- Email: [email protected]
Comparison of acute coronary syndromes in men versus women ≥70 years of age
registry, bleeding complications were not recorded and we therefore could not verify this hypothesis. Although our data are purely observational, with the biases inherent to such types of analyses, they offer the advantage of reflecting on the results of everyday clinical practice. They appear extremely reassuring with regard to the results of reperfusion therapy in elderly patients who have an improved 1-year outcome, even after adjusting for confounding variables. In this study on patients admitted with AMI to intensive care units in <24 hours in France (November 1995), reperfusion therapy was an independent predictor of improved 1-year survival. 1. ISIS 2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase oral aspirin both or neither among 17,187 cases of suspected AMI: ISIS 2. Lancet 1988;2:349 –360. 2. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico. GISSI-2: a factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12,490 patients with acute myocardial infarction. Lancet 1990;336:65–71. 3. ISIS 3 (Third International Study of Infarct Survival Collaborative Group). A randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and aspirin plus heparin vs aspirin alone among 41299 cases of suspected acute myocardial infarction. Lancet 1992;339:753–770. 4. The GUSTO Investigators. An international randomized trial comparing four
thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329: 383–389. 5. Weaver DW, Simes J, Betriu A, Grines CL, Zijlstra F, Garcia E, Grinfeld L, Gibbons RJ, Ribeiro EE, DeWood MA, Ribichini F. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction. A quantitative review. JAMA 1997;278:2093–2098. 6. Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O’Keefe J, Overlie P, Donohue B, Chelliah N, Timmis GC, et al, for the Primary Angioplasty in Myocardial Infarction Study Group. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993;328: 673–679. 7. Zijlstra F, de Boer MJ, Hoorntje JCA, Reiffers S, Reiber JHC, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328:680 –684. 8. Thiemann DR, Coresh J, Schulman SP, Gerstenblith G, Oetgen WJ, Powe NR. Lack of benefit of intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000;101:2239 –2246. 9. Danchin N, Vaur L, Gene`s N, Renault M, Ferrie`res J, Etienne S, Cambou JP. Management of acute myocardial infarction in intensive care units in 1995: a nationwide French survey of practice and early hospital results. J Am Coll Cardiol 1997;30:1598 –1605. 10. Cambou JP, Gene`s N, Vaur L, Dubroca I, Etienne S, Ferrie`re J, Danchin N. Epide´ miologie de l’infarctus du myocarde en France. Survie a` un an des patients de l’e´ tude USIK. Arch Mal Coeur 1998;91:1103–1110. 11. White HD, Barbash GI, Califf RM, for the GUSTO 1 Investigators. Age and outcome with contemporary thrombolytic therapy: results from the GUSTO 1 trial. Circulation 1996;94:1826 –1833. 12. Fibrinolytic Therapy Trialists Collaborative Group. Indications for fibrinolytic therapy in suspected myocardial infarction: collaborative overview of early mortality and majr morbidity results from all randomised trials of more than 1000 patients. Lancet 1994;343:311–322. 13. The GUSTO IIb Angioplasty Substudy Investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997;336:1621–1628.
Comparison of Acute Coronary Syndromes in Men Versus Women >70 Years of Age Stephen Woodworth, MD, Devraj Nayak, MD, Wilbert S. Aronow, Anthony L. Pucillo, MD, and Srinivas Koneru, MD
MD,
atients aged ⱖ75 years account for approximately 37% of hospital admissions for acute myocardial P infarction (AMI) and for 60% of the deaths from
formed, and the in-hospital incidence of mortality and recurrent AMI.
