Gender differences in diagnosis and prognosis of coronary artery disease

Abstract

The first aim of this thesis was to evaluate the diagnostic value of clinical symptoms for the diagnosis of CAD in women and men presenting with chest pain in the general practice and the emergency department. The second aim of this thesis was to investigate the influence of gender on treatment success and (long-term) prognosis. The treatment of CVD in general has improved enormously over the last decades resulting in a better prognosis of women and men. In the Netherlands, the mortality rates of CVD have decreased between 1980 and 2011 with 64% in men and 59% in women. The largest decline was the mortality of acute myocardial infarctions: 84% in men and 79% in women. This improvement in treatment includes better prevention (primary and secondary) for CVD, new medical options, the rise and improvement in (primary) percutaneous coronary interventions (PCI) and a decline in peri- and postoperative mortality after coronary artery bypass grafting (CABG). It remains uncertain whether women receive the same treatment as men, if they respond as good to treatment as men and if there are differences in the prognosis of CVD between sexes. To illustrate: the treatment of a STEMI has improved mainly due to the shift from thrombolysis to primary PCI. Therefore primary PCI is now the recommended treatment for STEMI in Europe and the United States. Many studies have looked for differences in outcome between women and men with a STEMI treated with primary PCI but the results remain conflicting. This is partly due to the fact that data are often difficult to compare as inclusion criteria frequently differ, and there is variation in outcome measures and duration of follow-up. In this thesis we focused on the treatment and prognosis of women and men with a STEMI treated with primary PCI, gender differences in long-term outcome after CABG and in patients with known CVD. Early recognition of high-risk individuals to prevent clinically manifest disease through lifestyle modifications or drug treatment is essential to prevent symptomatic cardiovascular disease. In an attempt to identify people at risk of CVD several prediction models have been developed throughout the years. The Framingham Risk Score, SCORE, and the Pooled Cohort Equations are examples of such frequently used algorithms that aim to predict 10-year absolute risk of CVD for individuals without CVD. Even though these prediction rules are sex-specific, they include the same combination of traditional risk factors for women and men. Female-specific risk factors are known to affect CVD risk but it is however unknown whether female-specific risk factors have any added value on top of the traditional risk factors to predict future risk of CVD in women. The third aim of this thesis was to investigate the added value of female-specific risk factors on top of the traditional risk factors for the prediction of CVD in healthy women.