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Lopez-Candales A, Sawalha K, Asif T. Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance. Postgrad Med 2024:1-11. [PMID: 38818874 DOI: 10.1080/00325481.2024.2360888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.
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Affiliation(s)
- Angel Lopez-Candales
- Cardiovascular Medicine Division University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Khalid Sawalha
- Cardiometabolic Fellowship, University Health Truman Medical Center and the University of Missouri-Kansas City, Kansas City, USA
| | - Talal Asif
- Division of Cardiovascular Diseases, University Health Truman Medical Center and the University of Missouri-Kansas City Kansas City, Kansas City, MO, USA
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Karakayali M, Altunova M, Yakisan T, Aslan S, Omar T, Artac I, Ilis D, Arslan A, Cagin Z, Karabag Y, Rencuzogullari I. The Relationship between the Systemic Immune-Inflammation Index and Ischemia with Non-Obstructive Coronary Arteries in Patients Undergoing Coronary Angiography. Arq Bras Cardiol 2024; 121:e20230540. [PMID: 38597536 DOI: 10.36660/abc.20230540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/13/2023] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Ischemia with the non-obstructive coronary artery (INOCA) is an ischemic heart disease that mostly includes coronary microvascular dysfunction and/or epicardial coronary vasospasm due to underlying coronary vascular dysfunction and can be seen more commonly in female patients. The systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery disease (CAD). OBJECTIVE This study aims to investigate the relationship between INOCA and SII, a new marker associated with inflammation. METHODS A total of 424 patients (212 patients with INOCA and 212 normal controls) were included in the study. Peripheral venous blood samples were received from the entire study population prior to coronary angiography to measure SII and other hematological parameters. In our study, the value of p<0.05' was considered statistically significant. RESULTS The optimal cut-off value of SII for predicting INOCA was 153.8 with a sensitivity of 44.8% and a specificity of 78.77% (Area under the curve [AUC]: 0.651 [95% CI: 0.603-0.696, p=0.0265]). Their ROC curves were compared to assess whether SII had an additional predictive value over components. The AUC value of SII was found to be significantly higher than that of lymphocyte (AUC: 0.607 [95% CI: 0.559-0.654, p = 0.0273]), neutrophil (AUC: 0.559 [95%CI: 0.511-0.607, p=0.028]) and platelet (AUC: 0.590 [95% CI: 0.541-0.637, p = 0.0276]) in INOCA patients. CONCLUSIONS A high SII level was found to be independently associated with the existence of INOCA. The SII value can be used as an indicator to add to the traditional expensive methods commonly used in INOCA prediction.
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Affiliation(s)
- Muammer Karakayali
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Mehmet Altunova
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training Research Hospital, Istanbul - Turquia
| | | | - Serkan Aslan
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training Research Hospital, Istanbul - Turquia
| | - Timor Omar
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Inanc Artac
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Doğan Ilis
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Ayca Arslan
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Zihni Cagin
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Yavuz Karabag
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
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Guldogan E, Yagin FH, Pinar A, Colak C, Kadry S, Kim J. A proposed tree-based explainable artificial intelligence approach for the prediction of angina pectoris. Sci Rep 2023; 13:22189. [PMID: 38092844 PMCID: PMC10719282 DOI: 10.1038/s41598-023-49673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023] Open
Abstract
Cardiovascular diseases (CVDs) are a serious public health issue that affects and is responsible for numerous fatalities and impairments. Ischemic heart disease (IHD) is one of the most prevalent and deadliest types of CVDs and is responsible for 45% of all CVD-related fatalities. IHD occurs when the blood supply to the heart is reduced due to narrowed or blocked arteries, which causes angina pectoris (AP) chest pain. AP is a common symptom of IHD and can indicate a higher risk of heart attack or sudden cardiac death. Therefore, it is important to diagnose and treat AP promptly and effectively. To forecast AP in women, we constructed a novel artificial intelligence (AI) method employing the tree-based algorithm known as an Explainable Boosting Machine (EBM). EBM is a machine learning (ML) technique that combines the interpretability of linear models with the flexibility and accuracy of gradient boosting. We applied EBM to a dataset of 200 female patients, 100 with AP and 100 without AP, and extracted the most relevant features for AP prediction. We then evaluated the performance of EBM against other AI methods, such as Logistic Regression (LR), Categorical Boosting (CatBoost), eXtreme Gradient Boosting (XGBoost), Adaptive Boosting (AdaBoost), and Light Gradient Boosting Machine (LightGBM). We found that EBM was the most accurate and well-balanced technique for forecasting AP, with accuracy (0.925) and Youden's index (0.960). We also looked at the global and local explanations provided by EBM to better understand how each feature affected the prediction and how each patient was classified. Our research showed that EBM is a useful AI method for predicting AP in women and identifying the risk factors related to it. This can help clinicians to provide personalized and evidence-based care for female patients with AP.
