.

Aim: The aim was to describe the experience of unexplained chest pain and its influence on daily life situation in men and women.

Methods: Nine women and eleven men with unexplained chest pain, aged 31–62 years were interviewed. A qualitative descriptive design was used. The interviews were analyzed by content analysis focusing on experience by gender.

Results: The results embraced two domains descriptions and consequences of chest pain and daily life situation. Words like pressure, cramp, strong, or burning were used in the descriptions of the chest pain experienced with more similarities than variations between men and women. Physical, psychological and social consequences due to chest pain influenced daily life. The men specifically reported having a ‘fast tempo’ in their lives, with stress at work being seen as a feature experienced by both men and women.

Conclusions: This study shows that men and women had more similarities than variations in descriptions of chest pain. Their unexplained chest pain influenced their functions in daily life that led to, especially for the men, few contacts outside the family and therefore a weak social network.

Validation and comparison of EuroQoL-5 dimension (EQ-5D) and Short Form-6 dimension (SF-6D) among stable angina patients

OBJECTIVES

Several preference-based health-related quality of life (HRQoL) instruments have been published and widely used in different populations. However no consensus has emerged regarding the most appropriate instrument in therapeutic area of stable angina. This study compared and validated the psychometric properties of two generic preference-based instruments, the EQ-5D and SF-6D, among Chinese stable angina patients.

METHODS

Convergent validity of the EQ-5D and SF-6D was examined with eight a priori hypotheses from stable angina patients in conjunction with Seattle Angina Questionnaire (SAQ). Responsiveness was compared using the effect size (ES), relative efficiency (RE) and receiver operating characteristic (ROC) curves. Agreement between the EQ-5D and SF-6D was tested using intra-class correlation coefficient (ICC) and Bland-Altman plot. Factors affecting utility difference were explored with multiple linear regression analysis.

RESULTS

In 411 patients (mean age 68.08 ± 11.35), mean utility scores (SD) were 0.78 (0.15) for the EQ-5D and 0.68 (0.12) for the SF-6D. Validity was demonstrated by the moderate to strong correlation coefficients (Range: 0.368-0.594, P< 0.001) for five of the eight hypotheses in both the EQ-5D and SF-6D. There were no serious floor effects for the EQ-5D and SF-6D, but ceiling effects for the EQ-5D were large. The areas under ROC of them all exceeded 0.5 (0.660-0.814, P< 0.001). The SF-6D showed a better discriminative capacity (ES: 0.573 to 1.179) between groups with different stable-angina-specific health status than the EQ-5D (ES: 0.426 to 1.126). RE suggested that the SF-6D (RE: 44.8 to 177.8%) was more efficient than the EQ-5D except for physical function. Poor agreement between them was observed with ICC (0.448, P< 0.001) and Bland-Altman plot analysis. Multiple liner regression showed that clinical variables significantly (P< 0.05) influenced differences in utility scores between the EQ-5D and SF-6D.

CONCLUSIONS

Both EQ-5D and SF-6D are valid and sensitive preference-based HRQoL instruments in Chinese stable angina patients. The SF-6D may be a more effective tool with lower ceiling effect and greater sensitivity. Further study is needed to compare other properties, such as reliability and longitudinal response.

Correlates of hospital use in homeless and unstably housed women: the role of physical health and pain

PURPOSE

To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical health and pain.

METHODS

We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used.

RESULTS

Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio [OR], 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations.

CONCLUSIONS

Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.

Chronic stable angina is associated with lower health-related quality of life: evidence from Chinese patients

Objectives

To compare health-related quality of life (HRQoL) between patients with stable angina and the general population in China and to examine factors associated with HRQoL among patients with stable angina.

