Clinical InvestigationSex differences in management and outcomes of patients with stable symptoms suggestive of coronary artery disease: Insights from the PROMISE trial
Section snippets
Study cohort and design
PROMISE was a pragmatic randomized trial that compared initial anatomic (CTA) versus stress testing in stable symptomatic patients with suspected CAD.9., 10. The choice of stress test was left up to the clinician (exercise electrocardiogram, stress echocardiography, or stress nuclear), as were all test interpretations and all subsequent clinical decisions in both testing arms. Randomization was stratified by study site and by the stress test type that was chosen by the provider prior to
Baseline characteristics
Among the 8,966 patients in PROMISE who underwent testing as randomized and who had interpretable results, 4,500 (52% female) had CTA and 4,466 (53% female) had stress testing (Supplemental Figure 1). As previously reported,12 in both the CTA and stress testing groups, women were older and more likely to have a history of hypertension, peripheral arterial disease or cerebrovascular disease, family history of premature CAD, depression, and a sedentary lifestyle compared with men (Table II). On
Discussion
Many prior studies have reported differences in management of established CAD by sex.3., 6., 13. However, the increasing use of CTA as an NIT strategy may have impacted the management of women and men with suspected CAD. Our data from the PROMISE trial suggest that the large majority of patients of both sexes undergoing NIT have negative results—in women more than in men and with stress testing more than with CTA. After accounting for differences in NIT results, women with stable symptoms
Conclusion
In the PROMISE trial population, women with stable symptoms concerning for ischemia had more normal and fewer abnormal NITs than men. Women with abnormalities on NIT were less likely to be referred for catheterization than men, regardless of whether they initially underwent stress testing or anatomic imaging with CTA, and they were less likely to receive statin therapy when indicated. Nonetheless, women had better CV outcomes than their male counterparts, perhaps related to the lower overall CV
Disclosures
D. B. M. reported receiving personal fees from Medtronic, CardioDx, and St Jude Medical and grant support from Eli Lilly, Bristol-Myers Squibb, Gilead Sciences, AGA Medical, Merck, Oxygen Biotherapeutics, and AstraZeneca. M. R. P. reported receiving grant support from Astra Zeneca, CSL, Heart Flow Technologies, Jansen, Johnson & Johnson, MAQUET, Medtronic, and the NHLBI and serving on advisory boards for Astra Zeneca, Bayer, CSL, Genzyme Corp., Janssen, Medtronic, and Merck. U. H. reported
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Philip F. Binkley, MD, MPH, served as guest editor for this article.
Clinical Trial Registration: ClinicalTrials.gov # NCT01174550.