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Affiliation(s)
- Emek Guldogan
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Inonu University, 44280, Malatya, Turkey
| | - Fatma Hilal Yagin
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Inonu University, 44280, Malatya, Turkey.
| | - Abdulvahap Pinar
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Inonu University, 44280, Malatya, Turkey
| | - Cemil Colak
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Inonu University, 44280, Malatya, Turkey
| | - Seifedine Kadry
- Noroff University College, Kristiansand, Norway
- Artificial Intelligence Research Center (AIRC), Ajman University, 346, Ajman, United Arab Emirates
- Department of Electrical and Computer Engineering, Lebanese American University, Byblos, Lebanon
| | - Jungeun Kim
- Department of Software, Kongju National University, Cheonan, 31080, Korea.
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Coronary Artery Disease in Women: Lessons Learned from Single-Center SPECT Registry and Future Directions for INOCA Patients. Medicina (B Aires) 2022; 58:medicina58091139. [PMID: 36143816 PMCID: PMC9505953 DOI: 10.3390/medicina58091139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/03/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
Background and objectives: Myocardial perfusion imaging with cardiac single-photon emission tomography (SPECT) is widely available for the detection of coronary artery disease (CAD) with high diagnostic and prognostic accuracy for women. A large proportion of symptomatic women with true myocardial perfusion defects in SPECT referred to coronary angiography have an absence of CAD—a condition named INOCA (ischemia with nonobstructive CAD). Additionally, the INOCA endotypes are rarely correctly diagnosed, and therefore, no tailored therapy is prescribed. Materials and methods: The cardiac SPECT for women was performed from 2018 to 2021. Patients with perfusion defect were analyzed according to further prescribed diagnostic tests used to diagnose CAD. According to the diagnostic criteria, patients with INOCA were selected as candidates for invasive microvascular physiology measurements. The correlation was calculated between SPECT results and clinical characteristics, symptoms, and risk factors. Results: A total of 726 women with suspected CAD were analyzed. True myocardial perfusion defects were detected in 125 patients (17.2%). During coronary angiography in 70 (56.0%) women, atherosclerosis in epicardial arteries was not observed. In 17 (20.9%) patients, obstructive CAD was present. Correlation was found between perfusion defect in SPECT and cardiovascular risk factors, including overweight, obesity, arterial hypertension, and dyslipidemia. Women with typical angina were more likely to have INOCA, but with “noncardiac” symptoms—CAD. In total, 68 female patients met three inclusion criteria for INOCA and were selected as candidates for invasive diagnostic testing. Conclusions: The created registry proves the important role of cardiac SPECT and great need for the development of invasively detected physiological measurements. The combination of both interventions could significantly change the future directions for INOCA patients, improving treatment strategies and clinical outcomes, especially knowing the number of risk factors and varying clinical presentation. The study will be continued by performing invasive testing of coronary microvascular function to expand the competence about what is known about INOCA patients.