Methods

A cross-sectional HRQoL survey of stable angina patients recruited from 4 hospitals (n = 411) and the general population recruited from 3 Physical Examination Centers (n = 549) was conducted from July to December, 2011 in two large cities, Tianjin and Chengdu. HRQoL was assessed using the EQ-5D, EQ-VAS, and SF-6D instruments. The health status specific to patients with stable angina was assessed using the Seattle Angina Questionnaire (SAQ). Information on socio-demographic, clinical, and lifestyle factors were also collected. Nested regressions were performed to explore how these factors were associated with HRQoL in patients with stable angina.

Results

Compared with the general population (44.2±10 years, 49.9% females), stable angina patients (68.1±12 years, 50.4% females) had significantly lower HRQoL scores in EQ-5D utility index (0.75±0.19 vs. 0.90±0.20, p<0.05), SF-6D utility index (0.68±0.12 vs. 0.85±0.11, p<0.05), and EQ-VAS (71.2±12.3 vs. 83.9±10.9, p<0.05). The differences remained (−0.05 for EQ-5D, −9.27 for EQ-VAS and −0.13 for SF-6D) after controlling for socio-economic characteristics. SAQ scores showed that stable angina patients experienced impaired disease-specific health status, especially in angina stability (40.5±34.6). Nested regressions indicated stable angina-specific health status explained most of the variation in HRQoL, among which disease perception, physical limitation, and angina stability were the strongest predictors. More physical exercise and better sleep were positively related with HRQoL.

Conclusions

Compared to the general population, stable angina patients were associated with lower HRQoL and lower health utility scores, which were largely impacted by clinical symptoms. Further studies are needed to characterize the influence of geographic and cultural factors on the variations of health-related utility in stable angina patients.

Self-reported health status in coronary heart disease patients: a comparison with the general population

BACKGROUND

The aim of our study was to compare Euroqol-5D (EQ-5D) outcomes in coronary heart disease (CHD) patients with those from the general population. We aimed to identify those dimensions which were mostly impaired.

METHODS

EQ-5D results (both the dimensions and the EQ-5D visual analogue scale (EQ-VAS)) from a European sample (11 countries) of coronary patients were compared with published age- and gender-specific normative data.

RESULTS

EQ-5D outcomes differed across countries and gender. Overall, the age-adjusted EQ-VAS scores were significantly lower in coronary patients compared with the general population, both in males (mean difference (MD)= -5.24(-7.59 to -2.88)) and in females (MD= -8.32 (-11.69 to -4.95)). Coronary patients had a significantly higher risk to report moderate or severe problems related to anxiety/depression (odds ratio (OR) male=1.84 (1.14-2.95); OR female=3.20 (2.32-4.40)). Furthermore, female coronary patients reported more problems on the mobility (OR=2.00 (1.38-2.90)), usual activity (OR= 2.54 (1.81-3.57)) and pain/discomfort dimension (OR=1.73 (1.23-2.43)) whereas in males, a borderline significant OR was found on the mobility (OR=1.43 (0.97-2.11)) and usual activity dimension (OR=1.44 (0.94-2.20)). The difference between the general population and the CHD patients attenuated as age increased.

CONCLUSIONS

CHD has a negative influence on patient's self-reported health status, both the EQ-VAS as well as the EQ-5D dimensions (with the exception of self-care in both genders and pain/discomfort in males) were impaired. The relative impairment was the greatest in female patients and the differences in the proportion of reported problems diminished with increasing age. The EQ-5D instrument is appropriate in capturing problems related to anxiety/depression, pain/discomfort, mobility and usual activities. Within clinical practice, particular attention should be given to females and younger CHD patients.

