Prevalence of Angina in Women Versus Men

Exploring Functional Improvements by Sex in Six-Minute Walk Test, Exertional Angina, and Dyspnea After Enhanced External Counterpulsation Therapy

PURPOSE

The objective of this study was to explore functional improvements by sex for patients with refractory angina pectoris using a 6-min walk test (6MWT) after enhanced external counterpulsation (EECP) therapy.

METHODS

All patients who completed EECP from 2015 to 2023 were identified for analysis retrospectively, utilizing the electronic medical record. Patients completed 35 1-hr EECP sessions 5 d/wk over 7 wk. All baseline and post-EECP intervention 6MWT, exertional angina, and dyspnea measurements were assessed on the first and last sessions, respectively. Paired and unpaired t tests and linear and stepwise multivariable regression analyses were performed.

RESULTS

The cohort consisted of 116 patients (24 female) with a mean age of 69 ± 13 yr. After EECP, there was a mean improvement of 128 m (72%) in distance walked during the 6MWT ( P < .001) with 126 ± 91 m improvement in males and 134 ± 73 m in females. The improvement in angina and dyspnea scores was 3.5 ± 2.1 and 4.2 ± 2.4, respectively. There were no differences between the sexes for improvements in 6MWT distance, angina, or dyspnea. Univariate associations for change in 6MWT distance included body mass index (BMI; adjusted R2  = .05) and being a nonsmoker (adjusted R2  = .03). The only independent predictor for increasing distance during 6MWT was BMI (adjusted R2  = .1; P = .001).

CONCLUSION

Patients who have refractory angina pectoris can improve their functional capacity while simultaneously decreasing exertional angina and dyspnea using EECP. This study highlights the equal efficacy of EECP therapy for females.

Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome

PURPOSE OF REVIEW

This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences.

RECENT FINDINGS

The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.

Effects of major air pollutants on angina hospitalizations: a correlation study

BACKGROUND

Angina is a crucial risk signal for cardiovascular disease. However, few studies have evaluated the effects of ambient air pollution exposure on angina.

OBJECTIVE

We aimed to explore the short-term effects of air pollution on hospitalization for angina and its lag effects.

METHODS

We collected data on air pollutant concentrations and angina hospitalizations from 2013 to 2020. Distributed lag nonlinear model (DLNM) was used to evaluate the short-term effects of air pollutants on angina hospitalization under different lag structures. Stratified analysis by sex, age and season was obtained.

RESULTS

A total of 39,110 cases of angina hospitalization were included in the study. The results showed a significant positive correlation between PM2.5, SO2, NO2, and CO and angina hospitalization. Their maximum harmful effects were observed at lag0-7 (RR = 1.042; 95% CI: 1.017, 1.068), lag0-3 (RR = 1.067; 95% CI: 1.005, 1.133), lag0-6 (RR = 1.078; 95% CI: 1.041, 1.117), and lag0-6 (RR = 1.244; 95% CI: 1.109, 1.397), respectively. PM10 did not have an overall risk effect on angina hospitalization, but it did have a risk effect on women and the elderly. O3 was significantly negatively correlated with angina hospitalization, with the most pronounced effect observed at lag0-6 (RR = 0.960; 95% CI: 0.940, 0.982). Stratified analysis results showed that women and the elderly were more susceptible to pollutants, and the adverse effects of pollutants were stronger in the cold season.

CONCLUSION

Short-term exposure to PM2.5, SO2, NO2, and CO increases the risk of hospitalization for angina.

Health outcomes and healthcare utilization associated with four undiagnosed chronic conditions: evidence from nationally representative survey data in Sri Lanka

Background

Low awareness of chronic conditions raises the risk of poorer health outcomes and may result in healthcare utilization and spending in response to symptoms of undiagnosed conditions. Little evidence exists, particularly from lower-middle-income countries, on the health and healthcare use of undiagnosed people with an indication of a condition. This study aimed to compare health (physical, mental, and health-related quality of life (HRQoL)) and healthcare (inpatient and outpatient visits and out-of-pocket (OOP) medical spending) outcomes of undiagnosed Sri Lankans with an indication of coronary heart disease (CHD), hypertension, diabetes, and depression with the outcomes of their compatriots who were diagnosed or had no indication of these conditions.

Methods

This study used a nationally representative survey of Sri Lankan adults to identify people with an indication of CHD, hypertension, diabetes, or depression, and ascertain if they were diagnosed. Outcomes were self-reported measures of physical and mental functioning (12-Item Short Form Survey (SF-12)), HRQoL (EQ-5D-5L), inpatient and outpatient visits, and OOP spending. For each condition, we estimated the mean of each outcome for respondents with (a) no indication, (b) an indication without diagnosis, and (c) a diagnosis. We adjusted the group differences in these means for socio-demographic covariates using ordinary least squares (OLS) regression for physical and mental function, Tobit regression for HRQoL, and a generalized linear model (GLM) for healthcare visits and OOP spending.

Results

An indication of each of CHD and depression, which are typically symptomatic, was associated with a lower adjusted mean of physical (CHD -2.65, 95% CI -3.66, -1.63; depression -5.78, 95% CI -6.91, -4.64) and mental functioning (CHD -2.25, 95% CI -3.38, -1.12; depression -6.70, 95% CI -7.97, -5.43) and, for CHD, more annual outpatient visits (2.13, 95% CI 0.81, 3.44) compared with no indication of the respective condition. There were no such differences for indications of hypertension and diabetes, which are often asymptomatic.

Conclusions

Living with undiagnosed CHD and depression was associated with worse health and, for CHD, greater utilization of healthcare. Diagnosis and management of these symptomatic conditions can potentially improve health partly through substitution of effective healthcare for that which primarily responds to symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00075-0.

The Prevalence and Epidemiological Features of Ischaemic Heart Disease in Sri Lanka

Background

There is limited evidence on the prevalence of ischaemic heart disease (IHD) and its association with risk factors and socioeconomic status (SES) in low- and middle-income countries (LMICs). Given the relatively high levels of access to healthcare in Sri Lanka, the association of IHD with SES may be different from that observed in other LMICs.

Objectives

To estimate the prevalence of IHD in Sri Lanka, determine its associated risk factors and its association with SES.

Methods

We analysed data from 6,513 adults aged ≥18 years examined in the 2018/19 Sri Lanka Health and Ageing Study. We used the Rose angina questionnaire to classify participants as having angina (Angina+) and used self-report or medical records to identify participants with a history of IHD (History+). The association of Angina+ and History+ with age, ethnicity, sector of residence, education level, household SES wealth quintile, area SES wealth quintile, hypertension, diabetes, smoking, total cholesterol, cholesterol-to-HDL ratio, waist-to-hip ratio and body mass index were analysed in unadjusted and adjusted models. Additional analyses were performed to investigate sensitivity to correction for missing data and to benchmark estimates against evidence from other studies.

Conclusions

We estimated prevalence of History+ of 3.9% (95% CI 3.3%-4.4%) and Angina+ of 3.0% (95% CI 2.4%-3.5%) in adults aged 18 years and over. The prevalence of Angina+ was higher in women than men (3.9% vs. 1.9%, p < 0.001) whilst prevalence of History+ was lower (3.8% vs. 4.0%, p = 0.8), which may suggest a higher rate of undiagnosed IHD in women. A history of IHD was strongly associated with age, hypertension and diabetes status even after adjusting for sociodemographic factors. Though the prevalence of History+ was higher in the most developed area SES tertile and urban areas, History+ was also associated with less education but not household SES, consistent with patterns emerging from other LMICs.