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Kumrular M, Karaca Ozer P, Elitok A. The Role of Aortic Stiffness Parameters in Evaluating Myocardial Ischemia. Cardiol Res 2020; 11:328-336. [PMID: 32849968 PMCID: PMC7430893 DOI: 10.14740/cr1125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/07/2020] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
| | - Pelin Karaca Ozer
- Department of Cardiology, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Ali Elitok
- Department of Cardiology, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
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Battu S, Yalavarthi PR, Subba Reddy G, Uma Maheswara Rao V, Jyothshna Devi K, Vadlamudi HC. Design and assessment of pulsatile technology based chronomodulated delivery systems of nifedipine. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2018. [DOI: 10.1016/j.bjbas.2018.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Makarović Z, Makarović S, Bilić-Ćurčić I, Mihaljević I, Mlinarević D. NONOBSTRUCTIVE CORONARY ARTERY DISEASE - CLINICAL RELEVANCE, DIAGNOSIS, MANAGEMENT AND PROPOSAL OF NEW PATHOPHYSIOLOGICAL CLASSIFICATION. Acta Clin Croat 2018; 57:528-541. [PMID: 31168187 PMCID: PMC6536284 DOI: 10.20471/acc.2018.57.03.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
SUMMARY – New data gathered from large clinical trials indicate that nonobstructive coronary artery disease (non-CAD) is a clinical entity that should not be ignored. It is estimated that 50% of female population undergoing coronarography are diagnosed with non-CAD. There is also an increase in the prevalence of non-CAD in both genders, which is probably due to gradual expanding of clinical indications for angiography in patients with angina. Furthermore, considering the increased mortality risk established recently, a prognosis of non-CAD is not benign as previously thought. However, the concept and definition of non-CAD remains elusive causing difficulties in diagnosis and treatment. One of the major shortcomings is the exclusion-based diagnosis of non-CAD. Furthermore, treatment of non-CAD still presents a great challenge and optimal therapy is yet to be determined. There are two major hypotheses explaining the pathophysiological mechanisms of non-CAD, i.e. ischemic hypothesis based on abnormal microvascular dysfunction and non-ischemic one based on altered pain perception. This review encompasses a broader spectrum of pathophysiological mechanisms of non-CAD, and proposes a new way of classification based on the major disorder involved: type I (ischemic mechanisms) and type II (non-ischemic mechanisms), depending on which mechanism predominates. Hopefully, this would provide new insights in the understanding of this disorder, thus leading to accurate and early diagnosis and successful treatment, especially considering the increased mortality risk in these patients.
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Affiliation(s)
| | - Sandra Makarović
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Cardiology, Osijek University Hospital Centre, Osijek, Croatia; 3Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 4Department of Nuclear Medicine and Radiation Protection, Osijek University Hospital Centre, Osijek, Croatia
| | - Ines Bilić-Ćurčić
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Cardiology, Osijek University Hospital Centre, Osijek, Croatia; 3Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 4Department of Nuclear Medicine and Radiation Protection, Osijek University Hospital Centre, Osijek, Croatia
| | - Ivan Mihaljević
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Cardiology, Osijek University Hospital Centre, Osijek, Croatia; 3Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 4Department of Nuclear Medicine and Radiation Protection, Osijek University Hospital Centre, Osijek, Croatia
| | - Dražen Mlinarević
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Cardiology, Osijek University Hospital Centre, Osijek, Croatia; 3Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 4Department of Nuclear Medicine and Radiation Protection, Osijek University Hospital Centre, Osijek, Croatia
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Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and meta-analysis. Int J Cardiol 2018; 254:1-9. [DOI: 10.1016/j.ijcard.2017.10.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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9
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Hamilton DJ, Gotto AM. Coronary Disease Survival with Diabetes. Cardiology 2017; 139:40-42. [PMID: 29224007 DOI: 10.1159/000484518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/23/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Dale J Hamilton
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
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Nelson MD. Left ventricular diastolic dysfunction in women with nonobstructive ischemic heart disease: insights from magnetic resonance imaging and spectroscopy. Am J Physiol Regul Integr Comp Physiol 2017; 313:R322-R329. [PMID: 28794105 DOI: 10.1152/ajpregu.00249.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/20/2017] [Accepted: 08/03/2017] [Indexed: 02/01/2023]
Abstract
Ischemic heart disease, in the absence of obstructive coronary artery disease, is prevalent in women and constitutes a major risk factor for developing major adverse cardiovascular events, including myocardial infarction, stroke, and heart failure. For decades, diagnosis was considered benign and often minimized; however, it is now known that this etiology carries much risk and is a significant burden to the health care system. This review summarizes the current state of knowledge on nonobstructive ischemic heart disease (NOIHD), the association between NOIHD and left ventricular diastolic dysfunction, potential links between NOIHD and the development of heart failure with preserved ejection fraction (HFpEF), and therapeutic options and knowledge gaps for patients living with NOIHD.
