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Women With Suspected CAD Classified as Lower Risk Than Men
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
FROM ACC 16
Women With Suspected CAD Classified as Lower Risk Than Men
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
FROM ACC 16
Women with suspected CAD classified as lower risk than men
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Despite symptomatic presentation, greater family history of premature coronary artery disease, and higher risk factor burden, including older age and greater prevalence of hypertension and dyslipidemia, the women in PROMISE were more likely to be characterized as low risk based on standard cardiovascular risk assessment scores and thus, not surprisingly, also were considered to be at lower risk by their providers. These findings add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.
The 2014 American Heart Association Consensus Statement on noninvasive diagnostic testing in women with suspected ischemic heart disease highlighted the development of novel diagnostic tools that have an expanded role in the evaluation of symptomatic female patients to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis as well as the identification of ischemia resulting from microvascular dysfunction. Such methods using advanced imaging are making steady progress in the understanding of microvascular disease and its consequences.
We agree with the PROMISE investigators that focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women. With emerging data on the full pathophysiologic spectrum of ischemic heart disease in women, diagnostic algorithms must include functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, for accurately establishing the diagnosis and prognosis of women with suspected IHD.
Dr. Jennifer H. Mieres is with Hofstra University, Hempstead, N.Y. Dr. Robert O. Bonow is with Northwestern University, Chicago. They had no disclosures. These comments are from their editorial (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.0089).
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Women with suspected coronary artery disease had similar symptoms and more heart disease risk factors, compared with men, but were assessed as lower risk by their providers and on all standard risk scores, according to a secondary analysis of the PROMISE trial.
The results “highlight the need for sex-specific approaches to coronary artery disease evaluation and testing,” said Kshipra Hemal at Duke Clinical Research Institute in Durham, N.C., and her associates. The findings will be presented April 3 at the annual meeting of the American College of Cardiology and were published online March 23 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
The PROMISE (Prospective Multicenter Imaging Study for the Evaluation of Chest Pain) trial is one of the largest contemporary trials of symptomatic, nonacute suspected CAD. The study included 10,003 stable outpatients, nearly half of whom were women. The researchers calculated the 2008 Framingham score, 2013 Atherosclerotic Cardiovascular Disease score, 1979 Diamond and Forrester score, modified 2011 Diamond and Forrester score, and 2012 combined Diamond-Forrester and Coronary Artery Surgery Study scores for all patients. Patients also were randomly assigned to either anatomical testing with CT angiography or to functional testing with exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram (J Am Coll Cardiol Img. 2016 Mar 23. doi: 10.1016/j.jcmg.2016.02.001).
Women in the study were an average of 3 years older than the men and were significantly more likely to be hypertensive (67% vs. 63%), dyslipidemic (69% vs. 66%), and to have a family history of premature CAD (35% vs. 29%; P less than .01 for all comparisons), the researchers reported. Nonetheless, all five risk scores characterized women as lower risk than men (P less than .001 for mean differences). Moreover, before testing, providers characterized 41% of women having a low (less than 30%) likelihood of CAD, compared with 34% of men (P less than .001).
Women were more likely than men to be referred for stress echocardiography or nuclear stress test, but only 9.7% had a positive noninvasive test, compared with 15% of men (P less than .001), the researchers also reported. “A number of characteristics predicted positive test results, and many characteristics were similar between the sexes,” they added. “However, in multivariable models, key predictors of test positivity were few and varied by sex.” Body mass index and Framingham risk score predicted a positive test for women, while both the Framingham and modified Diamond-Forrester risk scores predicted a positive test for men.
Chest pain was the most common primary symptom reported by nearly three-quarters of women and men and was described as “crushing/pressure/squeezing/tightness” 53% and 46% of the time, respectively (P less than .001). Dyspnea was the second most frequent primary symptom at 15% for both sexes. Women were more likely than men to describe back pain, neck or jaw pain, or palpitations, but only 0.6% to 2.7% of patients ranked these among their main symptoms.
