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Diagnostic and Prognostic Evaluation in Postmenopausal Women with Signs and Symptoms of Unstable Coronary Artery Disease
Linköping University, Department of Medicine and Care, Cardiology. Linköping University, Faculty of Health Sciences.
2000 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Coronary artery disease (CAD) is the major cause of death in both men and women in the western world. The majority of studies undertaken to evaluate diagnostic methods, risk stratification and treatment of CAD, have been performed on men. Although there are studies reporting gender differences in the presentation of symptoms, prognosis and response to treatment, current recommendations for practice are based on a model of the disease in men.

The diagnostic information from basic clinical data, ECG and an early symptomlimited exercise test was evaluated in a prospective study on 200 postmenopausal women with unstable CAD. The prevalence of atherosclerosis was high (85%). A patient history and markers of myocardial injury were good predictors of significant CAD and the exercise test was as valuable for the assessment of this diagnosis in women as that reported in men.

The incremental diagnostic values of basic clinical data, the exercise test and 201TI SPECT were assessed in 121 postmenopausal women after an episode of unstable CAD. There was an incremental diagnostic value of 201TI SPECT compared to basic data and the exercise test when diagnosing significant CAD, but not regarding the identification of extensive CAD.

Evaluation of symptom-limited exercise test for risk stratification in postmenopausal women with unstable CAD was carried out on a population of 395 women in the "FRagmin during InStability in CAD" (FRISC I) Study. The exercise test was a good predictor of future cardiac death and myocardial infarction (MI) if parameters reflecting cardiac performance also were taken under consideration and not only chest pain and ST-segment depression, two parameters reflecting ischaemia and often used in studies on men. However, the patients who, after admission, did not become stable enough to perform the exercise test, had the highest risk of adverse future events.

Comparison of symptom limited exercise test and troponin T measurements for risk stratification in women and men was performed in the FRISC I study population. It was concluded that the early symptom-limited exercise test and troponin T are at least as useful as prognostic risk indicators in women as they are in men.

The gender differences in outcome after early revascularisation compared to noninvasive management was assessed in 749 women and 1708 men in the "Fast Revascularisation during InStability in CAD" (FRISC II) Study. Women were older, had less severe CAD and a better prognosis than men. Men had a more favourable outcome if randomised to early revascularisation, whereas there was an opposite trend in women, although not significant. The different outcome in women may partly be explained by A high procedure-related event rate in the invasive group compared to the non-invasive group, and an overall low event rate during follow-up. Further research is needed in this area, and in the mean time, a more conservative approach to revascularisation in women, guided by risk stratification seems reasonable.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2000. , 110 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 647
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-27546Local ID: 12207ISBN: 91-7219-748-X (print)OAI: oai:DiVA.org:liu-27546DiVA: diva2:248098
Public defence
2000-11-10, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-08-15Bibliographically approved
List of papers
1. Unstable coronary artery disease in post-menopausal women: Identifying patients with significant coronary artery disease by basic clinical parameters and exercise test
Open this publication in new window or tab >>Unstable coronary artery disease in post-menopausal women: Identifying patients with significant coronary artery disease by basic clinical parameters and exercise test
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1998 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 19, no 6, 899-907 p.Article in journal (Refereed) Published
Abstract [en]

Background The diagnostic information from an ECG taken while at rest and an exercise test is considered less reliable in women than in men, mostly due to a high percentage offalse-positive tests. This can be explained by a lower pre-test likelihood of coronary heart disease.

Aims To evaluate the diagnostic information that can be gained from basic clinical parameters, an ECG and exercise test in a group of post-menopausal women with symptoms of unstable coronary artery disease in order to identify patients with significant coronary artery stenoses.

Methods and Results We prospectively studied 200 postmenopausal women admitted to the coronary care unit with symptoms of unstable coronary artery disease and ECG changes suggestive of ischaemia. The diagnostic value of common risk factors, myocardial enzymes and an early exercise test were assessed. A coronary angiogram was performed within 60 days. Median age was 67 years. On admission, 38% had ST depression on an ECG taken while at rest, 76% had T-wave inversion, and 41% increased enzyme levels. The coronary angiogram revealed that 15% had no atherosclerosis, 14% had atherosclerosis but no lesion ≥ 50% of luminal diameter and 71 % had at least one significant stenosis. Of patients with known indicators of atherosclerotic disease, all but one had atherosclerosis visualized on the coronary angiogram. A relative ST depression ≥ 0·1 m V and a low maximum workload at exercise test were strong predictors of significant coronary artery disease. The positive predictive value of ST depression was 91% and of low maximum workload 84%.