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Affiliation(s)
- Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Arlington, Texas
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11
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Abstract
A number of studies consistently report higher rates of all clinical outcomes including postinfarction mortality, need for repeat revascularization, and reinfarction in women with cardiovascular diseases than in men. As well, the gender gap in the prevalence of cardiovascular diseases decreases progressively with increasing age. Yet, the diagnosis and treatment of these diseases differ between genders and women remain underdiagnosed for coronary heart disease. In a recent retrospective analysis we showed that, along with vessel under study and age, gender is a determinant of adenosine responses during studies of fractional flow reserve, an effect that was probably due to differences in microvascular function and that influenced the interpretation of fractional flow reserve data. These data demonstrate that not only the clinical presentation is different, but also the diagnostic approach to coronary artery disease might differ between sexes.A gap still exists in the understanding of the mechanisms, awareness, and treatment of coronary artery disease in women, but also, as we show, in the application of diagnostic modalities that are well established in men.
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Brewer LC, Svatikova A, Mulvagh SL. The Challenges of Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. Cardiovasc Drugs Ther 2016. [PMID: 26210899 DOI: 10.1007/s10557-015-6607-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Increasing evidence suggests that there are significant differences in the presentation, diagnosis and treatment of ischemic heart disease in women compared to men. Women often present with atypical symptoms, and this, in association with a consistent underestimation of their risk for ischemic heart disease, leads to underdiagnosis and undertreatment in women. Cardiovascular risk factors unique to women have only recently been recognized, and moreover, traditional risk factors have recently been shown to have greater impacts on women. Consequently, women suffer more disability and poorer clinical outcomes, with higher cardiovascular morbidity and mortality. These discrepancies may in part be secondary to the higher prevalence of nonobstructive coronary artery disease in women with persistent chest pain symptoms as compared to men when evaluated invasively. Focused diagnostic and therapeutic strategies unique to women are thus needed, but unfortunately, such sex-specific guidelines do not yet exist, largely due to lack of awareness, both on the part of providers and patients, as well as a paucity of evidence-based research specific to women. Although underutilized in women, diagnostic modalities, including functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, are useful for establishing the diagnosis and prognosis of suspected ischemic heart disease in women. This review discusses the current challenges of prevention, diagnosis and treatment of ischemic heart disease in women.
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Pepine CJ, Ferdinand KC, Shaw LJ, Light-McGroary KA, Shah RU, Gulati M, Duvernoy C, Walsh MN, Bairey Merz CN. Emergence of Nonobstructive Coronary Artery Disease: A Woman's Problem and Need for Change in Definition on Angiography. J Am Coll Cardiol 2016; 66:1918-33. [PMID: 26493665 DOI: 10.1016/j.jacc.2015.08.876] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/12/2023]
Abstract
Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.