“Further studies are warranted to examine the underlying pathophysiology and implications for clinical care of the sex-based clinical differences observed along the entire diagnostic pathway of suspected CAD, including risk factor burden, presenting symptoms, and testing results,” the researchers concluded.
The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Ms. Hemal had no disclosures. Senior author Dr. Pamela S. Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
FROM ACC 16
Key clinical point: Women with suspected coronary artery disease had similar symptoms and more risk factors for coronary artery disease, compared with men, but were classified as lower risk on risk scores and by providers.
Major finding: All risk scores assessed women as being at lower risk than men. Providers characterized 41% of pretest women and 34% of men as low risk (P less than .001).
Data source: A prospective, multicenter, randomized trial of 10,003 symptomatic outpatients with suspected coronary artery disease.
Disclosures: The PROMISE study was funded by the National Heart, Lung, and Blood Institute. Dr. Hemal had no disclosures. Senior author Dr. Pamela Douglas disclosed grant support from HeartFlow and having served on a data and safety monitoring board for General Electric Healthcare. Two of the other 15 coinvestigators also disclosed relationships with industry; the rest had no disclosures.
Heart Attack Patients Getting Younger, Fatter, and Less Healthy
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
FROM ACC 16
Arterial Calcium Findings on Mammograms Can Predict Heart Disease Risk
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
FROM ACC 16
Arterial calcium findings on mammograms can predict heart disease risk
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
On Twitter @Alz_Gal
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
The question may not be whether breast arterial calcification provides useful information, but how to most efficiently incorporate it into routine clinical practice now, Dr. Khurram Nassir and Dr. John W. McEvoy wrote in an accompanying editorial.
BAC has always been visible on mammograms, but it’s never been clinically leveraged.
“Despite the fact that a tremendous amount of literature in the past has pointed attention that BAC significantly increases vulnerability to … myocardial infarction, stroke, peripheral artery disease, and even heart failure,” no individual or society has taken up the challenge of creating a standardized measure that can be consistently employed in clinical assessments.
This failure by the medical community is “disappointing,” they noted – but perhaps not unexpected. Cries for supporting clinical trials frequently hamper movement on new ideas, even those that are already well grounded in science.
“Rather than another outcome study, our stakeholders are more likely to cherish investigations designed to explore better health-delivery models using information” like the BAC score, they said. “The conventional response ‘lack of clinical trial’ should not be allowed to justify current inertia which has already impeded constructive dialogue.”
More studies are needed to fully flesh out the relationship and how to best employ BAC data, they agreed, but the relationship is solid and should be recognized as useful.
“Whether the best use of BAC is to trigger additional testing or directly inform preventive treatment decisions, either by flagging high-risk women to their providers or by reclassifying traditional [atherosclerotic cardiovascular disease] risk estimates is worth further discussion,” Dr. Nasir and Dr. McEvoy wrote. But for now, the report provides strong motivation for the widespread documentation of BAC in mammography reports, thereby improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic coronary vascular disease (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.09.017).
Dr. Nasir is director of the High-risk Cardiovascular Disease Clinic at Baptist Health South Florida, Miami. Dr. McEvoy is a clinical and research fellow at the Johns Hopkins Medical Center Cardiology and Vascular Institute, Baltimore.
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
On Twitter @Alz_Gal
Findings that are easily visible on mammograms – but never shared with patients – could be employed as a powerful new tool for cardiovascular risk assessment, a study showed.
In this prospective imaging study, breast arterial calcification in women without heart disease correlated with cardiovascular risk at least as well as the Framingham Risk Score, and a bit better than the 2013 Cholesterol Guidelines Pooled Cohort Equation.
It also increased the accuracy of both of these models for detecting women at high risk for heart disease, Dr. Laurie Margolies said at a press teleconference leading up to the annual meeting of the American College of Cardiology.
If validated in a larger cohort, the findings could well be “practice changing,” said Dr. Margolies, director of breast imaging at Mt. Sinai Hospital, New York.
She compared its potential impact to that of the now-critical breast density measurement for cancer detection. Until 2008, breast density was a visual, yet unreported and unemployed, mammographic finding.
