Lauer M S, Pashkow F J, Snader C E, Harvey S A, Thomas J D, Marwick T H
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Am Heart J. 1997 Nov;134(5 Pt 1):807-13. doi: 10.1016/s0002-8703(97)80003-8.
Controversy exists as to whether a sex bias exists that affects the diagnostic approach to suspected coronary artery disease: previous studies have used coronary angiography, but not other noninvasive testing, as a primary end point. This investigation examined posttest sex differences in diagnostic evaluation after exercise treadmill testing according to a broader end point than just coronary angiography alone. The design was a cohort analytic study with a 90-day follow-up. The study was done at the Cleveland Clinic Foundation, an academic group practice. Patients included consecutive adults (1023 men and 579 women) with chest pain but no documented coronary disease who were referred for symptom-limited exercise treadmill testing without adjunctive imaging; none had undergone prior invasive cardiac procedures. Main outcome measures included (1) performance of any subsequent diagnostic study (invasive or noninvasive) and (2) performance of coronary angiography as the next diagnostic study. During follow-up, 89 (8.7%) men and 48 (8.3%) women underwent a second diagnostic study (odds ratio 0.95; 95% confidence interval 0.66 to 1.37; p > 0.8), whereas 64 (6.3%) men and 21 (3.6%) women went straight to coronary angiography (odds ratio 0.56; 95% confidence interval 0.34 to 0.93; p = 0.02). In multivariable logistic regression analyses, which considered baseline clinical characteristics, the ST-segment response, and other prognostically important exercise responses, women tended to be less likely than men to be referred to any second test (adjusted odds ratio 0.70; 95% confidence interval 0.42 to 1.19; p > 0.1) but were markedly and significantly less likely to be referred straight to coronary angiography (adjusted odds ratio 0.33; 95% confidence interval 0.17 to 0.65). After exercise treadmill testing, women were only slightly less likely than men to be referred for subsequent diagnostic testing; they were, however, much less likely to be referred straight to coronary angiography as opposed to another noninvasive study.
以往的研究将冠状动脉造影而非其他非侵入性检测作为主要终点。本研究根据比单纯冠状动脉造影更广泛的终点，研究了运动平板试验后诊断评估中的检测后性别差异。研究设计为一项随访90天的队列分析研究。该研究在克利夫兰诊所基金会进行，这是一个学术团体诊所。患者包括连续的成年胸痛患者（1023名男性和579名女性），他们没有记录在案的冠状动脉疾病，因症状限制的运动平板试验而被转诊，且未进行辅助成像；没有人接受过先前的侵入性心脏检查。主要结局指标包括：（1）进行任何后续诊断性检查（侵入性或非侵入性）；（2）进行冠状动脉造影作为下一项诊断性检查。在随访期间，89名（8.7%）男性和48名（8.3%）女性接受了第二次诊断性检查（比值比0.95；95%置信区间0.66至1.37；p>0.8），而64名（6.3%）男性和21名（3.6%）女性直接进行了冠状动脉造影（比值比0.56；95%置信区间0.34至0.93；p=0.02）。在考虑基线临床特征、ST段反应和其他对预后重要的运动反应的多变量逻辑回归分析中，女性被转诊进行任何第二次检查的可能性往往低于男性（调整后的比值比0.70；95%置信区间0.42至1.19；p>0.1），但被直接转诊进行冠状动脉造影的可能性显著降低（调整后的比值比0.33；95%置信区间0.17至0.65）。运动平板试验后，女性被转诊进行后续诊断性检查的可能性仅略低于男性；然而，与另一项非侵入性检查相比，她们被直接转诊进行冠状动脉造影的可能性要低得多。
