A risk score for predicting coronary artery disease in women with angina pectoris and abnormal stress test finding.

Women with angina pectoris and abnormal stress test findings commonly have no epicardial coronary artery disease (CAD) at catheterization. The aim of the present study was to develop a risk score to predict obstructive CAD in such patients. Data were analyzed from 337 consecutive women with angina pectoris and abnormal stress test findings who underwent cardiac catheterization at our center from 2003 to 2007. Forward selection multivariate logistic regression analysis was used to identify the independent predictors of CAD, defined by ≥50% diameter stenosis in ≥1 epicardial coronary artery. The independent predictors included age ≥55 years (odds ratio 2.3, 95% confidence interval 1.3 to 4.0), body mass index <30 kg/m(2) (odds ratio 1.9, 95% confidence interval 1.1 to 3.1), smoking (odds ratio 2.6, 95% confidence interval 1.4 to 4.8), low high-density lipoprotein cholesterol (odds ratio 2.9, 95% confidence interval 1.5 to 5.5), family history of premature CAD (odds ratio 2.4, 95% confidence interval 1.0 to 5.7), lateral abnormality on stress imaging (odds ratio 2.8, 95% confidence interval 1.5 to 5.5), and exercise capacity <5 metabolic equivalents (odds ratio 2.4, 95% confidence interval 1.1 to 5.6). Assigning each variable 1 point summed to constitute a risk score, a graded association between the score and prevalent CAD (ptrend <0.001). The risk score demonstrated good discrimination with a cross-validated c-statistic of 0.745 (95% confidence interval 0.70 to 0.79), and an optimized cutpoint of a score of ≤2 included 62% of the subjects and had a negative predictive value of 80%. In conclusion, a simple clinical risk score of 7 characteristics can help differentiate those more or less likely to have CAD among women with angina pectoris and abnormal stress test findings. This tool, if validated, could help to guide testing strategies in women with angina pectoris.

The cardiovascular health of urban African Americans: diet-related results from the Genes, Nutrition, Exercise, Wellness, and Spiritual Growth (GoodNEWS) trial.

African Americans have a higher incidence of cardiovascular disease (CVD) than Americans in general and are thus prime targets for efforts to reduce CVD risk. Dietary intake data were obtained from African Americans participating in the Genes, Nutrition, Exercise, Wellness, and Spiritual Growth (GoodNEWS) Trial. The 286 women and 75 men who participated had a mean age of 49 years; 53% had hypertension, 65% had dyslipidemia, and 51% met criteria for metabolic syndrome. Their dietary intakes were compared with American Heart Association and National Heart, Lung, and Blood Institute nutrition parameters to identify areas for improvement to reduce CVD risk in this group of urban church members in Dallas, TX. Results from administration of the Dietary History Questionnaire indicated median daily intakes of 33.6% of energy from total fat, 10.3% of energy from saturated fat, 171 mg cholesterol, 16.3 g dietary fiber, and 2,453 mg sodium. A beneficial median intake of 2.9 cups fruits and vegetables per day was coupled with only 2.7 oz fish/week and an excessive intake of 13 tsp added sugar/day. These data indicate several changes needed to bring the diets of these individuals--and likely many other urban African Americans--in line with national recommendations, including reduction of saturated fat, sodium, and sugar intake, in addition to increased intake of fatty fish and whole grains. The frequent inclusion of vegetables should be encouraged in ways that promote achievement of recommended intakes of energy, fat, fiber, and sodium.

Clinical characteristics, vascular function, and inflammation in women with angina in the absence of coronary atherosclerosis: the Dallas Heart Study.

