Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients with Suspected Coronary Artery Disease Insights from the PROMISE Trial

Kshipra Hemal, Neha J. Pagidipati, Adrian Coles, Rowena J. Dolor, Daniel B. Mark, Patricia Pellikka, Udo Hoffmann, Sheldon E. Litwin, Melissa A. Daubert, Svati H. Shah, Kevin Ariani, Renée P. Bullock-Palmer, Beth Martinez, Kerry L. Lee, Pamela S. Douglas

Research output: Contribution to journalArticle

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Abstract

Objectives The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as "crushing/pressure/squeezing/tightness" in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. Conclusions Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

Original languageEnglish (US)
Pages (from-to)337-346
Number of pages10
JournalJACC: Cardiovascular Imaging
Volume9
Issue number4
DOIs
StatePublished - Apr 1 2016

Fingerprint

Chest Pain
Sex Characteristics
Multicenter Studies
Coronary Artery Disease
Outpatients
Demography
Nonparametric Statistics
Diamond
Smoke
Body Mass Index
Logistic Models
Odds Ratio
Confidence Intervals
Pressure

Keywords

  • angina
  • CAD
  • risk factors
  • sex

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging

Cite this

Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients with Suspected Coronary Artery Disease Insights from the PROMISE Trial. / Hemal, Kshipra; Pagidipati, Neha J.; Coles, Adrian; Dolor, Rowena J.; Mark, Daniel B.; Pellikka, Patricia; Hoffmann, Udo; Litwin, Sheldon E.; Daubert, Melissa A.; Shah, Svati H.; Ariani, Kevin; Bullock-Palmer, Renée P.; Martinez, Beth; Lee, Kerry L.; Douglas, Pamela S.

In: JACC: Cardiovascular Imaging, Vol. 9, No. 4, 01.04.2016, p. 337-346.

Research output: Contribution to journalArticle

Hemal, K, Pagidipati, NJ, Coles, A, Dolor, RJ, Mark, DB, Pellikka, P, Hoffmann, U, Litwin, SE, Daubert, MA, Shah, SH, Ariani, K, Bullock-Palmer, RP, Martinez, B, Lee, KL & Douglas, PS 2016, 'Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients with Suspected Coronary Artery Disease Insights from the PROMISE Trial', JACC: Cardiovascular Imaging, vol. 9, no. 4, pp. 337-346. https://doi.org/10.1016/j.jcmg.2016.02.001
Hemal, Kshipra ; Pagidipati, Neha J. ; Coles, Adrian ; Dolor, Rowena J. ; Mark, Daniel B. ; Pellikka, Patricia ; Hoffmann, Udo ; Litwin, Sheldon E. ; Daubert, Melissa A. ; Shah, Svati H. ; Ariani, Kevin ; Bullock-Palmer, Renée P. ; Martinez, Beth ; Lee, Kerry L. ; Douglas, Pamela S. / Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients with Suspected Coronary Artery Disease Insights from the PROMISE Trial. In: JACC: Cardiovascular Imaging. 2016 ; Vol. 9, No. 4. pp. 337-346.
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abstract = "Objectives The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6{\%} vs. 63.2{\%}), dyslipidemic (68.9{\%} vs. 66.3{\%}), and to have a family history of premature CAD (34.6{\%} vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6{\%} vs. 57.0{\%}; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8{\%} vs. 21.0{\%}; p = 0.30). Chest pain was the primary symptom in 73.2{\%} of women versus 72.3{\%} of men (p = 0.30), and was characterized as {"}crushing/pressure/squeezing/tightness{"} in 52.5{\%} of women versus 46.2{\%} of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30{\%}) pre-test probability of CAD (40.7{\%} vs. 34.1{\%}; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95{\%} confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7{\%} vs. 15.1{\%}; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. Conclusions Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.",
keywords = "angina, CAD, risk factors, sex",
author = "Kshipra Hemal and Pagidipati, {Neha J.} and Adrian Coles and Dolor, {Rowena J.} and Mark, {Daniel B.} and Patricia Pellikka and Udo Hoffmann and Litwin, {Sheldon E.} and Daubert, {Melissa A.} and Shah, {Svati H.} and Kevin Ariani and Bullock-Palmer, {Ren{\'e}e P.} and Beth Martinez and Lee, {Kerry L.} and Douglas, {Pamela S.}",
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T1 - Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients with Suspected Coronary Artery Disease Insights from the PROMISE Trial

AU - Hemal, Kshipra

AU - Pagidipati, Neha J.

AU - Coles, Adrian

AU - Dolor, Rowena J.

AU - Mark, Daniel B.

AU - Pellikka, Patricia

AU - Hoffmann, Udo

AU - Litwin, Sheldon E.

AU - Daubert, Melissa A.

AU - Shah, Svati H.

AU - Ariani, Kevin

AU - Bullock-Palmer, Renée P.

AU - Martinez, Beth

AU - Lee, Kerry L.

AU - Douglas, Pamela S.

PY - 2016/4/1

Y1 - 2016/4/1

N2 - Objectives The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as "crushing/pressure/squeezing/tightness" in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. Conclusions Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

AB - Objectives The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as "crushing/pressure/squeezing/tightness" in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. Conclusions Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

KW - angina

KW - CAD

KW - risk factors

KW - sex

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