AMI.2 Elderly patients and elderly women, in particular, are underrepresented in published randomized trials of acute coronary syndromes (ACS).3 Patients aged ⱖ75 years with angina pectoris despite optimal medical therapy can be offered coronary revascularization to improve symptoms and quality of life.4,5 We performed at Westchester Medical Center/New York Medical College a prospective study in which 177 consecutive unselected patients aged ⱖ70 years hospitalized for ACS underwent coronary angiography and consideration of coronary revascularization. This article reports in elderly women versus elderly men the prevalence of unstable angina pectoris, non–STsegment elevation AMI, ST-segment elevation AMI, coronary risk factors, coronary angiographic findings, the prevalence of coronary revascularizations per-
A prospective study was performed in which 177 consecutive unselected patients aged ⱖ70 years hospitalized for ACS during September 1, 2001, through December 31, 2001, had coronary angiography and consideration of coronary revascularization. All patients hospitalized with ACS during this 4-month period were included in the study and underwent coronary angiography. The study included 91 women, mean age 79 ⫾ 6 years (range 70 to 94), and 86 men, mean age 77 ⫾ 6 years (range 70 to 94), p ⫽ NS. Patients hospitalized with ischemic-type chest discomfort of ⬎30 minutes with ST-segment elevation ⱖ0.2 mV in ⱖ2 contiguous precordial leads or STsegment elevation ⱖ0.1 mV in ⱖ2 limb leads and an elevated serum creatine kinase-MB level (⬎10%) or an elevated serum cardiac-specific troponin I level (⬎2 ng/ml) were diagnosed as having ST-segment elevation AMI. Patients hospitalized with ischemictype chest discomfort of ⬎30 minutes without STsegment elevation but with an elevated serum creatine kinase-MB or a cardiac-specific troponin I level were diagnosed as having non–ST-segment elevation
1
From the Cardiology Division, Westchester Medical Center/New York Medical College, Valhalla, New York. Dr. Aronow’s address is: Cardiology Division, Westchester Medical Center/New York Medical College, 23 Pebble Way, New Rochelle, New York 10804. E-mail: [email protected]. Manuscript received June 5, 2002; revised manuscript received and accepted July 11, 2002. ©2002 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 90 November 15, 2002
•••
0002-9149/02/$–see front matter PII S0002-9149(02)02785-6
1145
TABLE 1 Prevalence of Unstable Angina Pectoris, Non–STSegment Elevation and ST-Segment Elevation AMI in Elderly Women Versus Elderly Men With Acute Coronary Syndromes
Unstable angina Non–ST-segment AMI ST-segment AMI
Women (n ⫽ 91)
Men (n ⫽ 86)
45 (50%) 32 (35%) 14 (15%)
50 (58%) 29 (34%) 7 (8%)
There was no significant difference for all variables listed.
TABLE 2 Prevalence of Coronary Risk Factors in Elderly Women Versus Elderly Men With Acute Coronary Syndromes
Age (yrs) Prior AMI Prior coronary revascularization Prior stroke Peripheral vascular disease Cigarette smoking Systemic hypertension Dyslipidemia Diabetes mellitus
Women (n ⫽ 91)
Men (n ⫽ 86)
79 ⫾ 6 30 (33%) 15 (17%) 9 (10%) 11 (12%) 29 (32%) 67 (74%) 57 (63%) 29 (32%)
77 ⫾ 6 50 (58%)* 38 (44%)* 9 (10%) 22 (26%)† 46 (53%)‡ 56 (65%) 52 (61%) 28 (33%)
TABLE 3 Prevalence of Coronary Angiographic Findings and Revascularization in Elderly Women Versus Elderly Men With Acute Coronary Syndromes Women (n ⫽ 91) Obstructive CAD Nonobstructive CAD No CAD 1-vessel CAD 2-vessel CAD 3-vessel CAD Left main CAD Left anterior descending or diagonal CAD Left circumflex or obtuse marginal CAD Right CAD Coronary angioplasty if obstructive CAD Coronary bypass surgery if obstructive CAD Coronary revascularization if obstructive CAD
73 15 3 26 23 24 2 53
(80%) (17%) (3%) (29%) (25%) (26%) (2%) (58%)
41 (45%)
Men (n ⫽ 86) 81 4 1 25 17 39 8 65
(94%)* (5%)† (1%) (29%) (20%) (45%)* (9%)‡ (76%)†
53 (62%)‡
48 (53%) 45/73 (62%)
56 (65%) 38/81 (47%)
6/73 (8%)
7/81 (9%)
51/73 (70%)
45/81 (56%)
*p ⬍0.01; †p ⬍0.02; ‡p ⬍0.05.
ization versus 4 of 81 (5%) who did not have coronary revascularization (p ⫽ NS).