Exploring the retrospective and prospective associations between the big five personality traits and clinical diagnosis of angina in middle-aged and older adults

OBJECTIVE

The goal of the present research was to test the retrospective and prospective associations between the Big Five personality traits and clinical diagnosis of angina while controlling for demographic characteristics.

METHODS

Data from middle-aged and older adults from a cohort study Understanding Society: the UK Household Longitudinal Study (UKHLS) were extracted and analyzed using binary logistic regressions (N = 10,124 for the retrospective study and N = 5485 for the prospective study). Personality was measured using a self-report 15-item version of the Big Five inventory between 2011 and 2012. Angina was measured by a self-report clinical diagnosis history question in each wave from until 2019. Covariates in our models included age, sex, income (monthly), education, and marital status.

RESULTS

Neuroticism was positively related to the likelihood of clinical angina diagnosis in both the retrospective (OR = 1.22, 95% C.I. [1.11, 1.34]) and the prospective (OR = 1.52, 95% C.I. [1.19, 1.94]) study whereas Extraversion had a positive association with odds of angina (OR = 1.52, 95% C.I. [1.17, 1.97]) in the prospective study only. The negative association between Openness and clinical angina diagnosis in the cross-sectional analysis is borderline significant (OR = 0.91, p = 0.048, 95% C.I. [0.83, 1.00]).

CONCLUSION

Our research indicated that personality traits are associated with the risk of angina. These findings emphasize the importance of considering personality traits in understanding the etiology of angina and potentially informing personalized prevention and intervention strategies.

Ischemic Heart Disease in Women

This review synthesizes the current understanding of ischemic heart disease in women, briefly discussing differences in risk factors, presentation, and treatment. We have underscored the unique clinical phenotype of IHD in women with a higher prevalence of ischemia with non-obstructive coronary arteries. Further research is needed to elucidate the complexities of ischemic heart disease in women, understand the discordance between ischemic burden and clinical symptoms, and optimize treatment strategies.

Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries

RATIONALE

Existing literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC) is limited.

AIMS AND OBJECTIVES

Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences.

METHODS

Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status.

RESULTS

We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence.

CONCLUSION

Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

Evaluating the performance of the HEART score in a Tanzanian emergency department

OBJECTIVE

The HEART score successfully risk stratifies emergency department (ED) patients with chest pain in high-income settings. However, this tool has not been validated in low-income countries.

METHODS

This is a secondary analysis of a prospective observational study that was conducted in a Tanzanian ED from January 2019 through January 2023. Adult patients with chest pain were consecutively enrolled, and their presenting symptoms and medical history were recorded. Electrocardiograms and point-of-care troponin assays were obtained for all participants. Thirty-day follow-up was conducted, assessing for major adverse cardiac events (MACEs), defined as death, myocardial infarction, or coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention). HEART scores were calculated for all participants. Likelihood ratios, sensitivity, specificity, and negative predictive values (NPVs) were calculated for each HEART cutoff score to predict 30-day MACEs, and area under the curve (AUC) was calculated from the receiver operating characteristic curve.

RESULTS

Of 927 participants with chest pain, the median (IQR) age was 61 (45.5-74.0) years. Of participants, 216 (23.3%) patients experienced 30-day MACEs, including 163 (17.6%) who died, 48 (5.2%) with myocardial infarction, and 23 (2.5%) with coronary revascularization. The positive likelihood ratio for each cutoff score ranged from 1.023 (95% CI 1.004-1.042; cutoff ≥ 1) to 3.556 (95% CI 1.929-6.555; cutoff ≥ 7). The recommended cutoff of ≥4 to identify patients at high risk of MACEs yielded a sensitivity of 59.4%, specificity of 52.8%, and NPV of 74.7%. The AUC was 0.61.

CONCLUSIONS

Among patients with chest pain in a Tanzanian ED, the HEART score did not perform as well as in high-income settings. Locally validated risk stratification tools are needed for ED patients with chest pain in low-income countries.

Prevalence of angina pectoris and association with coronary atherosclerosis in a general population

OBJECTIVE

To assess the contemporary prevalence of, and factors associated with angina pectoris symptoms, and to examine the relationship to coronary atherosclerosis in a middle-aged, general population.

METHODS

Data were based on the Swedish CArdioPulmonary bioImage Study (SCAPIS), in which 30 154 individuals were randomly recruited from the general population between 2013 and 2018. Participants that completed the Rose Angina Questionnaire were included and categorised as angina or no angina. Subjects with a valid coronary CT angiography (CCTA) were categorised by degree of coronary atherosclerosis; ≥50% obstruction (obstructive coronary atherosclerosis), <50% obstruction or any atheromatosis (non-obstructive coronary atherosclerosis) or none (no coronary atherosclerosis).

RESULTS

The study population consisted of 28 974 questionnaire responders (median age 57.4 years, female 51.6%, hypertension 19.9%, hyperlipidaemia 7.9%, diabetes mellitus 3.7%), of which 1025 (3.5%) fulfilled the criteria of angina. Coronary atherosclerosis was more common in individuals having angina compared with those with no angina (n=24 602, obstructive coronary atherosclerosis 11.8% vs 5.4%, non-obstructive coronary atherosclerosis 38.9% vs 37.0%, no coronary atherosclerosis 49.4% vs 57.7%, all p<0.001). Factors independently associated with angina were birthplace outside of Sweden (OR 2.58 (95% CI 2.10 to 2.92)), low educational level (OR 1.41 (1.10 to 1.79)), unemployment (OR 1.51 (1.27 to 1.81)), poor economic status (OR 1.85 (1.38 to 2.47)), symptoms of depression (OR 1.63 (1.38 to 1.92)) and high degree of stress (OR 2.92 (1.80 to 4.73)).

CONCLUSION

Angina pectoris symptoms are common (3.5%) among middle-aged individuals of the general population of Sweden, though with low association to obstructive coronary atherosclerosis. Sociodemographic and psychological factors are highly associated with angina symptoms, irrespective of degree of coronary atherosclerosis.

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults

BACKGROUND

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP).

METHODS

We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina.

RESULTS

A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts.

CONCLUSIONS

The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

Understanding the effect of angina on general and dimensions of psychological distress: findings from understanding society

Background

The current study aimed to examine how the general and dimensions of psychological distress are affected by angina.

Methods

First, a confirmatory factor analysis (CFA) was used to produce the three-factor solution of the GHQ-12. Second, a predictive normative modeling approach to predict the expected scores for 1,081 people with angina based on a model trained on demographics from 8,821 age and sex-matched people without angina. Finally, one-sample t-tests were used to determine the differences between the actual psychological distress scores and expected psychological distress scores in participants with angina.

Results

There were three underlying structures of the GHQ-12 labeled as GHQ-12A (social dysfunction & anhedonia), GHQ-12B (depression & anxiety), and GHQ-12C (loss of confidence). Moreover, participants with angina had more psychological distress as indicated by the GHQ-12 summary score (Cohen's d = 0.31), GHQ-12A (Cohen's d = 0.34), GHQ-12B (Cohen's d = 0.21), and GHQ-12C (Cohen's d = 0.20) comparing to controls.

Conclusion

The current study implies that GHQ-12 is a valid measure of psychological distress in people with angina, and there is a need to consider the dimensions of psychological distress in angina rather than solely focusing on certain dimensions of psychological distress such as depression or anxiety issues in people with angina. Clinicians should come up with interventions to reduce psychological distress in people with angina which can then lead to better outcomes.