Gender differences in symptoms during 60-second balloon occlusion of the coronary artery

Previous investigations have demonstrated the presence of gender differences in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations have had certain limitations, including being retrospective, an interview-related bias, a various duration of myocardial ischemia, and a lack of multivariate analysis, all of which would have affected the results. Accordingly, we prospectively examined the presence or absence of chest pain and non-chest pain symptoms during a 60-second balloon inflation in the setting of percutaneous coronary intervention, which provides a unique model of transient myocardial ischemia, in 110 men and 80 women with coronary artery disease. Chest pain and/or non-chest pain symptoms (occipital pain, jaw pain, neck/throat pain, shoulder pain, upper arm pain, back pain, and nausea) were observed during the balloon inflation in 72 men and 52 women. In the 124 patients with any symptoms during the balloon inflation, non-chest pain symptoms were more common in women than in men (31% vs 14%, p = 0.02); however, the incidence of chest pain did not differ between the men and women. After adjustment for covariables, including age, body mass index, hypertension, diabetes mellitus, current smoking, previous myocardial infarction, target vessels, β-blocker use, and calcium antagonist use, female gender remained significantly associated with non-chest pain symptoms (odds ratio 3.3, 95% confidence interval 1.2 to 9.9, p = 0.02). In conclusion, non-chest pain symptoms during the 60-second balloon occlusion of the coronary artery were more common in women than in men, supporting the presence of the gender difference in myocardial ischemic symptoms.

Pain prevalence and predictors among inpatients in a major Italian teaching hospital. A baseline survey towards a pain free hospital

Pain prevalence among inpatients is an important indicator of quality care; it may reach over 80% in various clinical settings. A cross-sectional survey was conducted in a teaching hospital to depict benchmark data regarding pain prevalence and predictors among the entire inpatient population. Overall 892 patients, 6 years old and hospitalized for at least 24 h in 57 hospital wards were interviewed using an internationally applied questionnaire. Patients self-reported their pain intensity at the time of the interview (T(0)) and worst pain perceived during the previous 24 h (T(-1)), using a numerical rating scale (NRS) and indicated current pain duration. Specific pain predictor data (hospital stay, gender, age and marital status) were obtained from patient medical charts. Pain prevalence at T(0) was 38% and 52% at T(-1). Pain was moderate to severe (NRS4) in approximately 25% of the patients at T(0) and in 40% at T(-1). High pain prevalence was found (at T(0) and T(-1), respectively) in Radiotherapy (63%;77%), Obstetrics (68%;54%), and Surgery (59%;45%) wards. Gender was a prominent determinant as pain was significantly associated with females. Pain prevalence was high among young adults or divorced/separated individuals and low among pediatric patients ( approximately 20%). Protracted hospitalization and prolonged pain duration were associated with major pain severity. Results yield Quality Assurance interventions to ameliorate pain undertreatment. Predictor analysis suggests that attention should be paid to pain management in young adults, socially vulnerable patients and those with protracted hospitalization and pain.

Gender bias revisited: new insights on the differential management of chest pain

Background

Chest pain is a common complaint and reason for consultation in primary care. Few data exist from a primary care setting whether male patients are treated differently than female patients. We examined whether there are gender differences in general physicians' (GPs) initial assessment and subsequent management of patients with chest pain, and how these differences can be explained

Methods

We conducted a prospective study with 1212 consecutive chest pain patients. The study was conducted in 74 primary care offices in Germany from October 2005 to July 2006. After a follow up period of 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the etiology of chest pain at the time of patient recruitment (delayed type-reference standard). We adjusted gender differences of six process indicators for different models.

Results

GPs tended to assume that CHD is the cause of chest pain more often in male patients and referred more men for an exercise test (women 4.1%, men 7.3%, p = 0.02) and to the hospital (women 2.9%, men 6.6%, p < 0.01). These differences remained when adjusting for age and cardiac risk factors but ceased to exist after adjusting for the typicality of chest pain.

Conclusions

While observed gender differences can not be explained by differences in age, CHD prevalence, and underlying risk factors, the less typical symptom presentation in women might be an underlying factor. However this does not seem to result in suboptimal management in women but rather in overuse of services for men. We consider our conclusions rather hypothesis generating and larger studies will be necessary to prove our proposed model.

Symptom clusters and health-related quality of life in people with chronic stable angina

AIM

This paper reports findings of a study to examine the independent contribution of chest pain, fatigue and dyspnoea to health-related quality of life in people with chronic stable angina.