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Affiliation(s)
- Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, Florida.
| | | | - Leslee J Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Rashmee U Shah
- Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martha Gulati
- The College of Medicine and The College of Clinical Public Health, The Ohio State University, Columbus, Ohio
| | - Claire Duvernoy
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
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Wu Q, Kling JM. Depression and the Risk of Myocardial Infarction and Coronary Death: A Meta-Analysis of Prospective Cohort Studies. Medicine (Baltimore) 2016; 95:e2815. [PMID: 26871852 PMCID: PMC4753948 DOI: 10.1097/md.0000000000002815] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Findings regarding the association between depression and risk of coronary heart disease are inconsistent. We aimed to assess the association between depression and risk of myocardial infarction (MI) and coronary death through a meta-analysis.We performed an electronic literature search of MEDLINE, EMBASE, PsycINFO, ISI Web of Science, and Scopus databases through August 1, 2015, and manual search of the references of the eligible papers and related review articles. Two investigators independently conducted study selection and data abstraction. Disagreement was resolved by consensus. Confounder-adjusted hazard ratios (HRs) were pooled using a random-effects model. Heterogeneity was evaluated using the Cochran Q statistic and Higgins index. Publication bias was assessed by funnel plot and Egger test. Study quality was appraised with the Newcastle-Ottawa Scale.Among 19 eligible cohort studies including 323,709 participants, 8447 cases of MI and coronary death were reported during follow-up ranging from 4 to 37 years. The pooled adjusted HRs for patients with depression (vs those without) were 1.22 (95% CI, 1.13-1.32) for combined MI and coronary death, 1.31 (95% CI, 1.09-1.57) for MI alone (9 studies), and 1.36 (95% CI, 1.14-1.63) for coronary death alone (8 studies). The increased risk of MI and coronary death associated with depression was consistent using modified inclusion criteria, across most subgroups, and after adjusting for possible publication bias.Depression is associated with a significantly increased risk of MI and coronary death. Effective prevention and treatment of depression may decrease such risk.
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Affiliation(s)
- Qing Wu
- From the Nevada Institute of Personalized Medicine (QW), and Department of Environmental and Occupational Health, School of Community Health Sciences (QW), University of Nevada Las Vegas, Las Vegas, NV, and Division of Women's Health Internal Medicine (JMK), Mayo Clinic, Scottsdale, AZ
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15
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Gijsberts CM, Agostoni P, Hoefer IE, Asselbergs FW, Pasterkamp G, Nathoe H, Appelman YE, de Kleijn DPV, den Ruijter HM. Gender differences in health-related quality of life in patients undergoing coronary angiography. Open Heart 2015; 2:e000231. [PMID: 26339493 PMCID: PMC4555073 DOI: 10.1136/openhrt-2014-000231] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 01/24/2023] Open
Abstract
Background Health-related quality of life (HRQOL) reflects the general well-being of individuals. In patients with coronary artery disease (CAD), HRQOL is compromised. Female patients with CAD have been reported to have lower HRQOL. In this study, we investigate gender differences in HRQOL and in associations of patient characteristics with HRQOL in patients with coronary angiography (CAG). Methods We cross-sectionally analysed patients from the Utrecht Coronary Biobank undergoing CAG. All patients filled in an HRQOL questionnaire (RAND-36 and EuroQoL) on inclusion. RAND-36 and EuroQoL HRQOL measures were compared between the genders across indications for CAG, CAD severity and treatment of CAD. RAND-36 HRQOL measures were compared with the general Dutch population. Additionally, we assessed interactions of gender with patient characteristics in their association with HRQOL (EuroQoL). Results We included 1421 patients (1020 men and 401 women) with a mean age of 65 in our analysis. Women reported lower HRQOL measures than men (mean EuroQoL self-rated health grade 6.84±1.49 in men, 6.46±1.40 in women, p<0.001). The reduction in RAND-36 HRQOL as compared with the general Dutch population was larger in women than in men. From regression analysis, we found that diabetes, a history of cardiovascular disease and symptoms of shortness of breath determined HRQOL (EuroQoL) more strongly in men than in women. Conclusions Women reported lower HRQOL than men throughout all indications for CAG and regardless of CAD severity or treatment. As compared with the general population, the reduction in HRQOL was more extreme in women than in men. Evident gender differences were found in determinants of HRQOL in patients undergoing CAG, which deserve attention in future research. Trial registration NCT02304744 (clinicaltrials.gov).
