Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
Am Heart J. 2019 Feb;208:28-36. doi: 10.1016/j.ahj.2018.11.002. Epub 2018 Nov 9.
Although sex differences exist in the management of acute coronary syndromes, less is known about the management and outcomes of women and men with suspected coronary artery disease being evaluated with noninvasive testing (NIT).
We investigated sex-based differences in NIT results and subsequent clinical management in 4,720 women and 4,246 men randomized to CT angiography versus stress testing in the PROMISE trial. Logistic regression models assessed relationships between sex and referral for catheterization, revascularization, and aspirin or statin use. Cox regression models assessed the relationship between sex and the composite of all-cause death, myocardial infarction, or unstable angina.
Women more often had normal NITs than men (61.0% vs 49.6%, P < .001) and less often had mild (29.3% vs 35.4%, P < .001), moderate (4.0% vs 6.8%, P < .001), or severe abnormalities (5.7% vs 8.3%, P < .001) found on NIT. Women were less likely to be referred for catheterization than men (7.6% vs 12.6%, adjusted OR 0.75 [0.62-0.90]; P = .002). Of those who underwent catheterization within 90 days of randomization (358 women, 534 men), fewer women than men had obstructive coronary artery disease (40.8% vs 60.9%, P < .001). At a 60-day visit, women were significantly less likely than men to report statin use when indicated (adjusted OR 0.81 [0.73-0.91]; P < .001) but were similarly likely to report aspirin use when indicated (adjusted OR 0.78 [0.56-1.08]; P = .13). Over a median follow-up of 25 months, women had better outcomes than men (adjusted OR 0.73 [0.57-0.94]; P = .017).
Although women more frequently had normal NITs compared with men, those with abnormalities on NIT were less likely to be referred for catheterization or to receive statin therapy. The high rates of negative NIT in women, coupled with the better outcomes compared with men, strongly support the need for a sex-specific algorithm to guide NIT and chest pain management.
尽管急性冠状动脉综合征的治疗存在性别差异，但对于接受非侵入性检查（NIT）评估的疑似冠状动脉疾病的女性和男性的治疗和结局，人们知之甚少。
我们研究了 PROMISE 试验中 4720 名女性和 4246 名男性在 CT 血管造影与应激试验之间随机分组后，NIT 结果和随后临床治疗的性别差异。Logistic 回归模型评估了性别与经导管治疗、血运重建、阿司匹林或他汀类药物使用之间的关系。Cox 回归模型评估了性别与全因死亡、心肌梗死或不稳定型心绞痛的复合终点之间的关系。
与男性相比，女性更常出现正常的 NIT（61.0%比 49.6%，P<0.001），更常出现轻度（29.3%比 35.4%，P<0.001）、中度（4.0%比 6.8%，P<0.001）和严重异常（5.7%比 8.3%，P<0.001）的 NIT。与男性相比，女性更不可能被推荐进行经导管治疗（7.6%比 12.6%，调整后 OR 0.75[0.62-0.90]；P=0.002）。在随机分组后 90 天内接受经导管治疗的患者中（358 名女性，534 名男性），女性中阻塞性冠状动脉疾病的比例低于男性（40.8%比 60.9%，P<0.001）。在 60 天的随访中，与男性相比，女性在有指征时使用他汀类药物的可能性显著降低（调整后 OR 0.81[0.73-0.91]；P<0.001），但在有指征时使用阿司匹林的可能性相似（调整后 OR 0.78[0.56-1.08]；P=0.13）。在中位随访 25 个月期间，女性的结局优于男性（调整后 OR 0.73[0.57-0.94]；P=0.017）。
尽管与男性相比，女性更常出现正常的 NIT，但 NIT 异常的患者更不可能被推荐进行经导管治疗或接受他汀类药物治疗。女性出现阴性 NIT 的比例较高，且与男性相比结局更好，这强烈支持制定一种基于性别的算法来指导 NIT 和胸痛管理。