*p ⬍0.001; †p ⬍0.025; ‡p ⬍0.005.
•••
AMI.6 Patients hospitalized with ischemic-type chest discomfort of ⬎30 minutes with normal serum creatine kinase-MB and cardiac-specific troponin I levels were diagnosed as having unstable angina pectoris.6 Patients with ST-segment elevation AMI or non– ST-segment elevation AMI underwent coronary angiography within 1 to 12 hours of hospitalization. Patients with unstable angina pectoris had coronary angiography performed within 24 to 48 hours of hospitalization after optimal medical management. Nonobstructive coronary artery disease (CAD) was diagnosed if there was ⬍50% stenosis in the coronary arteries. Chi-square tests were used to analyze dichotomous variables and Student’s t tests for continuous variables. Four of 91 women (4%) versus 1 of 86 men (1%) died during hospitalization (p ⫽ NS). Four of 91 women (4%) versus 2 of 86 men (2%) died or had recurrent AMI during hospitalization (p ⫽ NS). Table 1 shows the prevalence of unstable angina pectoris, non–ST-segment elevation AMI, and the prevalence of ST-segment elevation AMI in 91 elderly women versus 86 elderly men hospitalized with ACS. None of the differences was statistically significant. Table 2 shows the prevalence of coronary risk factors in elderly women versus elderly men and lists levels of statistical significance. Table 3 lists coronary angiographic findings in elderly women versus elderly men and lists levels of statistical significance. Table 3 also lists the prevalence of coronary angioplasty, coronary artery bypass surgery, and coronary revascularization in 73 elderly women versus 81 elderly men with obstructive CAD. None of the differences was statistically significant. One of 96 persons (1%) who had coronary revascularization died during hospital1146 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 90
The present prospective study of 177 consecutive unselected women and men between the ages of 70 and 94 years (mean age 79 years for women and 77 years for men) hospitalized for ACS showed that 54% of the patients had unstable angina pectoris, 34% had non–ST-segment elevation AMI, and 12% had STsegment elevation AMI. The prevalence of unstable angina pectoris, non–ST-segment elevation AMI, and of ST-segment elevation AMI was similar in elderly women and elderly men. Of the 82 elderly patients who had a documented AMI, 61 (75%) had non–STsegment elevation AMI. Elderly men had a higher prevalence of prior AMI, prior coronary revascularization, peripheral vascular disease, and cigarette smoking, and a similar mean age and prevalence of prior stroke, hypertension, dyslipidemia, and diabetes mellitus than elderly women. In the Thrombolysis In Myocardial Infarction (TIMI) III Registry of patients with unstable angina pectoris or non–ST-segment elevation AMI, women were less likely to undergo coronary angiography than men (relative risk 0.71; 95% confidence interval [CI] 0.65 to 0.78; p ⬍0.001) and were less likely to undergo coronary revascularization than men (relative risk 0.66; 95% CI 0.59 to 0.76; p ⬍0.001).7 In this study, elderly patients were also less likely to have coronary angiography than nonelderly patients (relative risk 0.65; 95% CI 0.58 to 0.73; p ⬍0.001) and coronary revascularization than nonelderly patients (relative risk 0.79; 95% CI 0.68 to 0.92; p ⬍0.001).7 Elderly patients had more severe and extensive CAD but fewer coronary revascularization procedures than younger patients and had a higher incidence of death, recurrent AMI, or recurrent ischemia by 42 days (relative risk 1.91; 95% CI 1.37 to 3.07; p ⬍0.001).7 NOVEMBER 15, 2002