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Affiliation(s)
- Crystel M Gijsberts
- Laboratory of Experimental Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands ; ICIN-Netherlands Heart Institute , Utrecht , The Netherlands
| | - Pierfrancesco Agostoni
- Department of Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Imo E Hoefer
- Laboratory of Experimental Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands ; Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute , Utrecht , The Netherlands ; Faculty of Population Health Sciences , Institute of Cardiovascular Science, University College London , London , UK
| | - Gerard Pasterkamp
- Laboratory of Experimental Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Hendrik Nathoe
- Department of Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Yolande E Appelman
- Department of Cardiology , VU University Medical Center , Amsterdam , The Netherlands
| | - Dominique P V de Kleijn
- Laboratory of Experimental Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands ; ICIN-Netherlands Heart Institute , Utrecht , The Netherlands ; Department of Surgery , Yong Loo Lin School of Medicine, National University of Singapore , Singapore , Singapore ; Cardiovascular Research Institute, National University Heart Centre, National University Health System , Singapore , Singapore
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, Division Heart and Lungs , University Medical Centre Utrecht , Utrecht , The Netherlands
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Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
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Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
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Stain N, Ridge D, Cheshire A. Gender comparisons in non-acute cardiac symptom recognition and subsequent help-seeking decisions: a mixed methods study protocol. BMJ Open 2014; 4:e005742. [PMID: 25361835 PMCID: PMC4216862 DOI: 10.1136/bmjopen-2014-005742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Coronary heart disease (CHD) is one of the leading causes of death in both men and women worldwide. Despite the common misconception that CHD is a 'man's disease', it is now well accepted that women endure worse clinical outcomes than men following CHD-related events. A number of studies have explored whether or not gender differences exist in patients presenting with CHD, and specifically whether women delay seeking help for cardiac conditions. UK and overseas studies on help-seeking for emergency cardiac events are contradictory, yet suggest that women often delay help-seeking. In addition, no studies have looked at presumed cardiac symptoms outside an emergency situation. Given the lack of understanding in this area, an explorative qualitative study on the gender differences in help-seeking for a non-emergency cardiac events is needed. METHODS AND ANALYSIS A purposive sample of 20-30 participants of different ethnic backgrounds and ages attending a rapid access chest pain clinic will be recruited to achieve saturation. Semistructured interviews focusing on help-seeking decision-making for apparent cardiac symptoms will be undertaken. Interview data will be analysed thematically using qualitative software (NVivo) to understand any similarities and differences between the way men and women construct help-seeking. Findings will also be used to inform the preliminary development of a cardiac help-seeking intentions questionnaire. ETHICS AND DISSEMINATION Ethical approvals were sought and granted. Namely, the University of Westminster (sponsor) and St Georges NHS Trust REC, and the Trust Research and Development Office granted approval to host the study on the Queen Mary's Roehampton site. The study is low risk, with interviews being conducted on hospital premises during working hours. Investigators will disseminate findings via presentations and publications. Participants will receive a written summary of the key findings.
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Affiliation(s)
- Nolan Stain
- Cardiology Department, Queen Mary's Roehampton, St Georges Healthcare NHS Trust, London, UK
| | - Damien Ridge
- Faculty of Science and Technology, University of Westminster, London, UK
| | - Anna Cheshire
- Faculty of Science and Technology, University of Westminster, London, UK
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18
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Makarovic Z, Makarovic S, Bilic-Curcic I. Sex-dependent association between coronary vessel dominance and cardiac syndrome X: a case-control study. BMC Cardiovasc Disord 2014; 14:142. [PMID: 25300376 PMCID: PMC4197336 DOI: 10.1186/1471-2261-14-142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 10/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated the relevance of left coronary artery dominance in the outcome and prognosis of obstructive coronary artery disease (CAD). However, no studies have investigated the influence of coronary vessel dominance on non obstructive CAD. The aim of this study was to establish the association of left and mixed dominance of the major epicardial arteries with the development of non obstructive CAD and evaluate potential sex-dependent differences in the coronary artery supply. METHODS A total of 484 patients underwent the same diagnostic procedures. The patients were divided into two groups based on their coronary angiogram results: the control group (242 patients with obstructive CAD; coronary artery stenosis of ≥50%) and the experimental group (242 patients with non obstructive CAD; coronary artery stenosis of <50%). RESULTS Significantly more women than men were affected by non obstructive CAD (P = 0.005). Left dominance was more frequent in the non obstructive CAD group than in the control group (P = 0.018) and was more pronounced in women than in men (P = 0.013). Among men with non obstructive CAD, a left supply was more frequent than a mixed supply (P = 0.012). Women with non obstructive CAD had a higher frequency of a left supply, whereas a mixed supply was less frequent in men than in patients with obstructive CAD (P = 0.013 and 0.018, respectively). CONCLUSION These results suggest that left dominance (particularly in women) and the absence of a mixed supply in men could cause regional ischemia, thus affecting the development of non obstructive CAD. Furthermore, sex may determine the incidence of specific coronary artery supply types, therefore influencing disease development and prognosis.
