Insights From the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study
Part I: Gender Differences in Traditional and Novel Risk Factors, Symptom Evaluation, and Gender-Optimized Diagnostic Strategies
Leslee J. Shaw, PhD*,*,
C. Noel Bairey Merz, MD*,
Carl J. Pepine, MD ,
Steven E. Reis, MD ,
Vera Bittner, MD**,
Sheryl F. Kelsey, PhD ,
Marian Olson, MS,
B. Delia Johnson, PhD,
Sunil Mankad, MD||,
Barry L. Sharaf, MD¶,
William J. Rogers, MD**,
Timothy R. Wessel, MD,
Christopher B. Arant, MD,
Gerald M. Pohost, MD,
Amir Lerman, MD,
Arshed A. Quyyumi, MD,
George Sopko, MD|||| for the WISE Investigators
* Division of Cardiology, Department of Medicine, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida
|| Division of Cardiology, Department of Medicine, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania
¶ Division of Cardiology, Rhode Island Hospital, Providence, Rhode Island
** Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
Division of Cardiology, University of Southern California, Los Angeles, California
Division of Cardiology, Mayo Clinic, Rochester, Minnesota
Division of Cardiology, Emory University, Atlanta, Georgia
|||| National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland.
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Figure 1 Cumulative % change in coronary heart disease mortality in black and white women as compared with men in the U.S. from 1979 to 1998. Based upon recent estimates, there has been greater declines in coronary heart disease mortality in men as compared with black or white women. Adapted from Benjamin EJ, et al. (20).
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Figure 2 From the National Institutes of Health-National Heart, Lung, and Blood Institute Women’s Ischemia Syndrome Evaluation (WISE) study, event-free survival by metabolic status was recently reported in women. These results reveal that women with the metabolic syndrome are at intermediate risk for major adverse cardiac events (MACE) (death, non-fatal myocardial infarction, stroke, or congestive heart failure). Reprinted from Marroquin OC, et al. (90).
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Figure 3 From the National Heart, Lung, and Blood Institute Women’s Ischemia Syndrome Evaluation (WISE), the Diamond probability of coronary artery disease (CAD) as compared with observed coronary disease prevalence in symptomatic women ages 35 to 45, 46 to 55, 56 to 65, and 66 to 75 years. These results note that probability estimates based upon data series of several decades ago overestimate the likelihood of coronary disease in women; as based upon a comparison of a contemporary series of women referred to coronary angiography. Atyp Ang = atypical angina; Nonang = non-angina; Typ Ang = typical angina. Solid bars = WISE prevalence; open bars = Diamond probability.
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Figure 4 Prognostic value of functional capacity in asymptomatic (n = 8,715) and symptomatic (n = 8,214) women as synthesized from published reports. This figure illustrates five-year mortality for asymptomatic and symptomatic women. METs = achieved metabolic equivalents during exercise testing; Pharm stress = women referred for adenosine or dipyridamole single-photon emission computed tomography or dobutamine stress echocardiography.
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Figure 5 A revision of the recent consensus statement from the American Society of Nuclear Cardiology’s (ASNC) work-up algorithm for non-invasive testing in women. The revision includes the application of ASNC’s guidelines to all cardiac imaging modalities. Adapted from Mieres JH, et al. (174). CAD = coronary artery disease; ECG = electrocardiogram; EF = ejection fraction; Ex = exercise; LV = left ventricular; METs = metabolic equivalents.
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Figure 6 Proposed paradigm for testing of asymptomatic and symptomatic women including detection of subclinical and obstructive coronary disease. *6% to 20% for intermediate Framingham risk scores and >20% for high Framingham risk scores. CHD = coronary heart disease; CMR = cardiovascular magnetic resonance imaging; CT = computed tomography; ECG = electrocardiogram; MI = myocardial infarction; SPECT = single-photon emission computed tomography.
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