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Taqueti VR, Shaw LJ, Cook NR, Murthy VL, Shah NR, Foster CR, Hainer J, Blankstein R, Dorbala S, Di Carli MF. Excess Cardiovascular Risk in Women Relative to Men Referred for Coronary Angiography Is Associated With Severely Impaired Coronary Flow Reserve, Not Obstructive Disease. Circulation 2016; 135:566-577. [PMID: 27881570 DOI: 10.1161/circulationaha.116.023266] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 10/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) fatality rates are higher for women than for men, yet obstructive coronary artery disease (CAD) is less prevalent in women. Coronary flow reserve (CFR), an integrated measure of large- and small-vessel CAD and myocardial ischemia, identifies patients at risk for CVD death, but is not routinely measured in clinical practice. We sought to investigate the impact of sex, CFR, and angiographic CAD severity on adverse cardiovascular events. METHODS Consecutive patients (n=329, 43% women) referred for invasive coronary angiography after stress testing with myocardial perfusion positron emission tomography and with left ventricular ejection fraction >40% were followed (median, 3.0 years) for a composite end point of major adverse cardiovascular events, including cardiovascular death and hospitalization for nonfatal myocardial infarction or heart failure. The extent and severity of angiographic CAD were estimated by using the CAD prognostic index, and CFR was quantified by using positron emission tomography. RESULTS Although women in comparison with men had lower pretest clinical scores, rates of prior myocardial infarction, and burden of angiographic CAD (P<0.001), they demonstrated greater risk of CVD events, even after adjustment for traditional risk factors, imaging findings, and early revascularization (adjusted hazard ratio, 2.05; 95% confidence interval, 1.05-4.02; P=0.03). Impaired CFR was similarly present among women and men, but in patients with low CFR (<1.6, n=163), women showed a higher frequency of nonobstructive CAD, whereas men showed a higher frequency of severely obstructive CAD (P=0.002). After also adjusting for CFR, the effect of sex on outcomes was no longer significant. When stratified by sex and CFR, only women with severely impaired CFR demonstrated significantly increased adjusted risk of CVD events (P<0.0001, P for interaction=0.04). CONCLUSIONS Women referred for coronary angiography had a significantly lower burden of obstructive CAD in comparison with men but were not protected from CVD events. Excess cardiovascular risk in women was independently associated with impaired CFR, representing a hidden biological risk, and a phenotype less amenable to revascularization. Impaired CFR, particularly absent severely obstructive CAD, may represent a novel target for CVD risk reduction.
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Affiliation(s)
- Viviany R Taqueti
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.).
| | - Leslee J Shaw
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Nancy R Cook
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Venkatesh L Murthy
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Nishant R Shah
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Courtney R Foster
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Jon Hainer
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Ron Blankstein
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Sharmila Dorbala
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Marcelo F Di Carli
- From Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., N.R.S., C.R.F., J.H., R.B., S.D., M.F.D.C.); Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (L.J.S.); Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, MA (N.R.C.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
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Zsilinszka R, Shrader P, DeVore AD, Hardy NC, Mentz RJ, Pang PS, Peacock WF, Fonarow GC, Hernandez AF. Sex Differences in the Management and Outcomes of Heart Failure With Preserved Ejection Fraction in Patients Presenting to the Emergency Department With Acute Heart Failure. J Card Fail 2015; 22:781-8. [PMID: 26687985 DOI: 10.1016/j.cardfail.2015.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/30/2015] [Accepted: 12/04/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction (HFpEF) is more common in women than in men; data characterizing sex differences in the management and outcomes of HFpEF patients presenting to the emergency department (ED) are limited. METHODS AND RESULTS Using Acute Decompensated Heart Failure National Registry Emergency Module data linked to Medicare claims, we conducted a retrospective analysis of acute HF patients in the ED, identifying HFpEF (ejection fraction [EF] ≥40%) patients and stratifying by sex to compare baseline characteristics, ED therapies, hospital length of stay (LOS), in-hospital mortality, and post-discharge outcomes. Of 4161 HFpEF patients, 2808 (67%) were women, who were more likely to be older and hypertensive, but less likely to be diabetic or smokers (all P < .01). Women more often presented with systolic blood pressure >140 mm Hg (62.5% vs 56.4%; P = .0001) and higher EF. There were no sex differences in ED therapies, adjusted 30- and 180-day all-cause mortality, in-hospital mortality, or 30- and 180-day readmissions. After adjustment, women had longer LOS (0.40 days, 95% confidence interval [CI] 0.10-0.70; P = .008). CONCLUSIONS Women with HFpEF presenting to the ED were more likely to have elevated systolic blood pressure, but overall ED management strategies were similar to those in men. We observed adjusted differences in hospital LOS, but no differences in 30- and 180-day outcomes.
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Affiliation(s)
| | - Peter Shrader
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina; Department of Emergency Medicine and the Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Peter S Pang
- Department of Emergency Medicine and the Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina.
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