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Mark Doyle,
Nicole Weinberg,
Gerald M Pohost,
C Noel Bairey Merz,
Leslee J Shaw,
George Sopko,
Anthon Fuisz,
William J Rogers,
Edward G Walsh,
B Delia Johnson, [......],
Carl J Pepine, Sunil Mankad,
Steven E Reis,
Diane A Vido,
Geetha Rayarao,
Vera Bittner,
Lindsey Tauxe,
Marian B Olson,
Sheryl F Kelsey,
Robert W W Biederman
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to assess the prognostic value of global magnetic resonance (MR) myocardial perfusion imaging (MPI) in women with suspected myocardial ischemia and no obstructive (stenosis <50%) coronary artery disease (CAD).
The prognostic value of global MR-MPI in women without obstructive CAD remains unknown.
Women (n = 100, mean age 57 ± 11 years, age range 31 to 76 years), with symptoms of myocardial ischemia and with no obstructive CAD, as assessed by coronary angiography, underwent MR-MPI and standard functional assessment. During follow-up (34 ± 16 months), time to first adverse event (death, myocardial infarction, or hospitalization for worsening anginal symptoms) was analyzed using global MPI and left ventricular ejection fraction (EF) data.
Adverse events occurred in 23 (23%) women. Using univariable Cox proportional hazards regression modeling, variables found to be predictive of adverse events were global MR-MPI average uptake slope (p < 0.05), the ratio of MR-MPI peak signal amplitude to uptake slope (p < 0.05), and EF (p < 0.05). Two multivariable Cox models were formed, 1 using variables that were performance site dependent: ratio of MR-MPI peak amplitude to uptake slope together with EF (chi square: 13, p < 0.005); and a model using variables that were performance site independent: MR-MPI slope and EF (chi square: 12, p < 0.005). Each of the 2 multivariable models remained predictive of adverse events after adjustment for age, disease history, and Framingham risk score. For each of the Cox models, patients were categorized as high risk if they were in the upper quartile of the model and as not high risk otherwise. Kaplan-Meier analysis of time to event was performed for high risk versus not high risk for site-dependent (log rank: 15.2, p < 0.001) and site-independent (log rank: 13.0, p < 001) models.
Among women with suspected myocardial ischemia and no obstructive CAD, MR-MPI-determined global measurements of normalized uptake slope and peak signal uptake, together with global functional assessment of EF, appear to predict prognosis.
JACC. Cardiovascular imaging 10/2010; 3(10):1030-6. · 14.29 Impact Factor
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Leslee J Shaw,
C Noel Bairey Merz,
Vera Bittner,
Kevin Kip,
B Delia Johnson,
Steven E Reis,
Sheryl F Kelsey,
Marian Olson, Sunil Mankad,
Barry L Sharaf,
William J Rogers,
Gerald M Pohost,
George Sopko,
Carl J Pepine
[show abstract]
[hide abstract]
ABSTRACT: For women, who are more likely to live in poverty, defining the clinical and economic impact of socioeconomic factors may aid in defining redistributive policies to improve healthcare quality.
The NIH-NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) enrolled 819 women referred for clinically indicated coronary angiography. This study's primary end point was to evaluate the independent contribution of socioeconomic factors on the estimation of time to cardiovascular death or myocardial infarction (MI) (n = 79) using Cox proportional hazards models. Secondary aims included an examination of cardiovascular costs and quality of life within socioeconomic subsets of women.
In univariable models, socioeconomic factors associated with an elevated risk of cardiovascular death or MI included an annual household income <$20,000 (p = 0.0001), <9th grade education (p = 0.002), being African American, Hispanic, Asian, or American Indian (p = 0.016), on Medicaid, Medicare, or other public health insurance (p < 0.0001), unmarried (p = 0.001), unemployed or employed part-time (p < 0.0001), and working in a service job (p = 0.003). Of these socioeconomic factors, income (p = 0.006) remained a significant predictor of cardiovascular death or MI in risk-adjusted models that controlled for angiographic coronary disease, chest pain symptoms, and cardiac risk factors. Low-income women, with an annual household income <$20,000, were more often uninsured or on public insurance (p < 0.0001) yet had the highest 5-year hospitalization and drug treatment costs (p < 0.0001). Only 17% of low-income women had prescription drug coverage (vs. >or=50% of higher-income households, p < 0.0001), and 64% required >or=2 anti-ischemic medications during follow-up (compared with 45% of those earning >or=$50,000, p < 0.0001).