BACKGROUND

People with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms yet there are no systematic studies examining the impact of symptom clusters on quality of life in people with chronic angina.

METHOD

Outpatients (n = 134), recruited over a 16-month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life.

RESULTS

The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) for the models predicting physical limitation (R² Δ 24·1%), disease perception (R² Δ 24·6%), Short Form-36 Physical Component Score (R² Δ 24·3%) and Mental Component Score (R² Δ 07·0%).

CONCLUSION

Symptom assessment and management of people with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up.

Gender specific variations in the description, intensity and location of angina pectoris: a cross-sectional study

BACKGROUND

Some research suggests that men and women may experience Angina Pectoris (AP) differently. More research is needed to characterize AP symptoms by gender and to familiarize health care providers with them, to enable proper education, diagnostic evaluation and timely management.

OBJECTIVE

This study examines gender differences in the description, intensity and location of AP in patients with CHD.

DESIGN

A cross-sectional study was performed to compare AP patients according to gender.

SETTINGS

This study was performed on patients residing in Tehran, who were being treated in a hospital and were admitted to cardiac units.

PARTICIPANTS

Five hundred patients with AP were selected. The participants were patients with AP who were diagnosed with CHD based on documented results from an angiography.

METHOD

Outpatients who were admitted to the cardiac units were screened. Informed consent was obtained from all study participants, who then completed the Iranian version of the AP characteristics questionnaire.

RESULTS

Women were significantly more likely to feel pain in the left arm and hand, odds ratio 1.5 (95% CI=1.0-2.1, P=0.04), left scapula, odds ratio 2.3 (95% CI=1.6-3.5, P<0.001), and neck, odds ratio 2.8 (95% CI=1.9-4.1, P<0.0001), while controlling for demographic and clinical factors. Women were significantly more likely to choose the possible pain descriptors for describing their AP and reported significantly greater intensity than men for all the pain descriptors. Significantly higher scores for sensory, affective, total and NRS (Numeric Rating Scale) scores were observed in women (P<0.001). Multiple linear regression analyses revealed that gender remained a statistically significant predictor of pain scores and NRS, while controlling for demographic and clinical factors.

CONCLUSION

Women and men differ with respect to description, intensity and location of AP. Educating the general public and informing health care providers about gender variation in AP may help to decrease delays in seeking medical care.

Gender differences in presentation and diagnosis of chest pain in primary care

Background

Chest pain is a common complaint and reason for consultation in primary care. Research related to gender differences in regard to Coronary Heart Disease (CHD) has been mainly conducted in hospital but not in primary care settings. We aimed to analyse gender differences in aetiology and clinical characteristics of chest pain and to provide gender related symptoms and signs associated with CHD.

Methods

We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out CHD in women and men.

Results

Women showed more psychogenic disorders (women 11,2%, men 7.3%, p = 0.02), men suffered more from CHD (women 13.0%, men 17.2%, p = 0.04), trauma (women 1.8%, men 5.1%, p < 0.001) and pneumonia/pleurisy (women 1.3%, men 3.0%, p = 0.04) Men showed significantly more often chest pain localised on the right side of the chest (women 9.1%, men 25.0%, p = 0.01). For both genders known clinical vascular disease, pain worse with exercise and age were associated positively with CHD. In women pain duration above one hour was associated positively with CHD, while shorter pain durations showed an association with CHD in men. In women negative associations were found for stinging pain and in men for pain depending on inspiration and localised muscle tension.

Conclusions

We found gender differences in regard to aetiology, selected clinical characteristics and association of symptoms and signs with CHD in patients presenting with chest pain in a primary care setting. Further research is necessary to elucidate whether these differences would support recommendations for different diagnostic approaches for CHD according to a patient's gender.