Risk of Cardiovascular Events and Lipid Profile Change in Patients with Breast Cancer Taking Aromatase Inhibitor: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) is one of the most common comorbidities in breast cancer survivors. Recently, the target population and treatment period for aromatase inhibitor (AI) treatment in breast cancer patients has been expanding. However, information on adverse CVD events from the long-term use of AI is still lacking. The aim of this study was to investigate the CVD side effects of AI treatment and to evaluate the changes in lipid profile during AI treatment. A systematic search of PubMed (Medline), EMBASE, and Cochrane Library databases reporting on cardiovascular outcomes or lipid profiles change in adult female breast cancer patients (>19 years old) with AI was performed. The pooled analysis of 25 studies showed that the prevalence rate of any type of cardiovascular disease was 6.08 per 100 persons (95% CI 2.91-10.31). Angina was the most common type of heart-related cardiovascular event accounting for 3.85 per 100 persons, followed by any type of stroke (3.34) and venous thromboembolism (2.95). Ischemic stroke (OR 1.39, 95% CI 1.07-1.81) and myocardial infarction (OR 1.30, 95% CI 0.88-1.93) were more common in AI compared with tamoxifen, whereas the prevalence of venous thromboembolism (OR 0.61, 95% CI 0.37-1) was significantly lower in the AI group. In addition, treatment with AI for 6-12 months showed a decrease in HDL-cholesterol and an increase in LDL-cholesterol and total cholesterol. Various CVDs can occur when using AI, and in particular, the risk of MI and ischemic stroke increases in comparison with the adverse effect of tamoxifen. The occurrence of CVD might be related to the deterioration of the lipid profile after AI treatment. Therefore, a customized individualization strategy considering each patient's CV risk factors is needed during AI treatment.

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States

BACKGROUND

The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States.

METHODS

Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model.

RESULTS

Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003).

CONCLUSIONS

The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

Shexiang Baoxin Pill reduces major adverse cardiovascular events in women with stable coronary artery disease: A subgroup analysis of a phase IV randomized clinical trial

Background

A previous phase IV trial revealed sex as a potential effect modifier of MUSKARDIA efficacy in stable coronary artery disease (CAD).

Objective

To assess the clinical effect of MUSKARDIA as a supplemental treatment to optimal medical therapy (OMT) in stable CAD cases.

Methods

This study was a subgroup analysis of a multicenter, randomized, double-blinded, placebo-controlled phase IV clinical study. Eligible individuals underwent randomization to the oral MUSKARDIA and placebo groups and were treated for 24 months. All participants received OMT according to existing guidelines. The primary composite outcome was the major adverse cardiovascular event (MACE), included cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. The secondary composite outcome encompassed all-cause mortality, non-fatal MI, non-fatal stroke, hospitalization for unstable angina and/or heart failure, and undergoing coronary procedure/surgery during treatment. Safety signals, especially cardiovascular adverse events (AEs), were analyzed.

Results

The female subgroup included 776 participants (384 and 392 in the MUSKARDIA and placebo groups, respectively). The occurrence of the primary composite outcome was lower in the MUSKARDIA group compared with placebo-treated individuals (HR = 0.27, 95%CI: 0.09–0.83; P = 0.02), but the secondary composite outcome showed no significant difference (HR = 0.77, 95%CI: 0.47–1.25; P = 0.29). The MUSKARDIA group had reduced incidence of cardiovascular AEs compared with placebo-treated cases (2.9% vs. 5.6%).

Conclusion

As a supplemental treatment to OMT, 24-month administration of MUSKARDIA is effective and safe in female stable CAD cases.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT01897805].

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women

PURPOSE OF REVIEW

Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.

RECENT FINDINGS

There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

The prevalence and predictors of cardiovascular diseases in Kherameh cohort study: a population-based study on 10,663 people in southern Iran

BACKGROUND

The prevalence of cardiovascular disease (CVD) is rapidly increasing in the world. The present study aimed to assess the prevalence and Predictors factors of CVD based on the data of Kherameh cohort study.

METHODS

The present cross-sectional, analytical study was done based on the data of Kherameh cohort study, as a branch of the Prospective Epidemiological Studies in Iran (PERSIAN). The participants consisted of 10,663 people aged 40-70 years. CVD was defined as suffering from ischemic heart diseases including heart failure, angina, and myocardial infarction. Logistic regression was used to model and predict the factors related to CVD. Additionally, the age-standardized prevalence rate (ASPR) of CVD was determined using the standard Asian population.

RESULTS

The ASPR of CVD was 10.39% in males (95% CI 10.2-10.6%) and 10.21% in females (95% CI 9.9-10.4%). The prevalence of CVD was higher among the individuals with high blood pressure (58.3%, p < 0.001) as well as among those who smoked (28.3%, p = 0.018), used opium (18.2%, p = 0.039), had high triglyceride levels (31.6%, p = 0.011), were overweight and obese (66.2%, p < 0.001), were unmarried (83.9%, p < 0.001), were illiterate (64.2%, p < 0.001), were unemployed (60.9%, p < 0.001), and suffered from diabetes mellitus (28.1%, p < 0.001). The results of multivariable logistic regression analysis showed that the odds of having CVD was 2.25 times higher among the individuals aged 50-60 years compared to those aged 40-50 years, 1.66 folds higher in opium users than in non-opium users, 1.37 times higher in smokers compared to non-smokers, 2.03 folds higher in regular users of sleeping pills than in non-consumers, and 4.02 times higher in hypertensive individuals than in normotensive ones.

CONCLUSION

The prevalence of CVD was found to be relatively higher in Kherameh (southern Iran) compared to other places. Moreover, old age, obesity, taking sleeping pills, hypertension, drug use, and chronic obstructive pulmonary disease had the highest odds ratios of CVD.

Reproducible disease phenotyping at scale: Example of coronary artery disease in UK Biobank

IMPORTANCE

A lack of internationally agreed standards for combining available data sources at scale risks inconsistent disease phenotyping limiting research reproducibility.

OBJECTIVE

To develop and then evaluate if a rules-based algorithm can identify coronary artery disease (CAD) sub-phenotypes using electronic health records (EHR) and questionnaire data from UK Biobank (UKB).

DESIGN

Case-control and cohort study.

SETTING

Prospective cohort study of 502K individuals aged 40-69 years recruited between 2006-2010 into the UK Biobank with linked hospitalization and mortality data and genotyping.

PARTICIPANTS

We included all individuals for phenotyping into 6 predefined CAD phenotypes using hospital admission and procedure codes, mortality records and baseline survey data. Of these, 408,470 unrelated individuals of European descent had a polygenic risk score (PRS) for CAD estimated.

EXPOSURE

CAD Phenotypes.

MAIN OUTCOMES AND MEASURES

Association with baseline risk factors, mortality (n = 14,419 over 7.8 years median f/u), and a PRS for CAD.

