The Economic Burden of Angina in Women With Suspected Ischemic Heart Disease

Abstract

MD; for the Women's Ischemia Syndrome Evaluation (WISE) InvestigatorsBackground-Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, Ͻ50% stenosis) coronary artery disease (CAD) is frequently reported. Few data exist regarding the type and intensity of resource consumption in women with chest pain after coronary angiography. Methods and Results-A total of 883 women referred for coronary angiography were prospectively enrolled in the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE). Cardiovascular prognosis and cost data were collected. Direct (hospitalizations, office visits, procedures, and drug utilization) and indirect (out-of-pocket, lost productivity, and travel) costs were estimated through 5 years of follow-up. Among 883 women, 62%, 17%, 11%, and 10% had nonobstructive and 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Five-year cardiovascular death or myocardial infarction rates ranged from 4% to 38% for women with nonobstructive to 3-vessel CAD (PϽ0.0001). Five-year rates of hospitalization for chest pain occurred in 20% of women with nonobstructive CAD, increasing to 38% to 55% for women with 1-vessel to 3-vessel CAD (PϽ0.0001). The volume of repeat catheterizations or angina hospitalizations was 1.8-fold higher in women with nonobstructive versus 1-vessel CAD after 1 year of follow-up (PϽ0.0001). Drug treatment was highest for those with nonobstructive or 1-vessel CAD (PϽ0.0001). The proportion of costs for anti-ischemic therapy was higher for women with nonobstructive CAD (15% versus 12% for 1-vessel to 3-vessel CAD; Pϭ0.001). For women with nonobstructive CAD, average lifetime cost estimates were $767 288 (95% CI, $708 480 to $826 097) and ranged from $1 001 493 to $1 051 302 for women with 1-vessel to 3-vessel CAD (Pϭ0.0003). Conclusions-Symptom-driven care is costly even for women with nonobstructive CAD. Our lifetime estimates for costs of cardiovascular care identify a significant subset of women who are unaccounted for within current estimates of the economic burden of coronary heart disease. (Circulation. 2006;114:894-904.)

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

“…Additionally, many of these patients have an adverse quality of life, functional status, and exercise capacity with relatively frequent visits to healthcare providers for persistent or recurring disabling symptoms 42. Elevated MACE rates are observed both early after the index coronary angiogram (eg within the first year) and at longer‐term follow‐up.…”

Microvascular Coronary Dysfunction in a Woman With Signs and Symptoms of Myocardial Ischemia but No Obstructive Coronary Artery Disease

“…Eighty six percent of patients with continued chest pain and no evidence of CAD were found to have chest pain at least weekly for up to one year post-angiogram, with unchanged or even worsening pain, and with half reporting functional disability including limitations on activities of daily living and/or inability to work [9,10]. Despite open coronary angiograms, twenty to fifty percent of patients are re-hospitalized for chest pain with an average lifetime cost per patient set at approximately eight hundred thousand dollars [7]. Approximately 50% of women with symptoms of persistent chest pain, evidence of ischemia, and presence of no obstructive CAD have been found to have MCD [11].…”

“…It is therefore important to identify and diagnose in the appropriate clinical setting, as MCD is associated with an increased risk of adverse cardiovascular events. Moreover, MCD is the presumable cause of symptoms that can lead to repeated testing, hospitalization, and disability, creating substantial economic, physical, and emotional hardships [7]. It is imperative that clinicians are aware of this condition, as early identification of MCD by CRT in the appropriate clinical setting may be beneficial in prognostication and/ or stratification of these patients for optimal medical therapy.…”

“…Identification of angina caused by MCD is crucial due to the associated major adverse cardiac events such as myocardial infarction, congestive heart failure, and sudden cardiac death [5,6]. MCD as a cause of angina also contributes to poor quality of life, morbidity, and health care costs [7]. Thus, a thorough evaluation of patients with persistent chest pain is important for accurate diagnosis and treatment.…”

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

“…There is an abundance of economic literature on the comparative evaluation of stress nuclear imaging for patients with stable chest pain symptoms (51)(52)(53)56,(67)(68)(69)(70)(71). Several reports have noted that, compared with a direct angiographic approach, stress nuclear imaging can provide significant cost savings (;30%240%) for 2-3 y of follow-up cardiac care (52,53,56,69,70).…”