Angina symptoms are associated with mortality in older women with ischemic heart disease

BACKGROUND

Angina symptoms have been reported to predict mortality in men. The aim of this study was to investigate the association between angina symptoms and mortality in women.

METHODS AND RESULTS

In 2004, 873 older participants in the Australian Longitudinal Study on Women's Health with self-reported ischemic heart disease participated in a nested substudy. Women were 77 to 83 years of age; 165 (19%) died during the 4.5-year follow-up. Angina symptoms were established with Seattle Angina Questionnaire (SAQ) scores for physical limitation, angina frequency, angina stability, and disease perception. Proportional hazards modeling was used to examine the relationship of SAQ score differences with mortality. Physical limitation scores were associated with mortality, with hazard ratios of 1.1, 1.9, and 3.4 for mild, moderate, and severe versus minimal limitations, respectively (P<0.001). Angina frequency scores were also associated with death, with hazard ratios of 1.2, 1.2, and 4.8 for mild, moderate, and severe versus minimal angina frequency, respectively (P<0.001). Age (hazard ratio 1.1, 95% confidence interval 1.0 to 1.2), pulmonary disease (hazard ratio 1.6, 95% confidence interval 1.2 to 2.3), and kidney disease (hazard ratio 1.7, 95% confidence interval 1.1 to 2.5) were statistically significantly associated with mortality in a multivariable model of clinical predictors. In a combined model with SAQ scores and clinical predictors, SAQ scores for physical limitation and angina stability remained statistically significantly associated with mortality.

CONCLUSIONS

In older women with ischemic heart disease, angina symptoms assessed by use of SAQ scores for physical limitations and angina frequency were associated with mortality; SAQ scores may therefore prove to be a useful tool for risk assessment in this patient group.

Cardiovascular disease in older women: a challenge in diagnosis and treatment

Cardiovascular disease is the leading cause of death in women and more heart disease is present in elderly women than men. Risk factors for heart disease affect men and women differently, with a greater impact of diabetes, hyperlipidemia and smoking in women. Diagnosis of heart disease can be more challenging in women, especially when elderly, as symptoms may be vague. Understanding the appropriate use of diagnostic testing and appropriate treatment is essential, given the high burden of disease in elderly women. This article will discuss the current guidelines for diagnosis and therapy of heart disease in women and will discuss the appropriate role of prevention strategies.

Changes in quality of life, physical activity, and symptomatic status one year after myocardial revascularization for stable angina

BACKGROUND

This study investigates changes of quality of life (QOL), physical activity (PA) and symptomatic status (NYHA) at one-year post-coronary artery bypass grafting (CABG).

METHODS

Of 568 patients undergoing a primary isolated CABG for stable angina (NYHA <IV) pre- and 1-year postoperative data on QOL, PA, and NYHA were complete. Studied outcomes were changes in QOL, EuroQoL questionnaire, PA, the Corpus Christi Heart Project criteria and NYHA. Analysis was based on three age groups. Group A, age <65 years: 285 patients, group B, 65-74 years: 210 patients, and group C, age >or=75 years: 73 patients.

RESULTS

There is a similar, significant decrease of NYHA class (1.4) for the three groups (p<0.0005). An overall significant improvement for QOL and PA is however different in the three subgroups. PA improvement is not significant in group C (p=0.74), significant in group B (p=0.005) and in group A (p<0.0005). For the QOL, group A shows a significant improvement for the five different domains, group B for two, and group C only for one domain. The visual analogue score as part of the QOL registration shows a significant increase for the three groups, however the improvement is minor with age, and between A (14.6) and C (9.1) this improvement is significantly different (p=0.047).

CONCLUSIONS

Elderly patients have the same improvement of their symptomatic status as younger patients. However despite this improvement they have less benefit from CABG regarding to their quality of life and physical activity.

Differences according to gender in reporting physical symptoms during echocardiographic screening in healthy teenage athletes

BACKGROUND

Many studies have suggested that more women then men present with physical symptoms. There is no data available, however, on the differences in reporting of physical symptoms between teenage male and female athletes. Our objective was to evaluate the differences according to gender in physical symptoms in healthy teenage athletes.

