Mark D B, Shaw L K, DeLong E R, Califf R M, Pryor D B
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
N Engl J Med. 1994 Apr 21;330(16):1101-6. doi: 10.1056/NEJM199404213301601.
It has been suggested that women with clinical evidence of coronary artery disease are less often referred for cardiac catheterization than are men. To determine whether there is sex-related bias in referral for cardiac catheterization, we prospectively studied a cohort of 410 symptomatic outpatients (280 men and 130 women) who were being evaluated with exercise testing for possible-coronary artery disease.
Before the patients underwent exercise testing, 15 cardiologists from an academic medical center were asked to predict the probability that the patients they saw in the cardiology clinic would have angiographic evidence of any obstructive coronary disease (stenosis of 75 percent or more); the probability of severe coronary disease (three-vessel or left main coronary artery disease); the probability of left main coronary artery disease; and the probability of survival one, three, and five years after the evaluation. Similar predictions were generated by previously validated statistical models with use of data collected before exercise testing from the history, physical examination, and 12-lead electrocardiography with the patient at rest.
Overall, women were referred for cardiac catheterization significantly less often than men (18 percent vs. 27 percent, P = 0.03). As compared with men, women had a significantly lower pretest probability of coronary disease (as estimated by their physicians) and a lower rate of positive exercise-test results. After accounting for differences in these two factors, sex was not an independent predictor of referral for catheterization. Comparing physicians' estimates of outcome with those generated by the statistical models revealed no evidence that the physicians were underestimating the risk of coronary disease in women. Furthermore, physicians' predictions did not underestimate the probability of any obstructive coronary disease in men and women who subsequently underwent catheterization.
Academic cardiologists made appropriately lower pretest predictions of categories of disease in women with possible coronary artery disease than in men, and these assessments, along with women's lower rate of positive exercise tests, rather than bias based on sex, accounted for the lower rate of catheterization among women.
有人提出，有冠状动脉疾病临床证据的女性接受心脏导管插入术的比例低于男性。为了确定在心脏导管插入术的转诊中是否存在性别相关偏见，我们前瞻性地研究了一组410名有症状的门诊患者（280名男性和130名女性），他们正在接受运动试验以评估是否可能患有冠状动脉疾病。
在患者进行运动试验之前，来自一所学术医疗中心的15位心脏病专家被要求预测他们在心脏病诊所看到的患者有任何阻塞性冠状动脉疾病（狭窄75%或更高）的血管造影证据的概率；严重冠状动脉疾病（三支血管或左主干冠状动脉疾病）的概率；左主干冠状动脉疾病的概率；以及评估后1年、3年和5年的存活概率。使用运动试验前从病史、体格检查和静息状态下的12导联心电图收集的数据，通过先前验证的统计模型生成类似的预测。
总体而言，女性接受心脏导管插入术的比例显著低于男性（18%对27%，P = 0.03）。与男性相比，女性冠状动脉疾病的预检概率（由其医生估计）显著较低，运动试验阳性率也较低。在考虑这两个因素的差异后，性别不是导管插入术转诊的独立预测因素。将医生对结果的估计与统计模型生成的估计进行比较，没有证据表明医生低估了女性冠状动脉疾病的风险。此外，医生的预测并没有低估随后接受导管插入术的男性和女性有任何阻塞性冠状动脉疾病的概率。
学术心脏病专家对可能患有冠状动脉疾病的女性疾病类别的预检预测比男性适当低，这些评估以及女性较低的运动试验阳性率，而非基于性别的偏见，导致了女性导管插入术比例较低。
