Abstract
Background
Management of acute coronary syndrome (ACS) patients with nonobstructive epicardial coronary artery disease (CAD) remains poorly understood.
Hypothesis
Acute coronary syndrome patients with nonobstructive CAD are less likely to receive effective cardiac medications upon discharge from the hospital.
Methods
We identified patients hospitalized with ACS that underwent coronary angiography and had a 6‐month follow‐up. Patients were grouped by CAD severity: nonobstructive CAD (<50% blockage in all vessels) or obstructive CAD (≥50% blockage in ≥ 1 vessels). Data were collected on demographics, medications at discharge, and adverse outcomes at 6 months, for all patients.
Results
Of the 2264 ACS patients included in the study: 123 patients had nonobstructive CAD and 2141 had obstructive CAD. Cardiac risk factors including hypertension and diabetes were common among patients with nonobstructive CAD. Men and women with nonobstructive CAD were less likely to receive cardiac medications compared to patients with obstructive CAD including aspirin (87.8% vs 95.0%, P = 0.001), β‐blockers (74.0% vs 89.2%, P < 0.001), or statins (69.1% vs 81.2%, P = 0.001). No gender‐related differences in discharge medications were observed for patients with nonobstructive CAD. However, women with nonobstructive CAD had similar rates of cardiac‐related rehospitalization as men with obstructive CAD (23.3% and 25.9%, respectively).
Conclusions
Patients with nonobstructive CAD are less likely to receive evidence‐based medications compared to patients with obstructive CAD, despite the presence of CAD risk factors and occurrence of an ACS event. Further research is warranted to determine if receipt of effective cardiac medications among patients with nonobstructive CAD would reduce cardiac‐related events. Copyright © 2010 Wiley Periodicals, Inc.
Full Text
The Full Text of this article is available as a PDF (118.6 KB).
References
- 1. Bugiardini R, Manfrini O, De Ferrari GM. Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography. Arch Intern Med 2006; 166(13): 1391–1395. [DOI] [PubMed] [Google Scholar]
- 2. Lichtlen PR, Bargheer K, Wenzlaff P. Long‐term prognosis of patients with anginalike chest pain and normal coronary angiographic findings. J Am Coll Cardiol 1995; 25(5): 1013–1018. [DOI] [PubMed] [Google Scholar]
- 3. Hochman JS, McCabe CH, Stone PH, et al. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol 1997; 30(1): 141–148. [DOI] [PubMed] [Google Scholar]
- 4. Roe MT, Harrington RA, Prosper DM, et al. Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 2000; 102(10): 1101–1106. [DOI] [PubMed] [Google Scholar]
- 5. Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights from the NHLBI‐Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender‐based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006; 47(suppl 3): S21–S29. [DOI] [PubMed] [Google Scholar]
- 6. Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med 1999; 341(4): 226–232. [DOI] [PubMed] [Google Scholar]
- 7. Fox KA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333(7578): 1091. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Steg PG, Goldberg RJ, Gore JM, et al. Baseline characteristics, management practices, and in‐hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 2002; 90(4): 358–363. [DOI] [PubMed] [Google Scholar]
- 9. Latchamsetty R, Fang J, Kline‐Rogers E, et al. Prognostic value of transient and sustained increase in in‐hospital creatinine on outcomes of patients admitted with acute coronary syndrome. Am J Cardiol 2007; 99(7): 939–942. [DOI] [PubMed] [Google Scholar]
- 10. Patel MR, Chen AY, Peterson ED, et al. Prevalence, predictors, and outcomes of patients with non‐ST‐segment elevation myocardial infarction and insignificant coronary artery disease: results from the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative. Am Heart J 2006; 152(4): 641–647. [DOI] [PubMed] [Google Scholar]
- 11. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST‐segment elevation. N Engl J Med 2001; 345(7): 494–502. [DOI] [PubMed] [Google Scholar]
- 12. Dwyer JP, Redfern J, Freedman SB. Low utilisation of cardiovascular risk reducing therapy in patients with acute coronary syndromes and nonobstructive coronary artery disease. Int J Cardiol 2008; 129(3): 394–398. [DOI] [PubMed] [Google Scholar]
- 13. Papanicolaou MN, Califf RM, Hlatky MA, et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986; 58(13): 1181–1187. [DOI] [PubMed] [Google Scholar]
- 14. Maynard C, Litwin PE, Martin JS, et al. Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med 1992; 152(5): 972–976. [PubMed] [Google Scholar]
- 15. Robinson K, Conroy RM, Mulcahy R, et al. Risk factors and in‐hospital course of first episode of myocardial infarction or acute coronary insufficiency in women. J Am Coll Cardiol 1988; 11(5): 932–936. [DOI] [PubMed] [Google Scholar]
- 16. Fiebach NH, Viscoli CM, Horwitz RI. Differences between women and men in survival after myocardial infarction. Biology or methodology? JAMA 1990; 263(8): 1092–1096. [PubMed] [Google Scholar]
- 17. Chiriboga DE, Yarzebski J, Goldberg RJ, et al. A community‐wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction. Am J Cardiol 1993; 71(4): 268–273. [DOI] [PubMed] [Google Scholar]
- 18. Jackson EA, Sivasubramian R, Spencer FA, et al. Changes over time in the use of aspirin in patients hospitalized with acute myocardial infarction (1975 to 1997): a population‐based perspective. Am Heart J 2002; 144(2): 259–268. [DOI] [PubMed] [Google Scholar]
- 19. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004; 350(15): 1495–1504. [DOI] [PubMed] [Google Scholar]
- 20. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high‐risk individuals: a randomised placebo‐controlled trial. Lancet 2002; 360(9326): 7–22. [DOI] [PubMed] [Google Scholar]
- 21. Pecora MJ, Roubin GS, Cobbs BW Jr, Ellis SG, Weintraub WS, King SB III. Presentation and late outcome of myocardial infarction in the absence of angiographically significant coronary artery disease. Am J Cardiol 1988; 62(7): 363–367. [DOI] [PubMed] [Google Scholar]