Conclusion In post-menopausal women with signs of unstable angina and ischaemia on an ECG taken while at rest, the prevalence of coronary atherosclerosis is high, 85%. Contrary to earlier studies, ST T-changes at the early exercise test had a high positive predictive value, especially in combination with a low maximum workload with no false-positive results.

Keyword
women, coronary angiography, unstable angina, exercise test, electrocardiography, risk factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26815 (URN)10.1053/euhj.1997.0867 (DOI)11427 (Local ID)11427 (Archive number)11427 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
2. Early symptom-limited exercise test for risk stratification in post menopausal women with unstable coronary artery disease
Open this publication in new window or tab >>Early symptom-limited exercise test for risk stratification in post menopausal women with unstable coronary artery disease
2000 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 21, no 3, 230-238 p.Article in journal (Refereed) Published
Abstract [en]

Aims The exercise test is considered less reliable in women than in men both for diagnostic and prognostic purposes. The value, however, of the exercise test might vary with the population that is examined, the way the test is performed and which exercise test variables are taken into consideration in the analysis. The aim of the study was to evaluate an early symptom-limited exercise test as a tool for risk stratification in women with unstable coronary artery disease admitted to the coronary care unit.

Methods and Results Of the 543 women in the FRISC I study, 395 stabilized on medical treatment and performed a symptom-limited exercise test 5–8 days after inclusion. Sixteen patients with a cardiac event before the scheduled exercise test were excluded. During the 6 months follow-up 17% of the women who did not perform the exercise test and 9% of the 395 women who did, died or had a myocardial infarction (P<0·01). Multivariate stepwise logistic regression analysis was performed to assess the value of clinical variables and findings at the predischarge exercise test to predict cardiac events. Based on the exercise test results three risk groups were identified with an event rate of 19%, 9% and 1%, respectively. The exercise test was better than any of the tested clinical variables in predicting cardiac events.

Conclusion Women with unstable coronary artery disease who do not stabilize within a few days have a high event rate early during follow-up. For women who are medically stabilized, considering not only variables like ST depression and chest pain but also parameters reflecting the cardiac performance such as maximal workload and increase in rate-pressure product, an early symptom-limited exercise test is a good predictor of future cardiac events.

Keyword
Women, unstable angina, exercise test, prognosis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-27174 (URN)10.1053/euhj.1999.1735 (DOI)11823 (Local ID)11823 (Archive number)11823 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Risk stratification in unstable coronary artery disease: Exercise test and troponin T from a gender perspective
Open this publication in new window or tab >>Risk stratification in unstable coronary artery disease: Exercise test and troponin T from a gender perspective
2000 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 35, no 7, 1791-1800 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES

The study was done to determine the prognostic yield of an early symptom-limited exercise test (ET) and measurement of troponin T (TnT) in men and women with unstable coronary artery disease (CAD), with special reference to gender differences.

BACKGROUND

Early risk assessment is essential for the application of appropriate treatment and further management in patients with unstable CAD. The early symptom-limited ET together with specific biochemical marker determination is an inexpensive, widely applicable method for early risk stratification. In women, however, the ET is considered less reliable, and there are few data on biochemical markers for risk stratification in women.

METHODS

In a substudy of the Fragmin during InStability in Coronary artery disease (FRISC I) trial, 395 women and 778 men with unstable CAD who performed an early ET were followed for six months. Blood samples for TnT determination were taken in 342 women and 621 men at inclusion.

RESULTS

Based on the ET results, low-, intermediate-, and high-risk response groups were identified with event rates of cardiac death or myocardial infarction (MI) of 1%, 9%, and 19%, respectively, among women and 8%, 14%, and 20%, respectively, among men. Patients who could not perform the ET had an event rate similar to the high-risk group. The TnT levels were divided into three groups: <0.06, 0.06–0.19, and ≥0.20 μg/liter with event rates of 1%, 10%, and 18%, respectively, among women and 9%, 14%, and 18%, respectively, among men. Combining the ET results with TnT levels identified a low-risk group with an event rate of 3% in the male population and no events in the female population.

