Diagnostic and Prognostic Evaluation in Postmenopausal Women with Signs and Symptoms of Unstable Coronary Artery Disease

Abstract: Coronary artery disease (CAD) is the major cause of death in both men and women in the western world. The majority of studies undertaken to evaluate diagnostic methods, risk stratification and treatment of CAD, have been performed on men. Although there are studies reporting gender differences in the presentation of symptoms, prognosis and response to treatment, current recommendations for practice are based on a model of the disease in men.The diagnostic information from basic clinical data, ECG and an early symptomlimited exercise test was evaluated in a prospective study on 200 postmenopausal women with unstable CAD. The prevalence of atherosclerosis was high (85%). A patient history and markers of myocardial injury were good predictors of significant CAD and the exercise test was as valuable for the assessment of this diagnosis in women as that reported in men.The incremental diagnostic values of basic clinical data, the exercise test and 201TI SPECT were assessed in 121 postmenopausal women after an episode of unstable CAD. There was an incremental diagnostic value of 201TI SPECT compared to basic data and the exercise test when diagnosing significant CAD, but not regarding the identification of extensive CAD.Evaluation of symptom-limited exercise test for risk stratification in postmenopausal women with unstable CAD was carried out on a population of 395 women in the "FRagmin during InStability in CAD" (FRISC I) Study. The exercise test was a good predictor of future cardiac death and myocardial infarction (MI) if parameters reflecting cardiac performance also were taken under consideration and not only chest pain and ST-segment depression, two parameters reflecting ischaemia and often used in studies on men. However, the patients who, after admission, did not become stable enough to perform the exercise test, had the highest risk of adverse future events.Comparison of symptom limited exercise test and troponin T measurements for risk stratification in women and men was performed in the FRISC I study population. It was concluded that the early symptom-limited exercise test and troponin T are at least as useful as prognostic risk indicators in women as they are in men.The gender differences in outcome after early revascularisation compared to noninvasive management was assessed in 749 women and 1708 men in the "Fast Revascularisation during InStability in CAD" (FRISC II) Study. Women were older, had less severe CAD and a better prognosis than men. Men had a more favourable outcome if randomised to early revascularisation, whereas there was an opposite trend in women, although not significant. The different outcome in women may partly be explained by A high procedure-related event rate in the invasive group compared to the non-invasive group, and an overall low event rate during follow-up. Further research is needed in this area, and in the mean time, a more conservative approach to revascularisation in women, guided by risk stratification seems reasonable.