Relationship Between Gender and Clinical Management After Stress Testing
Relationship Between Gender and Clinical Management After Stress Testing
Background: Controversy remains regarding whether gender differences exist in clinical management after exercise treadmill testing (ETT).
Methods: We studied 7,506 patients (49.8% women) without documented coronary heart disease referred for ETT from July 2001 to June 2004 in a community-based setting. We assessed the relationship between gender and subsequent diagnostic testing (secondary stress testing or coronary angiography) within 6 months after ETT. Secondary outcomes included subsequent stress testing, coronary angiography, and new cardiology visits in the 6-month interval. Multivariable analyses assessed the relationship between gender and these outcomes adjusting for demographic, clinical, and stress test characteristics. In subsequent analyses, patients were stratified by Duke Treadmill Scores (Duke University, Durham, NC).
Results: Compared with men, women referred for ETT were older, had a higher prevalence of some cardiac risk factors, achieved lower peak workloads, and, more often, experienced chest pain or ST-segment changes. After accounting for differences in clinical and ETT parameters, gender was not associated with any subsequent diagnostic testing in the 6 months after ETT (OR 1.0, 95% CI 0.85-1.18). In secondary analyses, women were less likely to undergo angiography (OR 0.63, 95% CI 0.47-0.83) with a trend toward more subsequent stress testing. Stratified analyses revealed less subsequent testing in high-to-intermediate Duke Treadmill Score women compared with men (OR 0.61, 95% CI 0.48-0.79). Women and men were equally likely to die (hazards ratio 0.93, 95% CI 0.61-1.44) in the adjusted survival analysis.
Conclusions: Overall, women and men equally underwent subsequent diagnostic testing after ETT. Although women were less likely to undergo angiography and higher-risk women were less likely to undergo subsequent testing, adverse events were not higher in women. Given these findings, assumptions regarding gender disparities in clinical management after ETT should be reevaluated in other settings.
With recent advances in the diagnosis and treatment of coronary heart disease (CHD), national death rates have declined; however, this change has not been as pronounced in women as it has been in men. Reasons for this mortality difference in women are not clearly understood. Biologic factors, such as differences in risk factors, presentation, physiology, diagnostic test validity, and treatment response, have been proposed as possible explanations. Alternatively, these differences raise important concerns about the potential differential use of guideline-recommended therapeutic and diagnostic strategies between women and men.
Current guidelines recommend exercise treadmill testing (ETT) for women and men in the initial evaluation of suspected CHD and subsequent care that is similarly informed by the ETT results, regardless of gender. Despite these gender-neutral recommendations, several prior studies have suggested that gender-based variations in care exist. However, findings of gender differences in clinical management after ETT have not been consistent. Earlier work has been primarily based on limited stress test variables to determine risk and has generally been performed in specialized study settings. In addition, most studies have focused primarily upon subsequent angiography without accounting for additional noninvasive testing, and few have investigated whether management differences found influence patient outcomes. Therefore, questions remain about whether gender differences in management after ETT exist and how they contribute to outcomes.
Accordingly, we compared CHD evaluation strategies in a contemporary community-based cohort after ETT between women and men. Specifically, we evaluated the rates of subsequent diagnostic testing (angiography or secondary stress testing) and cardiology specialist evaluation in the 6 months after ETT.
Background: Controversy remains regarding whether gender differences exist in clinical management after exercise treadmill testing (ETT).
Methods: We studied 7,506 patients (49.8% women) without documented coronary heart disease referred for ETT from July 2001 to June 2004 in a community-based setting. We assessed the relationship between gender and subsequent diagnostic testing (secondary stress testing or coronary angiography) within 6 months after ETT. Secondary outcomes included subsequent stress testing, coronary angiography, and new cardiology visits in the 6-month interval. Multivariable analyses assessed the relationship between gender and these outcomes adjusting for demographic, clinical, and stress test characteristics. In subsequent analyses, patients were stratified by Duke Treadmill Scores (Duke University, Durham, NC).
Results: Compared with men, women referred for ETT were older, had a higher prevalence of some cardiac risk factors, achieved lower peak workloads, and, more often, experienced chest pain or ST-segment changes. After accounting for differences in clinical and ETT parameters, gender was not associated with any subsequent diagnostic testing in the 6 months after ETT (OR 1.0, 95% CI 0.85-1.18). In secondary analyses, women were less likely to undergo angiography (OR 0.63, 95% CI 0.47-0.83) with a trend toward more subsequent stress testing. Stratified analyses revealed less subsequent testing in high-to-intermediate Duke Treadmill Score women compared with men (OR 0.61, 95% CI 0.48-0.79). Women and men were equally likely to die (hazards ratio 0.93, 95% CI 0.61-1.44) in the adjusted survival analysis.
Conclusions: Overall, women and men equally underwent subsequent diagnostic testing after ETT. Although women were less likely to undergo angiography and higher-risk women were less likely to undergo subsequent testing, adverse events were not higher in women. Given these findings, assumptions regarding gender disparities in clinical management after ETT should be reevaluated in other settings.
With recent advances in the diagnosis and treatment of coronary heart disease (CHD), national death rates have declined; however, this change has not been as pronounced in women as it has been in men. Reasons for this mortality difference in women are not clearly understood. Biologic factors, such as differences in risk factors, presentation, physiology, diagnostic test validity, and treatment response, have been proposed as possible explanations. Alternatively, these differences raise important concerns about the potential differential use of guideline-recommended therapeutic and diagnostic strategies between women and men.
Current guidelines recommend exercise treadmill testing (ETT) for women and men in the initial evaluation of suspected CHD and subsequent care that is similarly informed by the ETT results, regardless of gender. Despite these gender-neutral recommendations, several prior studies have suggested that gender-based variations in care exist. However, findings of gender differences in clinical management after ETT have not been consistent. Earlier work has been primarily based on limited stress test variables to determine risk and has generally been performed in specialized study settings. In addition, most studies have focused primarily upon subsequent angiography without accounting for additional noninvasive testing, and few have investigated whether management differences found influence patient outcomes. Therefore, questions remain about whether gender differences in management after ETT exist and how they contribute to outcomes.
Accordingly, we compared CHD evaluation strategies in a contemporary community-based cohort after ETT between women and men. Specifically, we evaluated the rates of subsequent diagnostic testing (angiography or secondary stress testing) and cardiology specialist evaluation in the 6 months after ETT.
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