The present prospective study showed that elderly men had a higher prevalence of obstructive CAD (94%) than elderly women (80%). The TIMI IIIB study reported that the prevalence of obstructive CAD in selected patients who underwent coronary angiography for ACS was 84% for men (mean age 58 years) and 75% for women (mean age 61 years).8 The present study and the TIMI IIIB study8 found a higher prevalence of 3-vessel CAD in men than in women. This study also showed that elderly men had a higher prevalence of left main CAD, left anterior descending or diagonal CAD, and left circumflex or obtuse marginal CAD than elderly women. These data were not reported in the TIMI IIIB study.8 The present study showed that although 17% of elderly women and 44% of elderly men had prior coronary revascularization, 70% of elderly women and 56% of elderly men had coronary revascularization during this hospitalization for ACS. The TIMI IIIB study showed that 52% of women and 59% of men underwent coronary revascularization.8 The mortality rates in patients undergoing coronary revascularization were similar in women as in men in the present study and in the TIMI IIIB study.8 To the best of our knowledge, these are the only data reporting on the prevalence of coronary angiographic findings, coronary revascularization rates, coronary risk factors, and mortality rates in all men versus all women aged ⱖ70 years hospitalized with ACS during a 4-month period with and without revascularization. Elderly women and men between 70 and 94 years of age hospitalized for an ACS have a high prevalence of coronary risk factors and obstructive CAD. The risk profile was different for elderly women versus elderly
men. Coronary anatomy was favorable for coronary revascularization in slightly more than half of elderly patients. Elderly patients with ACS have a high overall risk for advanced CAD. Appropriately selected patients in this age group can be offered coronary revascularization alternatives. 1. Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975 to 1995) long experience in the incidence;in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol 1999;33:1533–1539. 2. Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA 1992;268:1417–1422. 3. Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001;286:708 –713. 4. The TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 2001;358:951–957. 5. Aronow WS. Approach to symptomatic coronary disease in the elderly: TIME to change? (Commentary). Lancet 2001;358:945–946. 6. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000; 36:970 –1062. 7. Stone PH, Thompson B, Anderson HV, Kronenberg MW, Gibson RS, Rogers WJ, Diver DJ, Theroux P, Warnica JW, Nasmith JB, et al, for the TIMI III Registry Study Group. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction. The TIMI III Registry. JAMA 1996;275:1104 –1112. 8. Hochman JS, McCabe CH, Stone PH, Becker RC, Cannon CP, DeFeo-Fraulini T, Thompson B, Steingart R, Knatterud G, Braunwald E, for the TIMI Investigators. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. J Am Coll Cardiol 1997;30:141–148.
Comparison of Atherosclerotic Risk Factors in Asian Indian and American Caucasian Patients With Angiographic Coronary Artery Disease Srinivas Vallapuri, MD, Dhiraj Gupta, MD, DM, K.K. Talwar, MD, DM, Michael Billie, Mahaveer C. Mehta, MD, Anthony P. Morise, MD, and Abnash C. Jain, MD he prevalence of coronary artery disease (CAD) has been consistently observed to be high in imT migrant Asian Indians (AIs). Myocardial infarction 1–3
occurs at a younger age in AIs (50.2 vs 55.5 years) than in Caucasians.3 There are fewer data on the prevalence of CAD in India,4 but AIs living abroad have higher rates of CAD than other ethnic groups.5,6 Conventional risk factors for CAD are well known. From West Virginia University School of Medicine, Morgantown, West Virginia; and All India Institutes of Medical Sciences, New Delhi, India. Dr. Jain’s address is: Section of Cardiology, Robert C. Byrd Health Sciences Center, Room 2203, PO Box 9157, Morgantown, West Virginia 26506. E-mail: [email protected]. Manuscript received October 10, 2001; revised manuscript received and accepted March 1, 2002.
