Are there gender differences in patients presenting with unstable angina?

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Abstract

Background: There are limited studies on gender differences in patients with unstable angina. We investigated the influence of gender in these patients in a tertiary referral centre. Methods and results: Three hundred and thirteen consecutive patients (210 men and 103 women) with unstable angina were studied over a 42-month period. Patient characteristics, cardiovascular risk factors and subsequent management including coronary artery bypass graft (CABG) operation and percutaneous transluminal coronary angioplasty (PTCA) were investigated. There was no difference in age [61.6 (11.0) (S.D.) years for men vs. 63.5 (10.5) years for women]. Diabetes mellitus and hypertension were more common in women (diabetes, 11% vs. 23%, P=0.007; hypertension, 32% vs. 52%; P=0.001). The number of smokers was greater in men (73% vs. 46%, P=0.00001). There was no difference in the prevalence of hypercholesterolaemia or in the incidence of previous myocardial infarction, previous history of angina and family history of ischaemic heart disease. The duration of unstable angina before presentation to the referring hospital was similar in both sexes. The use of aspirin, intravenous heparin and antianginal drugs was also comparable in the two genders. The number of coronary arteries involved in men and women appeared similar (one vessel, 22% vs. 27%; two vessels, 26% vs. 21%; three vessels, 52% vs. 52% in men and women, respectively). The proportion of men and women who underwent subsequent revascularisation was also similar (CABG, 31% vs. 33%; PTCA, 42% vs. 40%). The overall in-hospital mortality was higher in women (6.8% vs. 2.8%), but was not statistically significant (P=0.18). Conclusions: Gender differences in unstable angina manifest in the preponderance of selected risk factors including diabetes mellitus and hypertension in women and smoking in men. There is no difference in age, the degree of coronary artery involvement and the subsequent management in a tertiary referral centre.

Introduction

Coronary artery disease is a leading cause of morbidity and mortality in women. In the United Kingdom, an estimated 900,000 women suffer from angina, and coronary artery disease accounts for a fifth of all deaths in women. Although women have a lower prevalence of coronary heart disease than men, the incidence of angina continues to rise with age in women in contrast to men, in whom angina increases with age initially, peaking between 55 and 65 years before declining [1], [2]. The mean age of onset of angina is greater in women (64 years vs. 61 years) and they are more likely to present with angina than myocardial infarction, unstable angina or death due to coronary artery disease. In contrast, almost half of the men have myocardial infarction as their first presentation. Women with stable angina have a worse risk profile with a higher incidence of hypercholesterolaemia, diabetes mellitus and hypertension. They have been reported to undergo cardiac catheterisation less frequently than men [3], [4], [5], [6], [7]. The outcome of the subsequent revascularisation procedure may be less favourable in women [8], [9]. Women with myocardial infarction have also been reported to be treated with thrombolysis less commonly than men, but this observation may be confounded by an age bias [10], [11], [12].

Unstable angina accounts for a large number of hospital admissions for coronary artery disease. Twice as many men are admitted with unstable angina, reflecting the higher prevalence of coronary artery disease in men. Although gender exerts an influence in the presentation of chronic stable angina, there are limited studies on gender differences in patients presenting with unstable angina [13]. We therefore investigated the influence of gender in patients presenting with unstable angina.

Section snippets

Patients and methods

We retrospectively studied the case notes of all patients with unstable angina and transferred to our institution (under the care of Dr Fox) with a view to coronary angiography and further management in a 42-month period between January 1994 and June 1997 inclusive. We investigated the past medical history including a history of angina pectoris, previous myocardial infarction and coronary artery bypass graft operation and the presence of risk factors. Most patients underwent coronary

Results

During this 42-month period, a total of 313 in-patients with a diagnosis of unstable angina were referred with a view to urgent coronary angiography and further management. All patients were accepted on the basis of ischaemic chest pain (angina post-myocardial infarction, 36 men, 18 women; electrocardiogram (ECG) showing ST elevation, 21 men, nine women; ECG showing ST depression, 59 men, 27 women; ECG showing T-wave changes, 87 men, 48 women; no significant ECG change, seven men, one woman).

Discussion

Our study highlights both the similarities and differences in men and women with unstable angina. There were more men with unstable angina referred for coronary angiography over the period of study, reflecting the higher prevalence of ischaemic heart disease in men. There was no apparent difference in the age of the patients. This is an interesting finding since the presentation of stable angina in women is usually delayed by several years. It may be that unstable angina in women truly

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