RESULTS

The algorithm classified individuals with CAD into prevalent MI (n = 4,900); incident MI (n = 4,621), prevalent CAD without MI (n = 10,910), incident CAD without MI (n = 8,668), prevalent self-reported MI (n = 2,754); prevalent self-reported CAD without MI (n = 5,623), yielding 37,476 individuals with any type of CAD. Risk factors were similar across the six CAD phenotypes, except for fewer men in the self-reported CAD without MI group (46.7% v 70.1% for the overall group). In age- and sex- adjusted survival analyses, mortality was highest following incident MI (HR 6.66, 95% CI 6.07-7.31) and lowest for prevalent self-reported CAD without MI at baseline (HR 1.31, 95% CI 1.15-1.50) compared to disease-free controls. There were similar graded associations across the six phenotypes per SD increase in PRS, with the strongest association for prevalent MI (OR 1.50, 95% CI 1.46-1.55) and the weakest for prevalent self-reported CAD without MI (OR 1.08, 95% CI 1.05-1.12). The algorithm is available in the open phenotype HDR UK phenotype library (https://portal.caliberresearch.org/).

CONCLUSIONS

An algorithmic, EHR-based approach distinguished six phenotypes of CAD with distinct survival and PRS associations, supporting adoption of open approaches to help standardize CAD phenotyping and its wider potential value for reproducible research in other conditions.

Cardiac CT angiography in current practice: An American society for preventive cardiology clinical practice statement✰

In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention - applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.

Construction of a femininity score in the UK Biobank and its association with angina diagnosis prior to myocardial infarction

Gender captures social components beyond biological sex and can add valuable insight to health studies in populations. However, assessment of gender typically relies on questionnaires which may not be available. The aim of this study is to construct a gender metric using available variables in the UK Biobank and to apply it to the study of angina diagnosis. Proxy variables for femininity characteristics were identified in the UK Biobank and regressed on sex to construct a composite femininity score (FS) validated using tenfold cross-validation. The FS was assessed as a predictor of angina diagnosis before incident myocardial infarction (MI) events. The FS was derived for 315,937 UK Biobank participants. In 3059 individuals with no history of MI at study entry who had an incident MI event, the FS was a significant predictor of angina diagnosis prior to MI (OR 1.24, 95% CI 1.10-1.39, P < 0.001) with a significant sex-by-FS interaction effect (P = 0.003). The FS was positively associated with angina diagnosis prior to MI in men (OR 1.37, 95% CI 1.19-1.57, P < 0.001), but not in women. We have provided a new tool to conduct gender-sensitive analyses in observational studies, and applied it to study of angina diagnosis prior to MI.

Gender differences in prevalence of myocardial infarction in rural West Texans

Background

Heart disease is the leading cause of death in the United States. Incidence rates of myocardial infarction (MI) in rural West Texas signify a lack of effective, risk-specific prevention programs. The purpose of this study was to identify gender-specific risk factors for MI in rural West Texans.

Subjects and methods

Hospital patient data for those with and without a history of MI were obtained from the Project FRONTIER database for rural West Texas counties. We used statistical software, such as SPSS, R, and WinBUGS to detect and understand the nature of MI risk factors. Statistical methods including t-tests, Chi-squared, logistic regression, and a Bayesian approach were utilized to analyze data.

Results

MI significant risk factors obtained for females were systolic blood pressure (p = 0.002), diastolic blood pressure (p = 0.004), pulse (p = 0.015), and smoking (p = 0.002). For males, these were glucose (p = 0.022), age (p = 0.050), body fat (p = 0.034), and smoking (p = 0.017). The mean risk parameter followed a normal distribution, while the precision parameter depicted skew for both sexes.

Conclusions

Gender-specific differences in MI risk factors exist, and incorporating such variables can guide relevant policymaking to reduce MI incidence in rural West Texans.

Underrepresentation of women in cardiac imaging trials: A review

Inclusion and equal representation of women in cardiovascular imaging trials are essential to provide insight into the factors impacting women's heart health and outcomes. Despite heart disease being the leading cause of mortality for women in the United States, women have been underrepresented in cardiovascular clinical trials, including imaging trials. Research demonstrates that women have key sex-specific differences in the pathophysiology of cardiovascular disease, the evolution of disease state, and disease manifestation (Solimene, 2010; Nevsky et al., 2011 [1,2]). This understanding and acknowledgment come decades after clinical providers have extrapolated data from cardiovascular disease clinical trials conducted primarily on Caucasian men, assuming the data were generalizable to sex, race, and ethnicity. The current cardiology society guidelines, which recommend optimal medical therapies for various cardiovascular diseases, are based on trials predominantly focused on men rather than women. Sex-based research, governmental and institutional task forces, and policies on gender equity have made inroads into the disproportionate number of women's enrollment in clinical research. The National Institutes of Health in the 1990s set forth requirements on incorporating women and minorities in research, including clinical trials (Mastroianni et al., 1994; Mieres et al., 2014 [3,4]). Continued progress is imperative to improve the gap in the number of women enrolled in clinical research trials.

Prevalence of Angina Pectoris and Associated Factors in the Adult Population of Brazil: National Survey of Health, 2019

OBJECTIVE

to estimate the prevalence and factors associated with angina pectoris in the Brazilian adult population and per federated units.

METHODS

Cross-sectional descriptive study that analyzed data from the National Survey of Health 2019 and assessed the prevalence of angina in the Brazilian population. Angina was defined as chest pain or discomfort when climbing hills or stairs, or when walking fast on flat terrain (angina I) or when walking at normal speed on flat terrain (angina II). Prevalence, crude and adjusted prevalence ratios were calculated, with a 95% confidence interval, according to sociodemographic characteristics (sex, age group, self-reported race/skin color and region of residence) and federative units.

RESULTS

The prevalence of mild angina (grade I) was 8.1% and of moderate/severe angina (grade II) was 4.5%, being both more prevalent in women (9.8 and 5.5%, respectively). The prevalence increased progressively with age and was inversely proportional to years of formal study. Grade I angina was higher in individuals self-reportedly black and residents of Sergipe (10,4%). Angina II was more prevalent in people self-reportedly brown and living in Amazonas (6.3%).

CONCLUSION

Angina affects more than 10% of the Brazilian population aged 18 years old and more, with higher prevalence in states in the North and Northeast. This is a problem that affects the most vulnerable populations unequally, which places coronary heart disease as a public health problem and points to the need to think about public policies aimed at these strata of the population.

Disparities in Reporting a History of Cardiovascular Disease Among Adults With Limited English Proficiency and Angina

IMPORTANCE

Individuals with limited English proficiency (LEP) may be unaware of underlying cardiovascular disease (CVD) owing to a lack of diagnostic testing or poor communication with health care practitioners.

OBJECTIVE

To evaluate whether participants with anginal symptoms and LEP would be less likely to report a history of CVD compared with those without LEP.

DESIGN, STUDY, AND PARTICIPANTS

This population-based cross-sectional study combined data from 5 National Health and Nutrition Examination Survey (NHANES) cycles conducted from 2007 to 2016. Each cycle includes an interview that collects demographic, dietary, and health-related data as well as a medical examination component in which physiological measurements are taken. All NHANES participants aged 40 years or older who took the Rose questionnaire were included. Data were analyzed from September 2020 to April 2021.

EXPOSURES

LEP was defined as a participant receiving the survey in a non-English language or by interpreter.

MAIN OUTCOMES AND MEASURES

The 7-item Rose questionnaire assessed the presence of anginal symptoms. Self-reported CVD was defined as history of heart failure, coronary heart disease, angina pectoris, or myocardial infarction. The association between LEP status and self-reported CVD among those with anginal symptoms was determined in multivariable-adjusted models. All analyses were weighted per NHANES analytic protocols.