Cardiovascular disease rates vary greatly between different ethnic groups. Patients with differing racial and cultural backgrounds may have different risk factors that contribute to the extent of CAD. The ethnic composition of the US population has been changing. One ethnic group is an AI population who are recognized to have up to a fourfold increase in risk of CAD compared with Caucasians of European descent and a 40% higher mortality due to CAD.7,8 To our knowledge there have been no cross-sectional studies performed to compare AIs and American Caucasians (ACs) to examine the differences in conventional risk factors in patients with angiographically significant CAD. This study examines whether there are differences in the conventional risk factors for CAD between these 2 racially and geographically distinct groups. BRIEF REPORTS
1147
thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329: 383–389. 5. Weaver DW, Simes J, Betriu A, Grines CL, Zijlstra F, Garcia E, Grinfeld L, Gibbons RJ, Ribeiro EE, DeWood MA, Ribichini F. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction. A quantitative review. JAMA 1997;278:2093–2098. 6. Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O’Keefe J, Overlie P, Donohue B, Chelliah N, Timmis GC, et al, for the Primary Angioplasty in Myocardial Infarction Study Group. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993;328: 673–679. 7. Zijlstra F, de Boer MJ, Hoorntje JCA, Reiffers S, Reiber JHC, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328:680 –684. 8. Thiemann DR, Coresh J, Schulman SP, Gerstenblith G, Oetgen WJ, Powe NR. Lack of benefit of intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000;101:2239 –2246. 9. Danchin N, Vaur L, Gene`s N, Renault M, Ferrie`res J, Etienne S, Cambou JP. Management of acute myocardial infarction in intensive care units in 1995: a nationwide French survey of practice and early hospital results. J Am Coll Cardiol 1997;30:1598 –1605. 10. Cambou JP, Gene`s N, Vaur L, Dubroca I, Etienne S, Ferrie`re J, Danchin N. Epide´ miologie de l’infarctus du myocarde en France. Survie a` un an des patients de l’e´ tude USIK. Arch Mal Coeur 1998;91:1103–1110. 11. White HD, Barbash GI, Califf RM, for the GUSTO 1 Investigators. Age and outcome with contemporary thrombolytic therapy: results from the GUSTO 1 trial. Circulation 1996;94:1826 –1833. 12. Fibrinolytic Therapy Trialists Collaborative Group. Indications for fibrinolytic therapy in suspected myocardial infarction: collaborative overview of early mortality and majr morbidity results from all randomised trials of more than 1000 patients. Lancet 1994;343:311–322. 13. The GUSTO IIb Angioplasty Substudy Investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997;336:1621–1628.
Comparison of Acute Coronary Syndromes in Men Versus Women >70 Years of Age Stephen Woodworth, MD, Devraj Nayak, MD, Wilbert S. Aronow, Anthony L. Pucillo, MD, and Srinivas Koneru, MD
MD,
atients aged ⱖ75 years account for approximately 37% of hospital admissions for acute myocardial P infarction (AMI) and for 60% of the deaths from
formed, and the in-hospital incidence of mortality and recurrent AMI.
