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Gender Differences in the Noninvasive Evaluation and Management of Patients with Suspected Coronary Artery Disease

Leslee J. Shaw, PhD; D. Douglas Miller, MD; James C. Romeis, PhD; Deborah Kargl, BS; Liwa T. Younis, MD, PhD; and Bernard R. Chaitman, MD
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From St. Louis University School of Medicine, St. Louis, Missouri; the Health Services Research and Development Program, Durham, North Carolina. Requests for Reprints: D. Douglas Miller, MD, St. Louis University Medical Center, Division of Cardiology, 3635 Vista Avenue at Grand Boulevard, P.O. Box 15250, St. Louis, MO 63110-0250. Acknowledgments: The authors thank Robert McMahon, PhD, from the Maryland Medical Research Institute, Baltimore, Maryland for his statistical advice. Grant Support: In part by a grant from the Lichtenstein Foundation, St. Louis, Missouri.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(7):559-566. doi:10.7326/0003-4819-120-7-199404010-00005
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Objective: To determine if gender-based differences exist in the posttest management and clinical outcome of patients with clinically suspected coronary artery disease who have stress electrocardiographic or myocardial perfusion imaging evaluation.

Design: Retrospective cohort study.

Setting: University medical center.

Patients: From a cohort of 3975 middle-aged patients referred for outpatient stress testing, 840 (47% women) were evaluated noninvasively for clinically suspected coronary artery disease.

Measurements: The rates of subsequent diagnostic procedures and the incidence of subsequent coronary revascularization, myocardial infarction, or cardiac death were determined for women and men.

Results: Pretest cardiac risk profiles were similar, except hypertension and hypercholesterolemia were more frequent in women. Atypical angina was more common in women than in men (57.5% compared with 44.5%, respectively; P < 0.001). Rates of initial test positivity (defined as exercise-induced horizontal or downsloping ST-segment depression ≥ 1.0 mm or ≥ 1 reversible thallium-201 defect) were similar in women and men. Compared with men, most women with an initial positive test result had no additional coronary artery disease evaluation (62.3% compared with 38.0%; P = 0.002). Coronary revascularization procedures were done more frequently in men (4.9% [22 of 449] compared with 2.0% [8 of 391]; P = 0.03). Cardiac death or myocardial infarction occurred more often in women during 2 years of follow-up (6.9% [27 of 391] compared with 2.4% [11 of 449]; P = 0.002).

Conclusions: Women with suspected coronary artery disease have fewer additional diagnostic tests than men after an initial abnormal noninvasive stress test result, even though the incidence of typical angina, cardiac risk factors, and initial diagnostic test positivity rates are similar.


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Figure 1.
A gender-based comparison of noninvasive test use rates over time.PP

A greater percentage of men received follow-up noninvasive testing (NIVT) compared with women ( < 0.001). Similarly, a comparison of use of coronary arteriography during the 2-year follow-up period showed that a greater percentage of men than women subsequently had catheterization (Cath) ( < 0.001).

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Figure 2.
Cardiac events by gender.P

No cardiac events were recorded in women or in men who subsequently had catheterization (were revascularized [REV]). Patients who were revascularized had greater cardiac event-free survival ( < 0.001).

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