Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: findings from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) angiographic core laboratory

Abstract

Background: Women presenting with signs and symptoms of myocardial ischemia frequently have no or nonobstructive coronary artery disease (CAD).

Objective: This study aimed to investigate the associations between angiographic measures and longer-term clinical outcomes among women with signs and symptoms of ischemia referred for coronary angiography.

Methods: A prospective cohort analysis of women referred for coronary angiography and enrolled in the National Heart, Lung, and Blood Institute-sponsored WISE was performed. An angiographic severity score was prospectively developed, assigning points for any stenosis weighted by stenosis severity, location, and collaterals and was then tested for prediction for adverse outcome in 917 women, over a median of 9.3 years.

Setting: The study was conducted in referral centers.

Patients: Women with signs and/or symptoms of myocardial ischemia referred for coronary angiography were consecutively consented and enrolled in a prospective study.

Main outcome measures: Main outcomes included first occurrence of cardiovascular death or nonfatal myocardial infarction. Hospitalization for angina was a secondary outcome.

Results: Cardiovascular death or myocardial infarction at 10 years occurred in 6.7%, 12.8%, and 25.9% of women with no, nonobstructive, and obstructive CAD (P < .0001), respectively. Cumulative 10-year cardiovascular death or myocardial infarction rates showed progressive, near-linear increases for each WISE CAD severity score range of 5, 5.1 to 10, 10.1 to 20, 20.1 to 50, and >50. The optimal threshold in the WISE severity score classifications for predicting cardiovascular mortality was >10 (eg, 5.0-10 vs 10.1-89), with both a sensitivity and specificity of 0.64 and an area under the curve of 0.64 (P = .02, 95% CI 0.59-0.68).

Conclusions: Among women with signs and symptoms of ischemia, nonobstructive CAD is common and associated with adverse outcomes over the longer term. The new WISE angiographic score appears to be useful for risk prediction in this population.

Trial registration: ClinicalTrials.gov NCT00000554.

Conflict of interest statement

Disclosure/Conflicts of Interest: None

Copyright © 2013 Mosby, Inc. All rights reserved.

Figures

Figure 1

10-Year Freedom from CV Death by Coronary Artery Disease Category (CAD). N=917 (103 events) (Min = minimal or non-obstructive CAD; obstr = obstructive CAD). Event rates (%) estimated by Kaplan-Meier analysis *p<0.05 **p<0.01 ***p<0.001 ****p<0.0001 (compared to No)

Figure 2

10-Year Freedom from CV Death by Angiographic Severity Score Category. N=917 (103 events) Event rates (%) estimated by Kaplan-Meier analysis *p<0.05 **p<0.01 ***p<0.001 ****p<0.0001 (compared to lowest severity [5])

Figure 3

5-Year Freedom from Hospitalization for Angina by Angiographic Severity Score Category. N=883 (214 events) Event rates (%) estimated by Kaplan-Meier analysis *p<0.05 **p<0.01 ***p<0.001 ****p<0.0001 (compared to lowest severity [5])