METHODS

A total of 1,465 high school athletes, between the ages of 13 and 19 years participated in a mass echocardiographic screening programme for detection of cardiac abnormalities. Screening was conducted using a hand-carried cardiac ultrasound device (OptiGo, Philips). All participants were actively involved in a high school sport programme. Each athlete was required to fill out a questionnaire before the screening. The athletes were asked to report the occurrence of physical symptoms with activity or exercise. A physical examination was not performed during screening.

RESULTS

There were 1,031 (70.4%) male and 434 (29.6%) female participants. Significantly more female teenage athletes reported physical symptoms (190/434, 43.8% versus 267/1,031, 25.9%, odds ratio: 2.28, confidence interval: 1.76-2.81, p less than 0.001). Symptoms did not correlate with any echocardiographically identified cardiac abnormalities in either gender. The differences in the reporting of symptoms were significant for all physical symptoms addressed by the questionnaire.

CONCLUSION

There is a high prevalence of reporting physical symptoms in young healthy athletes without any relation to cardiac abnormalities. Young female athletes report physical symptoms nearly twice as often as their male counterparts.

Sex differences in prodromal symptoms of patients with acute coronary syndrome: a pilot study

Increasing evidence suggests that there are sex/gender differences in the presentation and prodromal symptoms of acute coronary syndrome (ACS). The purpose of this pilot study was to identify sex differences in the prodromal symptoms of ACS using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS). Telephone surveys using the MAPMISS were conducted between 4 and 6 months after the ACS event. Seventy-six patients (24 women) participated in the study. The women generally reported higher prodromal scores. Moreover, scores demonstrated differences in prodromal symptoms based on menopausal status. The premenopausal and perimenopausal women reported a greater number and higher frequency of symptoms compared with the men and menopausal women. The results of this study suggest that both men and women report nontraditional prodromal symptoms of ACS. In addition, there appears to be a difference in the frequency and number of symptoms reported based on menopausal status.

Assessing HRQL among Chinese patients with coronary heart disease: angina, myocardial infarction and heart failure

OBJECTIVE

To perform a psychometric evaluation of the Myocardial Infarction Dimensional Assessment Scale (MIDAS) in Chinese patients with coronary heart disease.

DESIGN AND SETTING

Patients with angina (n=162), MI (n=124) or heart failure (n=95) were recruited from a regional university-affiliated hospital. The Chinese version of the MIDAS (C-MIDAS), the Hospital Anxiety and Depression Scale (HADS) and the Short-Form 36 Health Survey (SF-36) were administered to all patients at baseline and the C-MIDAS was also administered seven day (n=92) and three months (n=363) later.

RESULTS

The C-MIDAS conforms to the 7-factor structure as proposed in the original version. It is reliable with Cronbach's alphas from 0.73 to 0.94 and test-retest reliabilities from 0.76 to 0.92. Four of its subscales (physical activity, insecurity, emotional reaction and dependency) correlated significantly with the SF-36 and the HADS in each diagnostic group and had good discriminative properties in terms of gender, emotional disturbance and perceived health deterioration, with responsiveness supported by medium-high effect sizes (0.43-0.83) and standardize response means (0.46-0.82). The other three subscales measuring treatment-related impacts added little to the validity and responsiveness of the C-MIDAS.

CONCLUSION

To render the C-MIDAS a core health-related quality of life measure for Chinese-speaking patients with coronary heart disease, further studies need to clarify the content adequacy and cultural relevancy of those subscales measuring treatment-related impact.

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care

Background

Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care.

