Sex Differences in Outcomes in Patients With Stable Angina
Background We comparatively evaluated clinical outcomes in men and women presenting with stable angina with no coronary artery disease (CAD), nonobstructive CAD, and obstructive CAD on coronary angiography.
Methods We studied all patients ≥20 years with stable angina, undergoing coronary angiography in British Columbia, Canada, from July 1999 to December 2002 (n = 13,695) with maximum follow-up to 3 years. No CAD, nonobstructive CAD, and obstructive CAD were defined as 0%, 1% to 49%, and ≥50% luminal narrowing in any epicardial coronary artery, respectively. Freedom from major adverse cardiac events (MACEs), which included the combined end points of all-cause mortality, nonfatal acute myocardial infarction, nonfatal stroke, and heart failure admissions, was estimated using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs for MACE were estimated up to 3 years postcatheterization and compared between sex and CAD groups.
Results Within the first year, women with nonobstructive CAD had a higher risk of MACE than men with nonobstructive CAD (adjusted HR 2.43, 95% CI 1.08–5.49). Furthermore, women with nonobstructive CAD had a 2.55-fold higher risk of MACE than women with no CAD (95% CI 1.33–4.88). In contrast, men with nonobstructive CAD had a similar risk as men with no CAD (adjusted HR 0.61, 95% CI 0.26–1.45). The differences in MACE according to extent of CAD were not evident in the longer term.
Conclusions Women with stable angina and nonobstructive CAD are 3 times more likely to experience a cardiac event within the first year of cardiac catheterization than men. A prospective trial to examine the impact of medical therapy on MACE in patients with nonobstructive CAD is warranted.
The prognosis for patients with stable angina and no obstructive coronary artery disease (CAD) is not clearly understood. Prior studies that examined major adverse cardiac event (MACE) rates in patients with stable angina and no CAD or nonobstructive CAD have yielded conflicting results. Although some studies have concluded that the finding of no CAD or nonobstructive CAD was associated with a benign prognosis, more recent studies, which included reference populations, have reported elevated MACE rates. Specific to women, the Women's Ischemia Syndrome Evaluation has demonstrated adverse outcomes in women with no and nonobstructive CAD but persistent chest pain compared with women without persistent chest pain.
Few studies have examined sex differences in MACE rates among stable angina patients with no CAD and nonobstructive CAD. Two recent studies from Europe demonstrated similar hazard ratios (HRs) associated with no and nonobstructive CAD in men and women. However, Johnston et al reported low event rates associated with no and nonobstructive CAD, whereas Jespersen et al found elevated MACE rates in these patients, irrespective of sex. A recent report of nonobstructive CAD using computed tomographic angiography has similarly described elevated MACE rates. To provide further insight into the prognosis of patients with no and nonobstructive CAD, we evaluated clinical outcomes in men and women with stable angina in British Columbia (BC), Canada, following coronary angiography, stratified by extent of CAD.
Abstract and Introduction
Abstract
Background We comparatively evaluated clinical outcomes in men and women presenting with stable angina with no coronary artery disease (CAD), nonobstructive CAD, and obstructive CAD on coronary angiography.
Methods We studied all patients ≥20 years with stable angina, undergoing coronary angiography in British Columbia, Canada, from July 1999 to December 2002 (n = 13,695) with maximum follow-up to 3 years. No CAD, nonobstructive CAD, and obstructive CAD were defined as 0%, 1% to 49%, and ≥50% luminal narrowing in any epicardial coronary artery, respectively. Freedom from major adverse cardiac events (MACEs), which included the combined end points of all-cause mortality, nonfatal acute myocardial infarction, nonfatal stroke, and heart failure admissions, was estimated using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs for MACE were estimated up to 3 years postcatheterization and compared between sex and CAD groups.
Results Within the first year, women with nonobstructive CAD had a higher risk of MACE than men with nonobstructive CAD (adjusted HR 2.43, 95% CI 1.08–5.49). Furthermore, women with nonobstructive CAD had a 2.55-fold higher risk of MACE than women with no CAD (95% CI 1.33–4.88). In contrast, men with nonobstructive CAD had a similar risk as men with no CAD (adjusted HR 0.61, 95% CI 0.26–1.45). The differences in MACE according to extent of CAD were not evident in the longer term.
Conclusions Women with stable angina and nonobstructive CAD are 3 times more likely to experience a cardiac event within the first year of cardiac catheterization than men. A prospective trial to examine the impact of medical therapy on MACE in patients with nonobstructive CAD is warranted.
Introduction
The prognosis for patients with stable angina and no obstructive coronary artery disease (CAD) is not clearly understood. Prior studies that examined major adverse cardiac event (MACE) rates in patients with stable angina and no CAD or nonobstructive CAD have yielded conflicting results. Although some studies have concluded that the finding of no CAD or nonobstructive CAD was associated with a benign prognosis, more recent studies, which included reference populations, have reported elevated MACE rates. Specific to women, the Women's Ischemia Syndrome Evaluation has demonstrated adverse outcomes in women with no and nonobstructive CAD but persistent chest pain compared with women without persistent chest pain.
Few studies have examined sex differences in MACE rates among stable angina patients with no CAD and nonobstructive CAD. Two recent studies from Europe demonstrated similar hazard ratios (HRs) associated with no and nonobstructive CAD in men and women. However, Johnston et al reported low event rates associated with no and nonobstructive CAD, whereas Jespersen et al found elevated MACE rates in these patients, irrespective of sex. A recent report of nonobstructive CAD using computed tomographic angiography has similarly described elevated MACE rates. To provide further insight into the prognosis of patients with no and nonobstructive CAD, we evaluated clinical outcomes in men and women with stable angina in British Columbia (BC), Canada, following coronary angiography, stratified by extent of CAD.
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