In this series, although women comprised the minority of patients referred with chest pain, a diagnosis of normal coronary arteries was five times more common in women than men. Risk factor analysis and exercise testing were of limited value in predicting coronary artery disease in women. There was no sex bias regarding revascularisation procedures, and outcome was similar. A diagnosis of non-cardiac chest pain in patients with normal coronary arteries was of little benefit to the patient with regard to morbidity.
Objective-To determine the diagnostic value of the exercise tolerance test (ETT) in women presenting with chest pain. Design-Prospective study of all women presenting to a centre with chest pain between 1987 and 1993 who were assessed by an ETT and coronary angiography. Setting-The outpatient clinic of one consultant cardiologist in a tertiary referral centre. Patients-Alil women referred to this outpatient clinic with chest pain were screened. For inclusion, patients had to perform ETT and undergo coronary angiography. Of the 347 referred during this period, 142 were excluded because they were unable to perform ETT or because of Q waves or other abnormalities on their resting electrocardiogram. Results-Overall the sensitivity of the ETT was 68% and the specificity was 61%, with a positive predictive value of 0-61 and a negative predictive value of 0-68. There were 42 false positive and 31 false negative ETT results (36% of the study group). The predictive value of a negative test was higher in younger women (< 52 years) than in the older group () 52 years) (P = 0.004), but the positive predictive value in the two groups was not significantly different. The predictive value of a negative test was also higher in those with two or fewer risk factors than in those with three or more risk factors (P = 0.001). The negative predictive value for those women above 52 years with three or more risk factors (24% of the study group) was only 0 25. Lack of chest pain during ETT was associated with a higher negative predictive value in the younger group than in the older women (P = 0.006).Conclusions-In women with chest pain use of the ETT was a misleading predictor of the presence or absence of coronary disease in 36% of these patients. In particular, a negative test in older women with three or more risk factors had a very low predictive value. The inclusion of risk factors and division by age can, however, be used to identify a population at intermediate risk for coronary artery disease in whom the ETT result has the highest diagnostic utility. (Heart 1996;76:156-160) Keywords: exercise test; women; chest pain; coronary angiography.Coronary disease is a common cause of morbidity and mortality in women, and is the commonest cause of death in those over the age of 65 years.' According to the Framingham study2 the prevalence of coronary artery disease in younger women is lower than in men, but the death rates of the two sexes converge in late middle age. Women with chest pain account for a considerable proportion of cardiological referrals.3Exercise testing has been a widely used screening procedure for the assessment of cardiac status for over 30 years. None the less, the value of this procedure in the screening of women to predict the presence of obstructive coronary disease has been the subject of considerable controversy.4-8 The usual electrocardiographic criteria applied in exercise testing seem less valuable in women than in men.4 In symptom free women "significant" ST segment changes are up to three times...
The significant reduction in cardiovascular morbidity and mortality following oestrogen replacement therapy in postmenopausal women is only partly explained by an improved lipid profile. Given acutely, oestradiol causes vasodilatation and increases coronary blood flow and, in large doses, improves treadmill performance in postmenopausal women with coronary artery disease. However, the significance of oestrogen-mediated vasodilatation is unknown since the acute effects of oestradiol in doses and preparations commonly used clinically have not been tested. The aim of this study was to evaluate the acute effects of conventional replacement therapy with 17 beta-oestradiol on treadmill performance in 16 postmenopausal women with angina in a randomized, double-blind, placebo-controlled cross-over trial. Following baseline treadmill testing a transdermal oestrogen patch releasing 50 micrograms oestradiol. 24 h-1 or matching placebo was applied and the exercise test repeated 24 h later. The patch was then removed. Seven to 14 days later the sequence was repeated using the alternative patch. The changes in time to angina, time to 1 mm ST segment depression and total exercise time for each treatment compared with the corresponding baseline test were calculated. Plasma 17 beta-oestradiol increased with active therapy from 56 +/- 30 pmol.l-1 to 204 +/- 90 pmol.l-1, indicating adequate replacement. Compared with their respective baseline exercise tests there were no differences between active and placebo patches for time to angina (active: 13 +/- 55 s vs placebo: 10 +/- 47 s), time to 1 mm ST segment depression (active: -30 +/- 52 s vs placebo: 24 +/- 71 s) or total exercise time (active: 14 +/- 45 s vs placebo: 13 +/- 35 s). Despite the recognized acute vasodilator action of larger doses of oestrogen, doses conventionally used in hormone replacement therapy had no acute effect on treadmill performance in this group of postmenopausal women with coronary artery disease.
Objective-To assess whether intermittent transdermal treatment with glyceryl trinitrate causes clinically significant rebound in patients maintained on a blockers for stable angina pectoris.Design
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