AMI.2 Elderly patients and elderly women, in particular, are underrepresented in published randomized trials of acute coronary syndromes (ACS).3 Patients aged ⱖ75 years with angina pectoris despite optimal medical therapy can be offered coronary revascularization to improve symptoms and quality of life.4,5 We performed at Westchester Medical Center/New York Medical College a prospective study in which 177 consecutive unselected patients aged ⱖ70 years hospitalized for ACS underwent coronary angiography and consideration of coronary revascularization. This article reports in elderly women versus elderly men the prevalence of unstable angina pectoris, non–STsegment elevation AMI, ST-segment elevation AMI, coronary risk factors, coronary angiographic findings, the prevalence of coronary revascularizations per-
A prospective study was performed in which 177 consecutive unselected patients aged ⱖ70 years hospitalized for ACS during September 1, 2001, through December 31, 2001, had coronary angiography and consideration of coronary revascularization. All patients hospitalized with ACS during this 4-month period were included in the study and underwent coronary angiography. The study included 91 women, mean age 79 ⫾ 6 years (range 70 to 94), and 86 men, mean age 77 ⫾ 6 years (range 70 to 94), p ⫽ NS. Patients hospitalized with ischemic-type chest discomfort of ⬎30 minutes with ST-segment elevation ⱖ0.2 mV in ⱖ2 contiguous precordial leads or STsegment elevation ⱖ0.1 mV in ⱖ2 limb leads and an elevated serum creatine kinase-MB level (⬎10%) or an elevated serum cardiac-specific troponin I level (⬎2 ng/ml) were diagnosed as having ST-segment elevation AMI. Patients hospitalized with ischemictype chest discomfort of ⬎30 minutes without STsegment elevation but with an elevated serum creatine kinase-MB or a cardiac-specific troponin I level were diagnosed as having non–ST-segment elevation
1
From the Cardiology Division, Westchester Medical Center/New York Medical College, Valhalla, New York. Dr. Aronow’s address is: Cardiology Division, Westchester Medical Center/New York Medical College, 23 Pebble Way, New Rochelle, New York 10804. E-mail: [email protected]. Manuscript received June 5, 2002; revised manuscript received and accepted July 11, 2002. ©2002 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 90 November 15, 2002
•••
0002-9149/02/$–see front matter PII S0002-9149(02)02785-6
1145
TABLE 1 Prevalence of Unstable Angina Pectoris, Non–STSegment Elevation and ST-Segment Elevation AMI in Elderly Women Versus Elderly Men With Acute Coronary Syndromes
Unstable angina Non–ST-segment AMI ST-segment AMI
Women (n ⫽ 91)
Men (n ⫽ 86)
45 (50%) 32 (35%) 14 (15%)
50 (58%) 29 (34%) 7 (8%)
There was no significant difference for all variables listed.
TABLE 2 Prevalence of Coronary Risk Factors in Elderly Women Versus Elderly Men With Acute Coronary Syndromes
Age (yrs) Prior AMI Prior coronary revascularization Prior stroke Peripheral vascular disease Cigarette smoking Systemic hypertension Dyslipidemia Diabetes mellitus
Women (n ⫽ 91)
Men (n ⫽ 86)
79 ⫾ 6 30 (33%) 15 (17%) 9 (10%) 11 (12%) 29 (32%) 67 (74%) 57 (63%) 29 (32%)
77 ⫾ 6 50 (58%)* 38 (44%)* 9 (10%) 22 (26%)† 46 (53%)‡ 56 (65%) 52 (61%) 28 (33%)
TABLE 3 Prevalence of Coronary Angiographic Findings and Revascularization in Elderly Women Versus Elderly Men With Acute Coronary Syndromes Women (n ⫽ 91) Obstructive CAD Nonobstructive CAD No CAD 1-vessel CAD 2-vessel CAD 3-vessel CAD Left main CAD Left anterior descending or diagonal CAD Left circumflex or obtuse marginal CAD Right CAD Coronary angioplasty if obstructive CAD Coronary bypass surgery if obstructive CAD Coronary revascularization if obstructive CAD
73 15 3 26 23 24 2 53
(80%) (17%) (3%) (29%) (25%) (26%) (2%) (58%)
41 (45%)
Men (n ⫽ 86) 81 4 1 25 17 39 8 65
(94%)* (5%)† (1%) (29%) (20%) (45%)* (9%)‡ (76%)†
53 (62%)‡
48 (53%) 45/73 (62%)
56 (65%) 38/81 (47%)
6/73 (8%)
7/81 (9%)
51/73 (70%)
45/81 (56%)
*p ⬍0.01; †p ⬍0.02; ‡p ⬍0.05.
ization versus 4 of 81 (5%) who did not have coronary revascularization (p ⫽ NS).
*p ⬍0.001; †p ⬍0.025; ‡p ⬍0.005.
