Many Cardiovascular Deaths Occur in Women Without Obstructive Coronary Artery Disease
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
The WISE study (Women's Ischemia Syndrome Evaluation) was a prospective cohort study of 936 clinically stable symptomatic women who underwent coronary angiography to evaluate symptoms and signs of ischemia. Long-term mortality data for such women are limited.
METHODS AND RESULTS
Obstructive coronary artery disease (CAD) was defined as ≥50% stenosis on angiography by core laboratory. We conducted a National Death Index search to assess the mortality of women who were alive at their final WISE contact date. Death certificates were obtained. All deaths were adjudicated as cardiovascular or noncardiovascular by a panel of WISE cardiologists masked to angiographic data. Multivariate Cox proportional hazards regression was used to identify significant independent predictors of mortality. At baseline, mean age was 58±12 years; 176 (19%) were non-white, primarily black; 25% had a history of diabetes mellitus, 59% hypertension, 55% dyslipidemia, and 59% had a body mass index ≥30. During a median follow-up of 9.5 years (range, 0.2-11.5 years), a total of 184 (20%) died. Of these, 115 (62%) were cardiovascular deaths; 31% of all cardiovascular deaths occurred in women without obstructive CAD (<50% stenosis). Independent predictors of mortality were obstructive CAD, age, baseline systolic blood pressure, history of diabetes mellitus, history of smoking, elevated triglycerides, and estimated glomerular filtration rate.
CONCLUSIONS
Among women referred for coronary angiography for signs and symptoms of ischemia, 1 in 5 died from predominantly cardiac pathogeneses within 9 years of angiographic evaluation. A majority of the factors contributing to the risk of death seem to be modifiable by existing therapies. Of note, 1 in 3 of the deaths in this cohort occurred in women without obstructive CAD, a condition often considered benign and without guideline-recommended treatments. Clinical trials are needed to provide treatment guidance for the group without obstructive CAD.
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Additional Info
Ten-Year Mortality in the WISE Study (Women's Ischemia Syndrome Evaluation)
Circ Cardiovasc Qual Outcomes 2017 Dec 01;10(12)e003863, TS Kenkre, P Malhotra, BD Johnson, EM Handberg, DV Thompson, OC Marroquin, WJ Rogers, CJ Pepine, CN Bairey Merz, SF KelseyFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The WISE Study: Shining New Light on Causes of Death in Women With Signs and Symptoms of Coronary Ischemia
In the current study by Kenkre and colleagues, the authors examined causes and predictors of death for 936 women enrolled in the WISE study. The WISE study was a prospective cohort study of women who underwent coronary angiography to evaluate symptoms and signs of ischemia and who were followed for clinical outcomes. At baseline, the mean age of the population was 58 ± 12 years, 19% were non-white, and 25% had a history of diabetes mellitus. Among the notable findings, this population of relatively young women had a high rate of death. During a median follow-up of 9.5 years, the rate of all-cause mortality was 20% in the WISE cohort with a cardiac mortality rate of 12%. Independent predictors of mortality included the presence of significant coronary disease (>50% stenosis), age, baseline systolic blood pressure, history of diabetes mellitus, smoking, elevated triglycerides, and estimated glomerular filtration rate. The authors comment that many of these risk factors may be modifiable through either lifestyle changes or appropriate medication therapy.
Notably, 31% of all cardiovascular deaths occurred in women without obstructive CAD, translating into a 10-year risk of 13% that exceeds the proposed ACC/AHA threshold for initiation of statin therapy. Research has only recently begun to investigate why some women with signs and symptoms of ischemia have a high rate of death despite the absence of obstructive CAD. Unfortunately, the current analysis did not provide additional information regarding specific causes of cardiovascular death (eg, fatal MI, arrhythmia, heart failure, etc) in this patient population. This information could be revealing, as it may provide insights into preferred therapies to mitigate risk in this undertreated patient population. Perhaps surprisingly, the current or prior use of hormone replacement therapy was associated with a lower risk of cardiac mortality in the WISE cohort. However, given that the use of HRT has been previously shown to track with several socioeconomic factors that are associated with improved outcomes, these results may be confounded and are not currently supported by randomized trial data. In all, the current findings shine new light on disease progression in a patient population that is often understudied and undertreated.