“This is the same type of practice-changing, revolutionary way of reporting risk,” said Dr. Margolies. “We have a practical way of assessing coronary artery disease risk that adds no extra cost, no radiation, and very little time, and is superior to standard ways of [coronary artery disease] risk assessment. And since prevention is key to decreasing cardiovascular mortality, it would be very simple to report this score on all mammographies,” to give both patients and physicians a heads-up that cardiovascular health needs some quick attention.
The study was simultaneously published online (JACC Cardiovasc Imag. 2016 Mar 24. doi: 10.1016/j.jcmg.2015.10.022).
The cohort comprised 292 women who underwent digital screening mammography and a noncontrast chest CT scan during the same year. None had a history of coronary artery disease. Cardiovascular risk was assessed with three tools: the Framingham Risk Score (FRS), the 2013 Cholesterol Guidelines Pooled Cohort Equation (PCE), and the breast arterial calcification (BAC) score. The BAC score encompassed measurements of number of involved vessels, length of involved segments, and calcification density. Scores ranged from 1 to 12 and were classified by increasing severity: 0, 1-3, and 4-12.
Women were a mean of 61 years old; none had a history of coronary artery disease. Hypertension and hyperlipidemia were common (179 and 104 subjects, respectively). Diabetes was present in 79, smoking in 53, and chronic kidney disease in 57.
Any BAC was present in 42.5% of the group. Those with BAC were significantly older and more likely to have hypertension and kidney disease. Coronary artery calcification (CAC) was present in 47.6% of the overall group, but in 70% of those with BAC. These patients were also significantly older than those without CAC. Hypertension, chronic kidney disease, and diabetes were also more common.
The mean BAC score was 2.2. As women aged, the score was more likely to increase. A BAC score greater than 0 was present in 27% of those younger than 60 years, 47% of those aged 60-69 years, and 69% of those aged 70-92 years.
The mean CAC score was 1.6 ,and this also increased with age. The incidence of CAC for the three age groups was 28%, 55%, and 79%, respectively.
In a multivariate model, a severe BAC score of 4-12 conferred a threefold risk for CAC (odds ratio, 3.2), while older age and hypertension conferred a doubling of risk. “This shows us that BAC is a more powerful predictor than these standard risk factors,” Dr. Margolies said.
The mean 10-year Framingham Risk Score was 4.6. Most women in the cohort (85%) were low risk. Of these, 59% had a BAC of 0, and 63% had a CAC of 0. However, there was some disagreement in the models. Among the FRS low-risk group, 15% had an intermediate-risk BAC score of 1-3, and 22% had a high-risk BAC of 4-12. The CAC was intermediate risk in 29% and high risk in 13%.
Among those with an intermediate-risk FRS, the coronary artery calcification and breast arterial calcification scores were also intermediate risk in 45% and 12%, respectively; the CAC and BAC were high risk in 36% and 64%, respectively.
For the entire cohort, the FRS categories agreed with the BAC categories 55% of the time, and with the CAC categories 57% of the time.
The mean Cholesterol Guidelines Pooled Cohort Equation risk score was 11.8. This score tends to overestimate CAC presence, Dr. Margolies noted, an issue supported by the finding that only 42% of the cohort scored as low risk. In this low-risk group, 74% and 76% had CAC and BAC scores of 0, respectively. But in the PCE high-risk group, only 27% had high-risk CAC and 43% had high-risk BAC. In fact, the CAC and BAC scores were actually 0 in 33% and 40%, respectively.
For the entire cohort, the PCE risk agreed with the CAC 47% of the time and with the BAC 54% of the time.
By itself, a BAC score of more than 0 predicted a CAC score of more than 0 as well as both the Framingham Risk Score and the Pooled Cohort Equation score, with an area under the curve of 0.72 and 0.71, respectively.
BAC did, however, increase the accuracy of both these models for detecting high-risk CAC. In an analysis that included an additional 325 women with a history of coronary artery disease, the area under the curve increased to 0.77 when BAC was added to the FRS; it increased to 0.76 when added to the PCE model.