•••
AMI.6 Patients hospitalized with ischemic-type chest discomfort of ⬎30 minutes with normal serum creatine kinase-MB and cardiac-specific troponin I levels were diagnosed as having unstable angina pectoris.6 Patients with ST-segment elevation AMI or non– ST-segment elevation AMI underwent coronary angiography within 1 to 12 hours of hospitalization. Patients with unstable angina pectoris had coronary angiography performed within 24 to 48 hours of hospitalization after optimal medical management. Nonobstructive coronary artery disease (CAD) was diagnosed if there was ⬍50% stenosis in the coronary arteries. Chi-square tests were used to analyze dichotomous variables and Student’s t tests for continuous variables. Four of 91 women (4%) versus 1 of 86 men (1%) died during hospitalization (p ⫽ NS). Four of 91 women (4%) versus 2 of 86 men (2%) died or had recurrent AMI during hospitalization (p ⫽ NS). Table 1 shows the prevalence of unstable angina pectoris, non–ST-segment elevation AMI, and the prevalence of ST-segment elevation AMI in 91 elderly women versus 86 elderly men hospitalized with ACS. None of the differences was statistically significant. Table 2 shows the prevalence of coronary risk factors in elderly women versus elderly men and lists levels of statistical significance. Table 3 lists coronary angiographic findings in elderly women versus elderly men and lists levels of statistical significance. Table 3 also lists the prevalence of coronary angioplasty, coronary artery bypass surgery, and coronary revascularization in 73 elderly women versus 81 elderly men with obstructive CAD. None of the differences was statistically significant. One of 96 persons (1%) who had coronary revascularization died during hospital1146 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 90
The present prospective study of 177 consecutive unselected women and men between the ages of 70 and 94 years (mean age 79 years for women and 77 years for men) hospitalized for ACS showed that 54% of the patients had unstable angina pectoris, 34% had non–ST-segment elevation AMI, and 12% had STsegment elevation AMI. The prevalence of unstable angina pectoris, non–ST-segment elevation AMI, and of ST-segment elevation AMI was similar in elderly women and elderly men. Of the 82 elderly patients who had a documented AMI, 61 (75%) had non–STsegment elevation AMI. Elderly men had a higher prevalence of prior AMI, prior coronary revascularization, peripheral vascular disease, and cigarette smoking, and a similar mean age and prevalence of prior stroke, hypertension, dyslipidemia, and diabetes mellitus than elderly women. In the Thrombolysis In Myocardial Infarction (TIMI) III Registry of patients with unstable angina pectoris or non–ST-segment elevation AMI, women were less likely to undergo coronary angiography than men (relative risk 0.71; 95% confidence interval [CI] 0.65 to 0.78; p ⬍0.001) and were less likely to undergo coronary revascularization than men (relative risk 0.66; 95% CI 0.59 to 0.76; p ⬍0.001).7 In this study, elderly patients were also less likely to have coronary angiography than nonelderly patients (relative risk 0.65; 95% CI 0.58 to 0.73; p ⬍0.001) and coronary revascularization than nonelderly patients (relative risk 0.79; 95% CI 0.68 to 0.92; p ⬍0.001).7 Elderly patients had more severe and extensive CAD but fewer coronary revascularization procedures than younger patients and had a higher incidence of death, recurrent AMI, or recurrent ischemia by 42 days (relative risk 1.91; 95% CI 1.37 to 3.07; p ⬍0.001).7 NOVEMBER 15, 2002
The present prospective study showed that elderly men had a higher prevalence of obstructive CAD (94%) than elderly women (80%). The TIMI IIIB study reported that the prevalence of obstructive CAD in selected patients who underwent coronary angiography for ACS was 84% for men (mean age 58 years) and 75% for women (mean age 61 years).8 The present study and the TIMI IIIB study8 found a higher prevalence of 3-vessel CAD in men than in women. This study also showed that elderly men had a higher prevalence of left main CAD, left anterior descending or diagonal CAD, and left circumflex or obtuse marginal CAD than elderly women. These data were not reported in the TIMI IIIB study.8 The present study showed that although 17% of elderly women and 44% of