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Affiliation(s)
| | - Sandra Makarovic
- Department of Cardiology, University Hospital Center Osijek and School of Medicine, University of Osijek, J, Huttlera 4, 31000 Osijek, Croatia.
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Abstract
CONTEXT The possibility that differences in insulin sensitivity explain why women, especially younger women, have a lower cardiovascular disease (CVD) risk than men remains an unsettled issue. OBJECTIVE The objective of this study was to evaluate whether sex disparities in CVD risk are associated with differences in insulin resistance. DESIGN/SETTING/PARTICIPANTS This was a cross-sectional study of women (n = 468) and men (n = 354) who had the measurement of CVD risk factors and steady-state plasma glucose (SSPG) concentration (insulin resistance) using the insulin suppression test. The population was also divided by median age (51 y) to evaluate the effect of age on sex differences. MAIN OUTCOME MEASURES/RESULTS In general, the SSPG concentration was similar between sexes. At higher BMI (≥30 kg/m(2)), women had significantly lower SSPG concentration than men (sex × BMI interaction, P = .001). However, sex differences in CVD risk factors were not due to differences in SSPG but accentuated by a higher degree of insulin resistance in younger (age < 51 y) but not older (≥ 51 y) individuals. In younger individuals, women had significantly (P ≤ .007) lower diastolic blood pressure and fasting glucose and triglyceride concentration compared with men in SSPG tertile 3 (most insulin resistant) but not in tertile 1 (least insulin resistant). Older women had lower diastolic blood pressure compared with men, regardless of SSPG. High-density lipoprotein cholesterol remained higher in women, regardless of age or SSPG. CONCLUSIONS The female advantage is not due to a difference in insulin action but results from an attenuation of the relationship between insulin resistance and CVD risk, especially in younger individuals.
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Affiliation(s)
- Sun H Kim
- MD, MS, Stanford University Medical Center, 300 Pasteur Drive, Room S025, Stanford, California 94305-5103.
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Vasheghani-Farahani A, Nouri N, Seifirad S, Sheikh Fathollahi M, Hakki E, Alidoosti M, Davoodi G, Masoudkabir F, Poorhosseini H. Comparison of cardiovascular risk factors and biochemical profile in patients with cardiac syndrome X and obstructive coronary artery disease: A propensity score-matched study. ARYA ATHEROSCLEROSIS 2013; 9:269-73. [PMID: 24302934 PMCID: PMC3845698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 06/08/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study was designed to compare the frequency of conventional cardiovascular disease risk factors and clinical biochemistry profile in patients with cardiac syndrome X (CSX) and obstructive coronary artery disease (CAD). METHODS A cross-sectional study was conducted on patients with typical angina and positive exercise tolerance test undergoing coronary angiography in our center. 342 consecutive patients with CSX were enrolled into this study and were matched regarding age and sex with 342 patients with acute coronary syndrome (ACS) and also 342 patients with chronic stable angina (SA). Cardiovascular risk factors as well as biochemistry profile of the patients were recorded. RESULTS Mean age of the studied patients was 53.0 years and 41.5% were male. There was no significant difference between the CSX patients and CAD patients regarding body mass index (BMI). Frequency of diabetes mellitus, hyperlipidemia, smoking, family history of premature CAD and hypertension was significantly lower in patients with CSX than ACS and SA patients. Patients with CSX had significantly higher levels of high-density lipoprotein cholesterol (HDL-cholesterol) than comparators while the levels of low-density lipoprotein cholesterol (LDL-cholesterol), total cholesterol, triglyceride and fasting blood sugar (FBS) were significantly lower in patients with CSX than CAD patients. CONCLUSION The present study demonstrated that CSX patients had substantially lower frequency of all conventional CVD risk factors than patients with obstructive CAD. This might aid in developing novel scoring systems or appropriateness criteria for angiographic evaluation of patients with typical angina and positive exercise test in order to reduce the rate of negative results.