RESULTS

Among 19 320 participants (mean [SD] age, 57.8 [11.8] years; 9344 [47.2%] male; 4145 [10.6%] Black; 2743 [6.3%] Mexican American; 2111 [4.6%] other Hispanic; 8386 [71.6%] White; and 1935 [6.9%] other race), 583 (3.0%) reported anginal symptoms. Of these, most were non-LEP (484 [96.1%]), women (344 [62.1%]), White (251 [66.8%]), and did not report having CVD (347 [62.8%]). Among those with angina, 73 of 99 respondents with LEP (79.0%) reported not having a history of CVD, compared with 274 of 484 without LEP (61.4%; P = .002). Participants with LEP had 2.8-fold higher odds of not reporting a history of CVD compared with participants without LEP (odds ratio, 2.77; 95% CI, 1.38-5.55; P = .005).

CONCLUSIONS AND RELEVANCE

Among NHANES participants reporting anginal symptoms, participants with LEP were more likely not to report having CVD. This discrepancy may be because of higher rates of undiagnosed CVD or lower awareness of such diagnoses among individuals with LEP. Our findings highlight the relevance of communication strategies for individuals with LEP to provide effective intervention and treatment for CVD prevention.

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

OBJECTIVES

Gender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03-6.03 years).

RESULTS

There were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.

CONCLUSIONS

Females were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Health-related quality of life in men and women who experienced cardiovascular diseases: Tehran Lipid and Glucose Study

Background

Cardiovascular diseases (CVDs) are among the most common causes of death worldwide, including in Iran. Considering the adverse effects of CVDs on physical and psychosocial health; this study aims to investigate the association between experience of CVDs and health-related quality of life (HRQoL) in adult participants of the Tehran Lipid and Glucose Study (TLGS).

Methods

The participants of this cross-sectional study were 7009 adults (≥ 20 years) who participated in the TLGS during 2014–2017. Demographic information and HRQoL data was collected through validated questionnaires by trained interviewers. HRQoL was assessed by the Iranian version of the SF-12 questionnaire. Data was analyzed using the SPSS software.

Results

The mean age of participants was 46.8 ± 14.6 years and 46.1% of them were men. A total of 9.0% of men and 4.4% of women had CVDs. In men, the mean physical HRQoL summary score was significantly lower in those with CVDs compared to those without CVDs (46.6 ± 0.8 vs. 48.5 ± 0.7, p > 0.001). In women, the mean mental HRQoL summary scores was significantly lower in those with CVDs compared to those without CVDs (42.8 ± 1.0 vs. 45.2 ± 0.5, p = 0.009). In adjusted models, men with CVDs were more likely to report poor physical HRQoL compared to men without CVDs (OR(95%CI): 1.93(1.32–2.84), p = 0.001); whereas for women, the chance of reporting poor mental HRQoL was 68% higher in those with CVDs than those without CVDs (OR(95%CI): 1.68(1.11–2.54), p = 0.015).

Conclusion

The findings of the current study indicate poorer HRQoL in those who experienced CVDs compared to their healthy counterparts with a sex specific pattern. While for men, CVDs were associated with more significant impairment in the physical dimension of HRQoL, women experienced a similar impairment in the mental dimension of HRQoL.

Medical management of anginal symptoms in women with stable angina pectoris: A systematic review of randomised controlled trials

BACKGROUND

Medical therapies are used to improve stable anginal symptoms and quality of life in clinical practice however the evidence for the use of antianginal medication in women is largely unknown. We conducted a systematic review to investigate the extent of the evidence-base for the medical management of anginal symptoms in women with stable angina.

METHODS

MEDLINE, EMBASE, Cochrane and ClinicalTrials.gov databases were searched to the end of December 2019. Retrieved papers were hand searched. Included were randomised controlled trials with at least one week of follow-up that included women with stable angina pectoris, with or without significant coronary atherosclerosis, randomised to conventional antianginal medication or/and a comparator, with a primary or secondary endpoint of angina frequency or glyceryl trinitrate (GTN) consumption.

RESULTS

A total of 397 eligible publications were included in a qualitative analysis, with women comprising up to 20-30% of the study populations. No publication that included women and men reported all data separately for each sex. Twenty-six publications reported any female data separately from male data but only 18 reported angina data for women, 12 of which included fewer than 10 women.

CONCLUSIONS

Substantially fewer women than men were included in randomised trials of antianginal medications reporting effects on anginal symptoms, and reporting of data by sex was infrequent. As a result, there is little evidence on which to base treatment recommendations for anginal symptoms in women. Our results provide a platform for future studies to fill this void in the evidence.

Angina relates to coronary flow in women with ischemia and no obstructive coronary artery disease

BACKGROUND

Women with suspected ischemia and no obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD) as measured by impaired coronary flow reserve (CFR), which is associated with angina and adverse cardiovascular events. CFR is a ratio of hyperemic to baseline average peak velocity (bAPV), and the relation of baseline flow to angina is not understood.

METHODS

We evaluated 259 women enrolled in the WISE-Coronary Vascular Dysfunction (WISE-CVD) project with suspected CMD who underwent invasive coronary functional testing. We analyzed variables stratified by high (e.g. ≥22 cm/s) vs low (<22 cm/s) bAPV, using t-test or Wilcoxon rank; linear and multivariable regression was used with bAPV as a continuous variable.

RESULTS

Women with high bAPV had worse Seattle Angina Questionnaire (SAQ) angina frequency (58 ± 26 vs 67 ± 25, p = 0.005) and SAQ-7 scores (57 ± 22 vs 62 ± 21, p = 0.03), with higher nitrate (p = 0.02) and ranolazine use (p = 0.03). The high bAPV subgroup also had lower CFR (p < 0.001)). Linear regression related higher bAPV with lower SAQ-7 (p = 0.01) and lower angina frequency scores (p = 0.001). These results remained significant in multivariable modelling adjusting for baseline differences (p < 0.04). SAQ-7 was significantly predicted by bAPV.

CONCLUSIONS

Among women with suspected INOCA, angina relates to high bAPV, a result supported by the concomitant greater use of anti-anginal drugs. These results suggest that high bAPV contributes to impaired CFR and may represent a specific pathophysiologic contributor to CMD and may be a treatment target in INOCA subjects.

Prevalence of Angina Among Primary Care Patients With Coronary Artery Disease

IMPORTANCE

Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined.

OBJECTIVE

To ascertain the angina prevalence and frequency among stable outpatients with CAD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire-7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019.

EXPOSURE

SAQ-7 administration.

MAIN OUTCOMES AND MEASURES

Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression.

RESULTS

Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina.

CONCLUSIONS AND RELEVANCE

Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

Diagnosis and Management of Stable Angina: A Review

IMPORTANCE

Nearly 10 million US adults experience stable angina, which occurs when myocardial oxygen supply does not meet demand, resulting in myocardial ischemia. Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death. Diagnostic tests and medical therapies for stable angina have evolved over the last decade with a better understanding of the optimal use of coronary revascularization.

OBSERVATIONS

Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina due to higher sensitivity and comparable specificity compared with imaging-based stress testing. Moreover, coronary computed tomographic angiography allows detection of nonobstructive atherosclerosis that would not be identified with other noninvasive imaging modalities, improving risk assessment and potentially triggering more appropriate allocation of preventive therapies. Novel therapies treating lipids (proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl) and type 2 diabetes (sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists) have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care. Randomized clinical trials showed no improvement in the rates of mortality or myocardial infarction with revascularization (largely by percutaneous coronary intervention) compared with optimal medical therapy alone, even in the setting of moderate to severe ischemia. In contrast, revascularization provides a meaningful benefit on angina and quality of life compared with antianginal therapies. Measures of the effect of angina on a patient's quality of life should be integrated into the clinic encounter to assist with the decision to proceed with revascularization.