Adding BAC data to every mammogram would be an easy and very effective way to alert patients and their physicians to developing coronary artery disease, Dr. Margolies said.
“Even though heart disease kills 10 times more women than breast cancer does, there is no routine screening test for it. But digital mammography screening for breast cancer is a common procedure. I would advocate that we add the BAC data to mammogram reports so that we have a way to assess this risk. Women who were BAC positive could then undergo further risk assessment, preferably with a gated CT scan, with subsequent adjustment or initiation of statins,” she said.
Dr. Margolies had no relevant financial disclosures.
On Twitter @Alz_Gal
FROM ACC 16
Key clinical point: Breast arterial calcification information – available on every mammogram – could be used to help predict heart disease risk.
Major finding: The finding predicted coronary artery calcification as well as the Framingham score did in women without heart disease, and increased that system’s accuracy for high-risk women.
Data source: A prospective imaging study involving 292 low-risk women and 325 at high risk for heart disease.
Disclosures: Dr. Margolies had no relevant financial disclosures.
Heart attack patients getting younger, fatter, and less healthy
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
Despite advances in the prevention and early detection of cardiovascular disease, heart attack patients are getting younger, fatter, and less health conscious.
A look at 10 years’ worth of patient data reveals these and other “alarming trends,” according to Dr. Samir R. Kapadia of the Cleveland Clinic.
“What we found was so very contradictory to what we expected,” he said at a press briefing held in advance of the annual meeting of the American College of Cardiology. “Amazingly, we saw that patients presenting with myocardial infarction were getting younger, and their body mass index was going up. There was more smoking, more hypertension, and more diabetes. And all of this despite our better understanding of cardiovascular risk factors.”
The findings seem to point to a serious gap between gathering scientific knowledge and putting that knowledge into practice.
“We have to extend our efforts and put a lot more into educating patients,” Dr. Kapadia said. “Maybe it’s not enough to just tell people to eat right and exercise – maybe we should also be providing them with a structured program. But this is not just the job of the cardiologist. Primary care physicians have to also have this insight, communicate it to the patients, and get them the resources they need to help prevent heart attacks.”
His retrospective study comprised 3,912 consecutive patients who were treated for ST-segment elevation MI (STEMI) from 1995 to 2014. Data were collected on age, gender, diabetes, hypertension, smoking, lipid levels, chronic renal impairment, and obesity. The group was divided into four epochs: 1995-1999, 2000-2004, 2005-2009, and 2010-2014. The researchers examined these factors both in the entire cohort and in a subset of 1,325 who had a diagnosis of coronary artery disease at the time of their MI.
Patients became significantly younger over the entire study period. In epoch 1, the mean age of the entire cohort was 63.6 years. By epoch 3, this had declined to 60.3 years – a significant drop. The change was also evident in the CAD subset; among these patients, mean age declined from 64.1 years in epoch 1 to 61.8 years in epoch 4.
Tobacco use increased significantly in both groups as well. In the overall cohort, the rate was 27.7% in epoch 1 and 45.4% in epoch 4. In the CAD subset, it rose from 24.6% to 42.7%.
Hypertension in the entire cohort increased from 56.7% to 77.3%. In the CAD subset, it increased from 60.9% to 89%.
Obesity increased in both cohorts in overlapping trends, from about 30% in epoch 1 to 40% in epoch 4.
Diabetes increased as well. In the entire cohort, it rose from 24.6% to 30.6%. In the CAD subset, it rose from 25.4% to 41.5%.
Dr. Kapadia noted that the proportion of patients with at least three major risk factors rose from 65% to 85%, and that the incidence of chronic obstructive pulmonary disease increased from 5% to 12%, although he didn’t break this trend down by group.
He had no financial disclosures.
FROM ACC 16
Key clinical point: Despite advances in understanding heart disease prevention, patients with heart attack are younger and less healthy than they were 10 years ago.
Major finding: Patients are an average of 3 years younger than in 1994, and more are obese and use tobacco.
Data source: A retrospective study of 3,912 patients with acute ST-segment elevation MI.
Disclosures: Dr. Samir Kapadia had no financial disclosures.