elderly men had prior coronary revascularization, 70% of elderly women and 56% of elderly men had coronary revascularization during this hospitalization for ACS. The TIMI IIIB study showed that 52% of women and 59% of men underwent coronary revascularization.8 The mortality rates in patients undergoing coronary revascularization were similar in women as in men in the present study and in the TIMI IIIB study.8 To the best of our knowledge, these are the only data reporting on the prevalence of coronary angiographic findings, coronary revascularization rates, coronary risk factors, and mortality rates in all men versus all women aged ⱖ70 years hospitalized with ACS during a 4-month period with and without revascularization. Elderly women and men between 70 and 94 years of age hospitalized for an ACS have a high prevalence of coronary risk factors and obstructive CAD. The risk profile was different for elderly women versus elderly
men. Coronary anatomy was favorable for coronary revascularization in slightly more than half of elderly patients. Elderly patients with ACS have a high overall risk for advanced CAD. Appropriately selected patients in this age group can be offered coronary revascularization alternatives. 1. Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975 to 1995) long experience in the incidence;in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol 1999;33:1533–1539. 2. Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA 1992;268:1417–1422. 3. Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001;286:708 –713. 4. The TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 2001;358:951–957. 5. Aronow WS. Approach to symptomatic coronary disease in the elderly: TIME to change? (Commentary). Lancet 2001;358:945–946. 6. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000; 36:970 –1062. 7. Stone PH, Thompson B, Anderson HV, Kronenberg MW, Gibson RS, Rogers WJ, Diver DJ, Theroux P, Warnica JW, Nasmith JB, et al, for the TIMI III Registry Study Group. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction. The TIMI III Registry. JAMA 1996;275:1104 –1112. 8. Hochman JS, McCabe CH, Stone PH, Becker RC, Cannon CP, DeFeo-Fraulini T, Thompson B, Steingart R, Knatterud G, Braunwald E, for the TIMI Investigators. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. J Am Coll Cardiol 1997;30:141–148.
Comparison of Atherosclerotic Risk Factors in Asian Indian and American Caucasian Patients With Angiographic Coronary Artery Disease Srinivas Vallapuri, MD, Dhiraj Gupta, MD, DM, K.K. Talwar, MD, DM, Michael Billie, Mahaveer C. Mehta, MD, Anthony P. Morise, MD, and Abnash C. Jain, MD he prevalence of coronary artery disease (CAD) has been consistently observed to be high in imT migrant Asian Indians (AIs). Myocardial infarction 1–3
occurs at a younger age in AIs (50.2 vs 55.5 years) than in Caucasians.3 There are fewer data on the prevalence of CAD in India,4 but AIs living abroad have higher rates of CAD than other ethnic groups.5,6 Conventional risk factors for CAD are well known. From West Virginia University School of Medicine, Morgantown, West Virginia; and All India Institutes of Medical Sciences, New Delhi, India. Dr. Jain’s address is: Section of Cardiology, Robert C. Byrd Health Sciences Center, Room 2203, PO Box 9157, Morgantown, West Virginia 26506. E-mail: [email protected]. Manuscript received October 10, 2001; revised manuscript received and accepted March 1, 2002.
Cardiovascular disease rates vary greatly between different ethnic groups. Patients with differing racial and cultural backgrounds may have different risk factors that contribute to the extent of CAD. The ethnic composition of the US population has been changing. One ethnic group is an AI population who are recognized to have up to a fourfold increase in risk of CAD compared with Caucasians of European descent and a 40% higher mortality due to CAD.7,8 To our knowledge there have been no cross-sectional studies performed to compare AIs and American Caucasians (ACs) to examine the differences in conventional risk factors in patients with angiographically significant CAD. This study examines whether there are differences in the conventional risk factors for CAD between these 2 racially and geographically distinct groups. BRIEF REPORTS
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