CONCLUSIONS AND RELEVANCE

For patients with stable angina, emphasis should be placed on optimizing lifestyle factors and preventive medications such as lipid-lowering and antiplatelet agents to reduce the risk for cardiovascular events and death. Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms. Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy. Shared decision-making with an informed patient is important for effective treatment of stable angina.

The Role of Aortic Stiffness Parameters in Evaluating Myocardial Ischemia

BACKGROUND

Arterial stiffness is a process resulting in deterioration of hemodynamic function of the aorta, a decrease in its compliance and elasticity, caused by the proportional change of components of the extracellular matrix. Although many researches have been done to determine the etiologies of myocardial ischemia in the absence of obstructive coronary artery disease, none of them has investigated the relation between the parameters of aortic stiffness and the myocardial ischemia documented by the exercise stress test. The present cross-sectional study aimed to investigate the difference of aortic stiffness parameters between the groups separated by exercise stress test result as positive and negative ischemic findings in the absence of obstructive coronary artery disease.

METHODS

The present study included 79 patients who were admitted to Istanbul Faculty of Medicine, Department of Cardiology with complaint of chest pain. Forty patients (21 women and 19 men) have ischemic findings on the exercise electrocardiography (ECG) test and 39 patients (20 women and 19 men) have normal exercise ECG results. The patients who have positive exercise ECG findings underwent coronary angiography and all the patients had non-obstructive coronary artery disease. Demographic features (age, sex and comorbidities) were statistically similar between the groups. Aortic stiffness measurements (pulse wave velocity, pulse pressure, aortic augmented pressure, augmentation index, systolic pressure-time index, diastolic pressure-time index and subendocardial viability ratio) were done with tonometric methods.

RESULTS

There was no significant difference between the two groups in terms of the aortic stiffness parameters. Systolic blood pressure (P = 0.33), diastolic blood pressure (P = 0.24), pulse pressure (P = 0.60), systolic pressure-time index (P = 0.10), diastolic pressure-time index (P = 0.91), subendocardial viability ratio (P = 0.19), aortic augmented pressure (P = 0.87), augmentation index (P = 0.58) and pulse wave velocity (P = 0.56) were detected between the two groups. Biochemical parameters were found similar between the two groups. Only low-density lipoprotein levels were slightly higher in patients with negative exercise stress test result (139 vs. 123 mg/dL, P = 0.02).

CONCLUSION

There is no finding supporting that the aortic stiffness identifies the patients with non-obstructive coronary artery disease but with signs of myocardial ischemia and further investigation of other causes of myocardial ischemia is required.

Change in prevalence of Coronary Heart Disease and its risk between 1991-94 to 2010-12 among rural and urban population of National Capital Region, Delhi

OBJECTIVES

We aimed to measure the change in prevalence of Coronary Heart Disease (CHD) and Cardiovascular Diseases (CVDs) risk among those aged 35-64 years in urban and rural areas of National Capital Region (NCR) of Delhi, between 1991-1994 (survey 1) and 2010-2012 (survey 2).

METHODS

Both surveys used similar sampling methodology and mean ages of participants were similar. A total of 3048 and 2052 subjects were studied in urban Delhi and 2487 and 1917 participants recruited from rural Ballabgarh in survey 1 and in survey 2 respectively. CHD was diagnosed based on a Minnesota coded ECG and Rose angina questionnaire. Data on behavioural, physical, clinical and biochemical parameters were collected using standard methods. CVD Risk of participants was calculated using the gender specific Framingham risk equation.

RESULTS

The age and sex standardised prevalence of CHD in urban Delhi increased from 10.3% (95% CI: 9.2-11.4) to 14.1% (95% CI: 12.6-15.6) between the two surveys as compared to an increase from 6.0% (95% CI: 5.0-6.9) to 7.4% (95% CI: 6.3-8.6) in rural Ballabgarh. The highest increase in the prevalence of CHD was reported among urban women (10.1% to 16.6%).The proportion of population with high 10-year CVD risk increased to 4.1% from 1.2% in rural areas as compared to 4.8% from 2.5% in urban areas.

CONCLUSIONS

The CHD and CVD risk has increased over 20 years period in and around Delhi and the increase was more in rural population and women, traditionally considered to be at low risk.

Gender Differences in Patients Admitted to a Certified German Chest Pain Unit: Results from the German Chest Pain Unit Registry

INTRODUCTION

Gender-specific atypical clinical presentation in acute coronary syndrome and sex-specific outcomes in cardiovascular disease in women are well known. The aim of this study is to analyze possible differences between men and women presenting to certified German chest pain units (CPUs).

METHODS

Data from 13,900 patients derived from the German CPU registry were analyzed for gender differences in patient characteristics, cardiovascular disease manifestation, critical time intervals, treatment and prognosis.

RESULTS

A total of 37.8% of patients were female. Typical chest pain occurred more frequently in men, while atypical symptoms occurred more frequently in women. Female gender was associated with longer pre- and in-hospital time delays. Women were more often diagnosed with a nonischemic origin of pain. In a 3-month follow-up, there was no gender-specific difference in combined major adverse coronary and cerebrovascular events.

DISCUSSION/CONCLUSION

This study points out gender-specific differences in prehospital time intervals and a significantly higher percentage of atypical symptoms in suspected myocardial ischemia as well as more noncoronary diagnoses in women. Symptom awareness and a broader diagnostic workup in women are essential.

Household Air Pollution and Angina Pectoris in Low- and Middle-Income Countries: Cross-Sectional Evidence from the World Health Survey 2002-2003

The evidence regarding the effects of household air pollution on angina pectoris is limited in low-and middle-income countries (LMICs). We sought to examine the association between household air pollution and angina pectoris across several countries. We analyzed data of individuals from 46 selected countries participating in the cross-sectional World Health Survey (WHS) 2002–2003. Pooled and stratified (sex, continent) logistic regression with sampling weights was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to quantify associations between the use of different household fuels with angina pectoris. In the pooled sample, we observed lower odds of angina pectoris with electricity use (OR: 0.68, 95% CI: 0.56–0.83) compared to those households reporting the use of gas as a household fuel. Increased odds of angina pectoris were observed with the use of agriculture/dung/shrub/other (OR: 1.65, 95% CI: 1.30–2.09), mixed (solid and non-solid fuels) (OR: 1.31, 95% CI: 1.09–1.56), and mixed solid fuel use (OR: 1.59, 95% CI: 1.12–2.25). Higher odds of angina pectoris were observed mainly with solid fuel use. The results highlight the importance of addressing these issues, especially in regions with a high proportion of solid fuel users and increasing levels of cardiovascular disease.

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.

Risk factors differ by first manifestation of cardiovascular disease in type 1 diabetes

AIMS

We compared risk factors for three CVD manifestations and a composite outcome over 25 years' follow-up in the Pittsburgh Epidemiology of Diabetes Complications (EDC) prospective cohort study of childhood-onset (<17 years) type 1 diabetes (n = 658).

METHODS

First CVD manifestations examined were: (1) major atherosclerotic cardiovascular event (MACE, i.e. CVD death, myocardial infarction, stroke), (2) coronary revascularization, (3) soft coronary artery disease (CAD, i.e. ischemia ECG, angina), and a (4) composite (MACE + revascularization) outcome. Baseline and time-varying mean and current risk factors, including medication use, were assessed, in diabetes duration-adjusted models.

