Sex differences in management and outcomes of patients with stable symptoms suggestive of coronary artery disease: Insights from the PROMISE trial

Abstract

Background: Although sex differences exist in the management of acute coronary syndromes, less is known about the management and outcomes of women and men with suspected coronary artery disease being evaluated with noninvasive testing (NIT).

Methods: We investigated sex-based differences in NIT results and subsequent clinical management in 4,720 women and 4,246 men randomized to CT angiography versus stress testing in the PROMISE trial. Logistic regression models assessed relationships between sex and referral for catheterization, revascularization, and aspirin or statin use. Cox regression models assessed the relationship between sex and the composite of all-cause death, myocardial infarction, or unstable angina.

Results: Women more often had normal NITs than men (61.0% vs 49.6%, P < .001) and less often had mild (29.3% vs 35.4%, P < .001), moderate (4.0% vs 6.8%, P < .001), or severe abnormalities (5.7% vs 8.3%, P < .001) found on NIT. Women were less likely to be referred for catheterization than men (7.6% vs 12.6%, adjusted OR 0.75 [0.62-0.90]; P = .002). Of those who underwent catheterization within 90 days of randomization (358 women, 534 men), fewer women than men had obstructive coronary artery disease (40.8% vs 60.9%, P < .001). At a 60-day visit, women were significantly less likely than men to report statin use when indicated (adjusted OR 0.81 [0.73-0.91]; P < .001) but were similarly likely to report aspirin use when indicated (adjusted OR 0.78 [0.56-1.08]; P = .13). Over a median follow-up of 25 months, women had better outcomes than men (adjusted OR 0.73 [0.57-0.94]; P = .017).

Conclusions: Although women more frequently had normal NITs compared with men, those with abnormalities on NIT were less likely to be referred for catheterization or to receive statin therapy. The high rates of negative NIT in women, coupled with the better outcomes compared with men, strongly support the need for a sex-specific algorithm to guide NIT and chest pain management.

Trial registration: ClinicalTrials.gov NCT01174550.

Copyright © 2018 Elsevier Inc. All rights reserved.

Figures

Figure 1:

NIT test results by sex and NIT type. *This is the only non-statistically significant comparison between women and men presented in this figure.

Figure 2:

Associations between patient sex (women vs men) and the primary outcome of all-cause death, myocardial infarction, or unstable angina in different subsets of the PROMISE population. (1): Adjusted model controls for NIT modality (CTA/stress test); NIT results (4-tier); ICA referral and results (positive/negative); referral for revascularization; and factors listed in (2) below. (2): Adjusted model controls for BMI (kg/m2); age (standardized by sex); chest pain vs other as primary symptoms; chest pain typicality (typical, atypical, non-cardiac); and risk factors such as smoker (ever/never), diabetes, hypertension, history of peripheral artery or cerebrovascular disease, sedentary lifestyle, depression, family history of premature CAD, and dyslipidemia.