Methods

A cross-sectional survey undertaken in 8 sentinel centres serving 63,724 individuals in the city of Liverpool (15% of the city population). Aspects of clinical care assessed included: risk factor recording (smoking, cholesterol, blood pressure, body mass index); secondary prevention (aspirin, beta-blocker, statin); cardiac investigation (exercise ECG, perfusion scanning, angiography); and revascularisation (percutaneous coronary intervention, coronary artery bypass grafting). Male-to-female adjusted odds ratios (AOR) were calculated (adjusted for age, angina duration, age at diagnosis and previous MI) using logistic regression.

Results

1,162 patients (610 men; 552 women) with angina were identified. Women were older than men (71 vs 67 years), with a shorter duration of angina (6 vs 7 years), and a lower prevalence of previous MI (25% vs 43%). Men were significantly more likely than women to undergo detailed risk factor assessment (AOR = 1.35, 95%CI 1.06 to 1.73); receive 'triple' secondary prevention with aspirin, beta-blockers and statins (AOR = 1.47, 95%CI 1.07 to 2.02); access exercise ECG testing (AOR = 1.31, 95%CI 1.02 to 1.68); angiography (AOR = 1.61, 95%CI 1.23 to 2.12); and undergo coronary revascularisation (AOR = 1.93, 95%CI 1.39 to 2.68).

Conclusion

Systematic gender differences exist in the comprehensive clinical management of patients with angina in primary care.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Gender comparison of efficacy and safety of ranolazine for chronic angina pectoris in four randomized clinical trials

More women than men with myocardial infarction have previous stable angina pectoris. Women also have an increased incidence of angina after percutaneous coronary intervention and coronary artery bypass grafting. Data from 1,737 patients with stable angina pectoris in 4 international trials (Monotherapy Assessment of Ranolazine In Stable Angina [MARISA], Combination Assessment of Ranolazine In Stable Angina [CARISA], Ranolazine Versus Atenolol Comparison in Chronic Angina [RAN080], and Efficacy of Ranolazine in Chronic Angina [ERICA]) were used to compare efficacy and safety of ranolazine therapy for angina in women and men. MARISA, CARISA, and RAN080 included exercise testing; CARISA, RAN080, and ERICA assessed angina frequency and nitroglycerin consumption; and ERICA included quality-of-life assessment using the Seattle Angina Questionnaire. MARISA, CARISA, and ERICA used the extended-release formulation of ranolazine; RAN080 used ranolazine immediate release. All 4 studies showed overall efficacy and safety of ranolazine. In subgroup analyses, women showed less improvement than men in exercise testing. However, similar improvements for women and men were noted in angina frequency and nitroglycerin consumption, and in ERICA, in the angina frequency dimension of the Seattle Angina Questionnaire. In conclusion, explanations for the gender treatment differences for exercise parameters but comparable effects on decrease in angina frequency and nitroglycerin use are uncertain, but may include differences in patient demographics, reasons for stopping exercise, and type of exercise protocol used.

Pain characteristics in patients with unexplained chest pain and patients with ischemic heart disease

BACKGROUND

Little scientific attention has been paid to providing a comprehensive multidimensional description of chest pain in patients with unexplained chest pain.

AIMS

The aims of the present study were: (1) to describe the symptom chest pain, including the dimensions of intensity, quality, duration and location in patients with unexplained chest pain (UCP); and (2) to identify similarities and differences in how patients with UCP and patients with ischemic heart disease (IHD) describe chest pain.

METHOD

A descriptive, correlational and comparative design. Totally 208 consecutive UCP patients and 40 IHD patients below 70 years of age participated. Pain was assessed using the instrument Pain-O-Meter.

RESULTS

The occurrence of chest pain was 79% (n=165) in UCP patients versus 60% (n=22) in the IHD patients (p=0.001). Patients with UCP reported greater pain intensity and used more sensory and affective words than IHD patients (p<0.01). Relationships between pain location and amount of body surface involved in the pain and pain intensity in both groups were found (p<0.001).