RESULTS

MACE (n = 107) was predicted by ln(albumin excretion rate) (AER, HR = 1.3, p < 0.0001), systolic BP (SBP, HR = 1.03, p < 0.0001), white blood cell count (WBC, HR = 1.2, p < 0.0001), HbA1c (HR = 1.2p = 0.03), LDLc (HR = 1.01, p = 0.03). Soft CAD (n = 91) was predicted by ln(AER) (HR = 1.2, p = 0.004), SBP (HR = 1.03, p = 0.0002), WBC (HR = 1.2, p = 0.0003), HbA1c (HR = 1.2, p = 0.005). Revascularization (n = 38) was predicted by LDLc (HR = 1.03, p < 0.0001), eGFR (HR = 0.98, p = 0.002), HbA1c (HR = 1.3, p = 0.03). Adding revascularization to MACE enhanced the role of LDLc, while diminishing that of HbA1c, compared to MACE alone.

CONCLUSIONS

Important risk factor associations may be affected by examining composite CVD outcomes. More research is needed to determine how to best incorporate revascularization into composite CVD definitions.

CT coronary angiography in asymptomatic male patients with high atherosclerosis risk: Is it justified?

PURPOSE

To study the necessity of coronary artery screening with computerized tomography coronary angiography (CTCA) in asymptomatic male patients.

MATERIAL AND METHODS

A total of 226 asymptomatic male patients aged over 50 years were included in this prospective study, according to a clinical protocol approved by the Heraklion University Hospital's Ethics Committee. All participants had at least 3 or more known atherosclerosis risk factors. All patients had none or normal noninvasive cardiological tests in the past and had no contraindications for CTCA. All patients gave their informed consent after being notified regarding contrast medium and radiation dose risks.

RESULTS

Significant stenoses were found in 52 asymptomatic males (23%). Out of them, 38 male patients underwent invasive coronography and 14 patients were lost in follow-up. In 18 patients, no lesions were found (47.4%). In the other 20 (52.6%) patients, 28 lesions were found. Stent placement was performed in 11 patients, bypass surgery was proposed in 3 patients, and in another 6 patients conservative treatment was suggested. Patients with findings in CTCA were more likely to have a family history of coronary artery disease, compared to patients with normal CTCA (P < 0.05 by using Fischer's Exact Test). Sensitivity of CTCA for significant stenosis was 74.3% with a specificity of 62%.

CONCLUSION

CTCA may be used to screen for clinically significant coronary artery disease (CAD) in asymptomatic male patients, particularly those with positive family history or potentially high-risk patients with >3 risk factors for CAD.

Sex associations and computed tomography coronary angiography-guided management in patients with stable chest pain

AIMS

The relative benefits of computed tomography coronary angiography (CTCA)-guided management in women and men with suspected angina due to coronary heart disease (CHD) are uncertain.

METHODS AND RESULTS

In this post hoc analysis of an open-label parallel-group multicentre trial, we recruited 4146 patients referred for assessment of suspected angina from 12 cardiology clinics across the UK. We randomly assigned (1:1) participants to standard care alone or standard care plus CTCA. Fewer women had typical chest pain symptoms (n = 582, 32.0%) when compared with men (n = 880, 37.9%; P < 0.001). Amongst the CTCA-guided group, more women had normal coronary arteries [386 (49.6%) vs. 263 (26.2%)] and less obstructive CHD [105 (11.5%) vs. 347 (29.8%)]. A CTCA-guided strategy resulted in more women than men being reclassified as not having CHD {19.2% vs. 13.1%; absolute risk difference, 5.7 [95% confidence interval (CI): 2.7-8.7, P < 0.001]} or having angina due to CHD [15.0% vs. 9.0%; absolute risk difference, 5.6 (2.3-8.9, P = 0.001)]. After a median of 4.8 years follow-up, CTCA-guided management was associated with similar reductions in the risk of CHD death or non-fatal myocardial infarction in women [hazard ratio (HR) 0.50, 95% CI 0.24-1.04], and men (HR 0.63, 95% CI 0.42-0.95; Pinteraction = 0.572).

CONCLUSION

Following the addition of CTCA, women were more likely to be found to have normal coronary arteries than men. This led to more women being reclassified as not having CHD, resulting in more downstream tests and treatments being cancelled. There were similar prognostic benefits of CTCA for women and men.

Dazhu Hongjingtian Preparation as Adjuvant Therapy for Unstable Angina Pectoris: A Meta-Analysis of Randomized Controlled Trials

Objective: Dazhu hongjingtian [DZHJT, Rhodiola wallichiana var. cholaensis (Praeger) S.H. Fu] preparation as an add-on therapy has been applied to the treatment of angina pectoris. We aimed to evaluate the efficacy and safety of DZHJT as adjuvant therapy for the treatment of unstable angina pectoris (UAP). Methods: An extensive literature search was conducted on PubMed, Emase, Cochrane Library, Wanfang, CNKI, and VIP databases from inception to January 2019. Randomized controlled trials (RCTs) comparing DZHJT in combination with Western medicine with Western medicine alone were included. Two authors independently performed the literature search, data extraction and risk of bias assessment of included studies, and conducted the statistical analysis. Results: A total of 18 RCTs involving 1,679 patients were included in the meta-analysis. Adjuvant treatment with DZHJT significantly decreased ≥80% reduction in the frequency of angina attacks [risk ratio (RR) 1.57; 95% CI 1.36-1.81], weekly frequency of angina attacks [mean difference (MD) -1.03 times; 95% confidence interval (CI) -1.51 to -0.55], marked improved abnormal electrocardiogram (RR 1.46; 95% CI 1.23-1.74). In addition, DZHJT significantly reduced the whole-blood viscosity (MD -0.70 mPa.s; 95% CI -0.84 to -0.55), plasma viscosity (MD -0.28 mPa.s; 95% CI -0.38 to -0.19), serum level of fibrinogen (MD -0.67 g/L; 95% CI -0.79 to -0.54), thromboxanes B2 (MD -14.01 ng/L; 95% CI -20.86 to -7.15), and C-reactive protein (MD -1.48 mg/L; 95% CI -2.72 to -0.25). No significant differences in headache/dizziness (RR 0.72; 95% CI 0.31-1.67) were observed between two groups. Conclusion: Adjuvant treatment with DZHJT has an add-on effect in reducing angina pectoris attacks in patients with UAP. The beneficial effect may be correlated with regulating whole-blood viscosity, plasma viscosity, fibrinogen, thromboxanes B2, and CRP level. However, future well-designed prospective, randomized, double-blind placebo-controlled trials with large sample sizes are required to evaluate the evidence.

Neck Circumference is Associated with Incidence of Angina Pectoris in a Large Community-Based Population

BACKGROUND

Previous studies have found that neck circumference (NC) is associated with cardiovascular disease risk factors. This study investigated the relationship between NC and the incidence of angina pectoris (AP).

METHODS

Altogether 4821 participants (2212 males and 2609 females) from the Sleep Heart Health Study (SHHS) with a mean age of 63.4±11.0 years were selected in this study. Anthropometric measurements, including NC, waist circumference (WC), hip circumference (HC), and body mass index (BMI), were collected at baseline. AP was defined as the first occurrence between baseline and 2011. Linear and logistic regression analysis was used to explore the association between NC and incidences of AP.