OBJECTIVES: we sought to evaluate the relationship between angina and coronary artery calcium (CAC) in women, and among women without CAC, the associations between angina and clinical, vascular, and inflammatory factors. BACKGROUND: angina in women without coronary atherosclerosis is associated with significant morbidity, yet its determinants are poorly understood. METHODS: women ages 30 to 65 years from the Dallas Heart Study, a multiethnic probability sample of Dallas County residents, who completed a Rose angina questionnaire and had complete data for CAC by computed tomography were selected for this analysis. Soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1, high sensitivity C-reactive protein, monocyte chemoattractant protein-1 and aortic compliance by magnetic resonance imaging were measured. RESULTS: among the 1,480 women in this cohort (mean age 45 years, 49% African-American), angina was present in 6.9% but was not associated with CAC (19% CAC prevalence with angina vs. 15% without, p = 0.2). Among women without CAC, angina was related to variables reflecting obesity and insulin resistance and was independently associated with African-American ethnicity, premature family history of myocardial infarction, and waist circumference (all p < 0.05). Such women with angina also had higher levels of soluble intercellular adhesion molecule-1 (668 vs. 592 ng/ml, p = 0.02) and soluble vascular cell adhesion molecule-1 (1,106 vs. 968 ng/ml, p = 0.01) and reduced aortic compliance (mean 22 vs. 26 ml/mm Hg, p = 0.007) than such women without angina. Conversely, there was no difference in C-reactive protein or monocyte chemoattractant protein-1 levels for women with and without angina (p = not significant, each). CONCLUSIONS: angina among women in the general population is common and is not associated with subclinical atherosclerosis. Additionally, angina in the absence of subclinical atherosclerosis is not related to many traditional atherosclerotic risk factors but is associated with clinical, inflammatory, and vascular factors that reflect endothelial dysfunction and vascular stiffness, suggesting a distinct vascular etiology and alternative potential therapeutic targets.

Angina in Women without Obstructive Coronary Artery Disease.

Angina in the absence of obstructive coronary artery disease, sometimes referred to as cardiac syndrome X (CSX), is a debilitating condition that disproportionately affects women. More than 50% of women evaluated for angina have non-obstructive disease by cardiac catheterization, although the total numbers of women affected by CSX are unknown. Varying clinical definitions and the lack of large scale epidemiologic studies focusing on this illness have resulted in limited knowledge about its risk factors, although there appears to be an association with black race, estrogen deficiency, and insulin resistance. Contrary to prior beliefs about the benign nature of this entity, these women suffer considerable morbidity with costly economic implications that approach the lifetime costs of healthcare utilization for those with obstructive coronary disease. Two prevailing hypotheses have emerged to explain CSX: the ischemic hypothesis detailing abnormal coronary microvascular function and the non-ischemic hypothesis describing altered pain perception and myocardial hypersensitivity. Treatment strategies have focused on both of these pathways with the main goal of improving symptoms. Beta blockers provide the most convincing evidence for benefit, with other antianginals having secondary roles. Other promising pharmacologic therapies include xanthine derivatives, estrogen replacement therapy, ACE inhibitors, and statin medications, among other emerging treatment options. Neurostimulation and lifestyle factors including exercise can also be beneficial in reducing symptoms. However, managing patients with CSX can be frustrating for both patients and physicians, as there is a lack of data regarding an optimal treatment algorithm including few large-scale randomized controlled trials to clarify effective therapies.

Differential associations between soluble cellular adhesion molecules and atherosclerosis in the Dallas Heart Study: a distinct role for soluble endothelial cell-selective adhesion molecule.

OBJECTIVE: Endothelial cell-selective adhesion molecule (ESAM) is a junctional-type cellular adhesion molecule (CAM) that is uniquely expressed in vascular endothelium and activated platelets and mediates neutrophil and monocyte diapedesis across the endothelium. Given its role in endothelial pathobiology, we hypothesized that soluble ESAM (sESAM) would be independently associated with atherosclerosis and vascular stiffness. METHODS AND RESULTS: We measured sESAM, soluble intercellular adhesion molecule (sICAM)-1, and soluble vascular cell adhesion molecule (sVCAM)-1 in 3222 subjects participating in the Dallas Heart Study, a probability-based population sample. Coronary artery calcium (CAC) was measured by electron beam computed tomography, and abdominal aortic wall thickness (AWT), aortic plaque burden (APB), and aortic compliance (AC) by MRI. Increasing levels of sESAM were associated with all major cardiovascular risk factors as well as with inflammatory markers such as monocyte chemoattractant protein-1, but only weakly correlated with sICAM-1 and sVCAM-1. In multivariate analyses, sESAM was independently associated with prevalent CAC (OR 1.2 per SD increase, 95% CI 1.1 to 1.3; P=0.005), AWT (P=0.035), and AC (P=0.006), but not APB (P=0.15). In contrast, no independent associations were observed between sICAM-1 or sVCAM-1 and any of the atherosclerosis phenotypes. CONCLUSIONS: In this first reported clinical study of sESAM in humans, sESAM levels were independently associated with CAC, AWT, and AC, whereas sICAM-1 and sVCAM-1 were not. These findings support a unique role of this cellular adhesion molecule in atherosclerosis and suggest the need for further exploration of sESAM as a predictive biomarker and potential mediator of atherosclerosis.