Current issues of ACP Journal Club are published in Annals of Internal Medicine


Prognosis

Women with angina pectoris had longer survival and subsequent coronary heart disease events than men

ACP J Club. 1993 Nov-Dec;119:81. doi:10.7326/ACPJC-1993-119-3-081


Source Citation

Orencia A, Bailey K, Yawn BP, Kottke TE. Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death. JAMA. 1993 May 12,269:2392-7.


Abstract

Objective

To determine the effect of female gender on long-term survival and subsequent coronary heart disease events in patients with the first clinical manifestations of angina pectoris.

Design

Inception cohort identified from 1960 to 1979 and followed through 1982.

Setting

Community-based study in Rochester, Minnesota.

Patients

1033 patients (mean age 64 y, 53% women) with a first episode of angina pectoris based only on the history obtained from the patient (objective evidence of cardiac disease or abnormalities in resting or exercise electrocardiogram were not required for diagnosis). Exclusion criteria were congestive heart failure not caused by recent myocardial infarction and clinically significant valvular heart disease.

Assessment of prognostic factors

Age, gender, and year of diagnosis obtained from medical records.

Main outcome measures

Survival and subsequent coronary heart disease events including myocardial infarction (MI) and cardiac death.

Main results

Women presenting with angina pectoris were older than men (67 y vs 60 y, P < 0.001). 10-year survival was 70% for women compared with 59% for men ( P < 0.001). When stratified into 4 age groups (35 to 59 y, 60 to 69 y, 70 to 79 y, and ≥ 80 y), the longer survival of women was more apparent. In a multivariate proportional hazards model, female gender was associated with a lower risk for death (relative risk [RR] 0.45, 95% CI 0.37 to 0.55), whereas advancing age was associated with an increasing risk for death (RR 1.76 per 10-y increase in age, CI 1.59 to 1.95). There were no significant interactions among age, year of diagnosis, and gender. Risk for subsequent MI and cardiac death was lower for women than for men ( P < 0.001). When stratified by age, women still had a lower risk for MI and cardiac death. The risk for subsequent MI and cardiac death increased more rapidly for women (RR 1.58 per 10-y increase in age, Cl 1.33 to 1.89) than for men (RR 1.20, Cl 1.05 to 1.36). When adjusted for age, women had a risk for subsequent MI and cardiac death that was 0.47 times the risk for men (Cl 0.42 to 0.58).

Conclusion

Women with an initial diagnosis of angina pectoris had longer survival and lower risk for subsequent myocardial infarction and cardiac death than did men with the same presentation and of a similar age.

Source of funding: National Institutes of Health.

For article reprint: Dr. T.E. Kottke, Mayo Clinic, Harwick Building, Room 669, Rochester, MN 55905, USA. FAX 507-284-9349.


Commentary

In recent years there has been growing interest in coronary artery disease in women, particularly with regard to gender differences. We know from the Framingham study that women develop coronary disease at an older age and often have different presenting manifestations. For example, women are more likely to have chest pain as their initial symptom (1). Several studies have investigated gender differences with respect to outcome after myocardial infarction but relatively few have examined outcomes after diagnosis of angina.

The study by Orencia and colleagues compares outcomes in men and women with angina pectoris. The diagnosis of angina was based on symptoms alone and did not require objective evidence of ischemia. Details regarding the character of chest pain or the frequency of typical compared with atypical pain were not provided. The finding of a more favorable prognosis in women with an initial diagnosis of angina is encouraging but may be misleading. As the authors acknowledge, angina is often more difficult to diagnose in women. Symptoms tend to be less typical and are often attributed to other causes. In addition, objective studies used to confirm the diagnosis, such as treadmill exercise testing, are more likely to have false-positive results when applied to women (2). Further, women with angina are significantly more likely to have normal coronary anatomy or insignificant disease when studied with coronary arteriography. In this cohort of patients it is, therefore, difficult to assess the proportion of female patients with significant coronary artery disease at inception.

Despite these shortcomings, this study provides additional insights to our growing epidemiologic knowledge regarding coronary artery disease in women.

Vivian L. Clark, MD
Henry Ford HospitalDetroit, Michigan, USA


References

1. Kannel WB, Sorlie P, McNamara PM. Prognosis after initial myocardial infarction: The Framingham Study. Am J Cardiol. 1977:44;53.

2. Detry JR, Kapta BM, Cosyns J, et al. Diagnostic value of history and maximal exercise electrocardiography in men and women suspected of coronary heart disease. Circulation. 1977;56:756-61.