CONCLUSIONS

Direct comparison between men and women from the same population with a high pretest likelihood of disease suggests that both TnT and the early symptom-limited ET are at least as useful as prognostic risk indicators in women as they are in men.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-27170 (URN)10.1016/S0735-1097(00)00655-0 (DOI)11819 (Local ID)11819 (Archive number)11819 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
4. Assessment of the presence and extent of coronary artery disease in postmenopausal women after an episode of unstable coronary artery disease: incremental value of exercise electrocardiography and thallium-201 SPECT
Open this publication in new window or tab >>Assessment of the presence and extent of coronary artery disease in postmenopausal women after an episode of unstable coronary artery disease: incremental value of exercise electrocardiography and thallium-201 SPECT
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims To compare the incremental diagnostic properties of Thallium-201 (201TI) SPECT perfusion imaging with clinical and exercise test variables in a female population with a suspected high prevalence of coronary artery disease.

Methods and Results We prospectively studied 121 postmenopausal women admitted to the coronary care unit with symptoms of unstable coronary artery disease and ECG changes suggestive of ischaemia. Incremental diagnostic logistic algorithms were developed. These included pretest variables (age; body mass index; previous myocardial infarction; myocardial markers at inclusion and type of anginal symptoms); exercise test (maximum workload; occurrence of ST-depression ≥ 0.1mV and peak heart rate); and 201TI scintigram (extent of thallium uptake abnormalities during exercise and presence of reversibility). End points were presence of coronary artery disease (250% diameter stenosis) and extent ('severe coronary artery disease' defined as left main, three vessel disease and two vessel disease involving proximal left anterior descending). Diagnostic accuracy and incremental value were assessed by receiver operating characteristic curve analysis. Incremental curve areas for disease presence were pretest 0.76 ±0.04, post-exercise ECG 0.83 ±0.04 (p<0.02 for the increment), and post-thallium scintigraphy 0.89 ±0.03 (p<0.02) and for disease extent were pretest 0.82 ±0.04, post-exercise ECG 0.89 ±0.03 (p<0.01 for the increment), and post thallium scintigraphy 0.92 ±0.02 (p = ns).

Conclusion In postmenopausal women, stable after an episode of unstable coronary artery disease, there is an incremental value of adding 201TI SPECT to clinical parameters and exercise testing in the determination of coronary artery disease. In women with severe coronary artery disease there was no significant additive value of myocardial scintigraphy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79932 (URN)
Available from: 2012-08-15 Created: 2012-08-15 Last updated: 2013-09-11Bibliographically approved
5. Are There Different Effects of Invasive Treatment Between Women and Men During the Acute Stage of Unstable Coronary Artery Disease?
Open this publication in new window or tab >>Are There Different Effects of Invasive Treatment Between Women and Men During the Acute Stage of Unstable Coronary Artery Disease?
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

OBJECTIVES The FRISC II invasive trial compared an early invasive versus a noninvasive strategy concerning death and MI in CAD. This paper deals with the gender perspective in the same study.

METHODS There were 749 women and 1708 men included in the study with a mean age of 66 and 64 years in women and men respectively. The patients were randomized to early invasive or noninvasive strategy and to placebo controlled long-term low molecular mass (1mm) heparin ( dalteparin) treatment for 3 months. Coronary angiographies were performed within the first seven days in 96 % and 10 % and revascularisation was performed within the first 10 days in 71 % and 9 % in the invasive and noninvasive groups, respectively.

RESULTS Women were older but had less previous infarctions, better left ventricular function and less frequently had elevated troponin-levels. There were more patients with normal coronary arteries and less severe coronary artery lesions amongst the women. Accordingly, less interventions were performed in the female group although, among those who were revascularized, there was. no significant difference in the choice of procedure compared to men. There was no difference in the composite endpoint of MI and death at 12 months amongst women (12.4 vs. 10.5% in the invasive and non-invasive groups respectively) in contrast to the very favorable effect of the invasively treated group amongst the men (9.6 vs. 15.8%, p<0.001). In a multivariate interaction analysis there was different effect of early invasive strategy in the two genders (p=0.008)

CONCLUSIONS Women with symptoms and/or signs of unstable coronary artery disease are older but still have less severe CAD and a better prognosis than men. In contrast to men, an early invasive strategy did not reduce the risk for future events amongst women. Further research is warranted to identify the most appropriate treatment strategy in women with unstable CAD.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79933 (URN)
Available from: 2012-08-15 Created: 2012-08-15 Last updated: 2013-09-11Bibliographically approved

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