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Affiliation(s)
- Ali Vasheghani-Farahani
- Associate Professor, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Nouri
- Medical Student, Student Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroush Seifirad
- Research Fellow, Department of Cardiology, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Sheikh Fathollahi
- Assistant Professor, Department of Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Hakki
- Research Fellow, Department of Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Alidoosti
- Associate Professor, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Davoodi
- Associate Professor, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Cardiology Fellow and Research Fellow, Department of Cardiology, Tehran Heart Center, AND Student Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran,Correspondence to: Farzad Masoudkabir,
| | - Hamidreza Poorhosseini
- Associate Professor, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Lo MY, Bonthala N, Holper EM, Banks K, Murphy SA, McGuire DK, de Lemos JA, Khera A. A risk score for predicting coronary artery disease in women with angina pectoris and abnormal stress test finding. Am J Cardiol 2013; 111:781-5. [PMID: 23273531 DOI: 10.1016/j.amjcard.2012.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 10/27/2022]
Abstract
Women with angina pectoris and abnormal stress test findings commonly have no epicardial coronary artery disease (CAD) at catheterization. The aim of the present study was to develop a risk score to predict obstructive CAD in such patients. Data were analyzed from 337 consecutive women with angina pectoris and abnormal stress test findings who underwent cardiac catheterization at our center from 2003 to 2007. Forward selection multivariate logistic regression analysis was used to identify the independent predictors of CAD, defined by ≥50% diameter stenosis in ≥1 epicardial coronary artery. The independent predictors included age ≥55 years (odds ratio 2.3, 95% confidence interval 1.3 to 4.0), body mass index <30 kg/m(2) (odds ratio 1.9, 95% confidence interval 1.1 to 3.1), smoking (odds ratio 2.6, 95% confidence interval 1.4 to 4.8), low high-density lipoprotein cholesterol (odds ratio 2.9, 95% confidence interval 1.5 to 5.5), family history of premature CAD (odds ratio 2.4, 95% confidence interval 1.0 to 5.7), lateral abnormality on stress imaging (odds ratio 2.8, 95% confidence interval 1.5 to 5.5), and exercise capacity <5 metabolic equivalents (odds ratio 2.4, 95% confidence interval 1.1 to 5.6). Assigning each variable 1 point summed to constitute a risk score, a graded association between the score and prevalent CAD (ptrend <0.001). The risk score demonstrated good discrimination with a cross-validated c-statistic of 0.745 (95% confidence interval 0.70 to 0.79), and an optimized cutpoint of a score of ≤2 included 62% of the subjects and had a negative predictive value of 80%. In conclusion, a simple clinical risk score of 7 characteristics can help differentiate those more or less likely to have CAD among women with angina pectoris and abnormal stress test findings. This tool, if validated, could help to guide testing strategies in women with angina pectoris.
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Parsyan A, Pilote L. Cardiac syndrome X: mystery continues. Can J Cardiol 2012; 28:S3-6. [PMID: 22424282 DOI: 10.1016/j.cjca.2011.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/19/2011] [Accepted: 09/19/2011] [Indexed: 10/28/2022] Open
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