RESULTS

There was a significant difference in NC between AP and controls in both male (41.1±3.1 cm vs 40.3±3.2 cm; p<0.001) and female (35.2±3.1 cm vs 34.9±2.9 cm; p=0.006). Multivariable linear regression analysis showed that NC (every cm increase) was independently associated with the incidence of AP in both male (odds ratio [OR] 1.067; 95% confidence interval [CI] 1.035-1.100; p<0.001) and female (OR 1.067; 95% CI 1.035-1.101; p<0.001).

CONCLUSION

NC was significantly associated with the incidence of AP in both male and female. The role of NC in the incidence of AP is worthy of further investigation.

In-stent restenosis of drug-eluting stents: clinical presentation and outcomes in a real-world scenario

BACKGROUND

Drug-eluting stents (DES) have substantially reduced the incidence of coronary in-stent restenosis (ISR), but the problem persists. Clinical presentation and outcomes of DES-ISR in a real-world scenario remains underreported.

RESULTS

In this retrospective study, we examined medical records of 191 consecutive patients with DES-ISR (210 ISR lesions) hospitalized between January 2013 and December 2017. ISR clinical presentation was classified as acute coronary syndrome (ACS) or non-ACS. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI) and repeat-target lesion revascularization] for these two groups were compared. The mean age of study population was 61 ± 10 years and 81.2% were males. ACS was the dominant clinical presentation mode occurring in 118 (61.8%) patients. MI was seen in 66 (34.6%) patients. Female gender (odds ratio, 2.71; 95% confidence interval [CI], 1.13-6.52; P = 0.026) and chronic kidney disease (odds ratio, 3.85; 95% CI, 1.05-14.20; P = 0.043) correlated significantly with ACS ISR presentation. A majority [104 (54.5%)] of patients underwent percutaneous coronary intervention (PCI), of whom 72 (69.2%) received a new DES. The rest either underwent CABG (26.2%) or received medical therapy (19.4%). Patients presenting with ACS had a significantly worse clinical outcome at 1-year follow-up (ACS versus non-ACS presentation: hazard ratio [HR], 2.66; 95% CI, 1.09-6.50; P = 0.032).

CONCLUSIONS

DES-ISR presents most commonly as ACS. Female gender and chronic kidney disease seem to be associated with ACS presentation. ACS presentation of ISR is associated with worse 1-year outcomes. Early identification of those with ACS risk and closer follow-up may improve outcomes.

The association between psychological distress and angina pectoris: A population-based study

BACKGROUND

Psychological distress is an undifferentiated combination of symptoms that may be related to the occurrence of angina pectoris (AP). However, few studies have investigated the relationship between psychological distress and AP, particularly in Asian populations. The purpose of this study was to examine the relationship between psychological distress and AP in Taiwanese adults.

METHODS

We adopted a cross-sectional design to explore the data of the 2005-2008 Nutrition and Health Survey in Taiwan. In total, 2080 subjects (aged ≥ 19 years) responded to questionnaire interviews and underwent physical examinations. Each of the five dimensions of psychological distress (sleep disturbance, anxiety, hostility, depression, and feelings of inferiority) were scored (from 0-20) according to the Five-Item Brief Symptom Rating Scale (BSRS-5). A score ≥ 6 points indicated psychological distress. AP was evaluated using a modified Rose questionnaire.

FINDINGS

In total, 102 subjects (3.6%) had AP, and 231 subjects (8.8%) had symptoms of psychological distress. After adjusting for the basic data, metabolism, and lifestyle covariates, the BSRS-5 total score was associated with AP (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.13-1.26, p < 0.001). Subjects with psychological distress had a higher risk of AP (OR = 2.97, 95% CI = 1.76-4.99, p < 0.001).

CONCLUSIONS

The presence of AP is associated with psychological distress. Health care providers should therefore be aware of the impact of psychological distress on AP. Our study findings can serve as a reference for AP assessments. Large scale longitudinal studies are needed to confirm a causal relationship between psychological distress and AP.

The Gender Perspective Within the OFRECE Study: Differences in Health Care Among Patients Consulting for Chest Pain and/or Palpitations

INTRODUCTION AND OBJECTIVES

To analyze differences between sexes in the clinical management of patients presenting with symptoms of chest pain and/or palpitations within a population-based study.

METHODS

The OFRECE study included a random sample of 8400 individuals from the Spanish population aged 40 years and older; 1132 (13.5%) had previously consulted for chest pain and 1267 (15.1%) had consulted for palpitations and were included in the present study. We calculated both the crude and adjusted odds ratios (OR) of undergoing certain tests and the results of consultations by sex. Adjustment was performed by classic cardiovascular risk factors, a personal history of cardiovascular disease, and a diagnosis of stable angina or atrial fibrillation confirmed in the OFRECE study in each case.

RESULTS

No differences were observed in history of consultation for chest pain between women and men (13% vs 14.1%; P=.159) but differences were found in palpitations (19% vs 10.4%, respectively; P <.001). Women who had previously consulted for chest pain underwent fewer echocardiograms (32.5% vs 45.3%, respectively; P <.001), were less frequently referred to a cardiologist (49.1% vs 60.1%; P <.001), were less often admitted to hospital (20.1% vs 39.4%; P <.001), and less frequently received a confirmed diagnosis (60.9 vs 71, 9; P <.001). After full adjustment, all differences decreased and become nonsignificant echocardiograms: adjusted OR, 0.81; 95%CI, 0.60-1.09; referral to a cardiologist: adjusted OR, 0.86; 95%CI, 0.63-1.16; hospital admission: adjusted OR, 0.76; 95%CI, 0.54-1.09). For palpitations, crude differences were smaller and all became nonsignificant after adjustment.

CONCLUSIONS

This study does not confirm the existence of sex-related bias in the management of chest pain and palpitations. However, such bias cannot be completely ruled out in diagnoses confirmed within the OFRECE study, which might limit its ability to detect sex-related differences in health care.

Discovery of biomarkers for the presence and progression of left ventricular diastolic dysfunction and HEart faiLure with Preserved ejection Fraction in patients at risk for cardiovascular disease: rationale and design of the HELPFul case-cohort study in a Dutch cardiology outpatient clinic

INTRODUCTION

Left ventricular diastolic dysfunction (LVDD) is a common condition in both sexes that may deteriorate into heart failure (HF) with preserved ejection fraction (pEF), although this seems to happen more often in women than in men. Both LVDD and HFpEF often go unrecognised, necessitating the discovery of biomarkers that aid both the identification of individuals with LVDD at risk of developing HF and identification of individuals most likely to benefit from treatment.

METHODS AND ANALYSIS

HELPFul is an ongoing case-cohort study at a Dutch cardiology outpatient clinic enrolling patients aged 45 years and older without history of cardiovascular disease, who were referred by the general practitioner for cardiac evaluation. We included a random sample of patients and enriched the cohort with cases (defined as an E/e' ≥8 measured with echocardiography). Information about medical history, cardiovascular risk factors, electrocardiography, echocardiography, exercise test performance, common carotid intima-media thickness measurement and standard cardiovascular biomarkers was obtained from the routine care data collected by the cardiology outpatient clinic. Study procedure consists of extensive venous blood collection for biobanking and additional standardised questionnaires. Follow-up will consist of standardised questionnaires by mail and linkage to regional and national registries. We will perform cardiac magnetic resonance imaging and coronary CT angiography in a subgroup of patients to investigate the extent of macrovascular and microvascular coronary disease.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of the University Medical Center Utrecht. Results will be disseminated through national and international conferences and in peer-reviewed journals in cardiovascular disease.

TRIAL REGISTRATION

NTR6016;Pre-results.