CONCLUSIONS

Our results showed some defining characteristics of the UCP group, but the many similarities between the two groups in their experience of chest pain made it impossible to clearly differentiate the groups' pain profiles.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain

Research suggests that anxiety sensitivity may be an important component in the negative response to pain sensations, especially those with cardiopulmonary origin. Furthermore, there is experimental evidence to suggest that such effects may be stronger in women than men. The primary aim of the current investigation was to determine the relative roles that anxiety sensitivity and gender have on the pain reports of patients referred to a hospital clinic with chest pain. A total of 78 female and 76 male adults were recruited on entry to a Rapid Access Medical Clinic. All patients had been referred with chest pain, and were administered a range of pain and anxiety measures prior to diagnosis. Results indicate that males were more likely to receive a diagnosis of cardiac chest pain, whereas females were more likely to receive a diagnosis of non-cardiac chest pain. Additionally, anxiety sensitivity was related to pain in women but not men. Finally, evidence was found for the mediating effect of negative interpretative bias on the relationship between anxiety sensitivity and pain. However, this mediating effect was only found in women. These results not only confirm that anxiety sensitivity is related to greater negative pain responses in women, but that this may be due to an increased tendency to negatively interpret sensations.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

Women with coronary artery disease report worse health-related quality of life outcomes compared to men

BACKGROUND

Although there have been substantial medical advances that improve the outcomes following cardiac ischemic events, gender differences in the treatment and course of recovery for patients with coronary artery disease (CAD) continue to exist. There is a general paucity of data comparing the health related quality of life (HRQOL) in men and women undergoing treatment for CAD. The purpose of this study was to compare HRQOL outcomes of men and women in Alberta, at one-year following initial catheterization, after adjustment for known demographic, co-morbid, and disease severity predictors of outcome.

METHOD

The HRQOL outcome data were collected by means of a self-reported questionnaire mailed to patients on or near the one-year anniversary of their initial cardiac catheterization. Using the Seattle Angina Questionnaire (SAQ), 5 dimensions of HRQOL were measured: exertional capacity, anginal stability, anginal frequency, quality of life and treatment satisfaction. Data from the APPROACH registry were used to risk-adjust the SAQ scale scores. Two analytical strategies were used including general least squares linear modeling, and proportional odds modeling sometimes referred to as the "ordinal logistic modeling".

RESULTS

3392 (78.1%) patients responded to the follow-up survey. The adjusted proportional odds ratios for men relative to women (PORs > 1 = better) indicated that men reported significantly better HRQOL on all 5 SAQ dimensions as compared to women. (PORs: Exertional Capacity 3.38 (2.75-4.15), Anginal Stability 1.23 (1.03-1.47), Anginal Frequency 1.70 (1.43-2.01), Treatment Satisfaction 1.27 (1.07-1.50), and QOL 1.74 (1.48-2.04).

CONCLUSIONS

Women with CAD consistently reported worse HRQOL at one year follow-up compared to men. These findings underline the fact that conclusions based on research performed on men with CAD may not be valid for women and that more gender-related research is needed. Future studies are needed to further examine gender differences in psychosocial adjustment following treatment for CAD, as adjustment for traditional clinical variables fails to explain sex differences in health related quality of life outcomes.

Gender differences in the perception of chest pain

This study investigated gender differences in pain perception as characterized by pain symptoms in patients diagnosed with unstable angina pectoris. Twenty-nine women and 32 men were asked to characterize their chest pain using a semi-open questionnaire assessing pain intensity (by numerical rating), pain location, pain characteristics, complaints following chest pain, factors that evoked or reduced chest pain, and whether the chest pain was related to heart disease. Significant gender differences were found. Women scored the intensity of their chest pain significantly higher than men (Chi-square 14.8, P < 0.0001), and related their chest pain less to heart disease (Chi-square 24.6, P < 0.0001). The women described an atypical clinical picture of chest pain that was significantly different from men's. The results are discussed in light of pschological theories regarding gender differences in pain perception. These findings imply the need for special attention to the unique clinical pictures that appear for women and men.