Economic disadvantage prominently affects cardiovascular disease outcomes for women with chest pain symptoms. These results further support a profound intertwining between poverty and poor health. Cardiovascular disease management strategies should focus on policies that track unmet healthcare needs and worsening clinical status for low-income women.
Journal of Women s Health 09/2008; 17(7):1081-92. · 1.57 Impact Factor
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Timothy R Wessel,
Christopher B Arant,
Susan P McGorray,
Barry L Sharaf,
Steven E Reis,
Richard A Kerensky,
Gregory O von Mering,
Karen M Smith,
Daniel F Pauly,
Eileen M Handberg, Sunil Mankad,
Marian B Olson,
B Delia Johnson,
C Noel Bairey Merz,
George Sopko,
Carl J Pepine
[show abstract]
[hide abstract]
ABSTRACT: Altered coronary reactivity is frequent in women with findings of myocardial ischemia without significant obstructive disease. This suggests a defect in coronary microvascular function. The adenosine-related component of this altered reactivity has been described in male and mixed gender populations, while the factors influencing this component of coronary reactivity in symptomatic women have received limited attention. Accordingly, the relationship between adenosine-related microvascular coronary reactivity and risk factors in symptomatic women evaluated for suspected ischemia remains uncertain.
Abnormal coronary microvascular reactivity to adenosine is predicted by atherosclerosis risk factors in women.
As part of the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE), we investigated the relationship between risk factors and coronary microvascular reactivity as flow velocity reserve to intracoronary adenosine (CFVR(Ado)) in 210 women referred for angiography to evaluate suspected ischemia.
Univariate analyses identified associations between CFVR(Ado) and multiple risk conditions; however, after adjusting for age, none remained significant. The best multivariable model using combinations of risk conditions to predict CFVR(Ado) yielded an R2 of only 0.18.
Among women with suspected ischemia, risk factors account for <20% of observed variability in CFVR(Ado). Therefore, other as yet unidentified factors must primarily account for coronary microvascular reactivity to adenosine.
Clinical Cardiology 02/2007; 30(2):69-74. · 2.15 Impact Factor
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[show abstract]
[hide abstract]
ABSTRACT: Insulin resistance is present in the setting of congestive heart failure. Glucagon-like peptide-1 (GLP-1) is a naturally occurring incretin with both insulinotropic and insulinomimetic properties.
We investigated the safety and efficacy of a 5-week infusion of GLP-1 (2.5 pmol/kg/min) added to standard therapy in 12 patients with New York Heart Association class III/IV heart failure and compared the results with those of 9 patients with heart failure on standard therapy alone. Echocardiograms, maximum myocardial ventilation oxygen consumption (VO2 max), 6-minute walk test, and Minnesota Living with Heart Failure quality of life score (MNQOL) were assessed. Baseline demographics, background therapy, and the degree of left ventricular dysfunction were similar between groups. GLP-1 significantly improved left ventricular ejection fraction (21 +/- 3% to 27 +/- 3% P < .01), VO2 max (10.8 +/- .9 ml/O2/min/kg to 13.9 +/- .6 ml/O2/min/kg; P < .001), 6-minute walk distance (232 +/- 15 m to 286 +/- 12 m; P < .001) and MNQOL score (64 +/- 4 to 44 +/- 5; P < .01). Benefits were seen in both diabetic and non-diabetic patients. There were no significant changes in any of the parameters in the control patients on standard therapy. GLP-1 was well tolerated with minimal episodes of hypoglycemia and gastrointestinal side effects.
Chronic infusion of GLP-1 significantly improves left ventricular function, functional status, and quality of life in patients with severe heart failure.
Journal of cardiac failure 12/2006; 12(9):694-9. · 3.25 Impact Factor
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J Rogers,
Gerald M Pohost,
George Sopko,
William Kip,
Sheryl F Kelsey,
Marian Olson,
B Delia Johnson, Sunil Mankad,
Barry L Sharaf,
Leslee J Shaw,
C Noel,
Bairey Merz,
Carl J Pepine,
Steven E Reis,
Vera Bittner
09/2006; 114:894-904.
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Thomas Rutledge,
Steven E Reis,
Marian B Olson,
Jane Owens,
Sheryl F Kelsey,
Carl J Pepine, Sunil Mankad,
William J Rogers,
C Noel Bairey Merz,
George Sopko,
Carol E Cornell,
Barry Sharaf,
Karen A Matthews,
Viola Vaccarino
[show abstract]
[hide abstract]
ABSTRACT: Depression is associated with clinical events and premature mortality among patients with established coronary artery disease (CAD). Typically, however, studies in this area focus only on baseline symptom severity and lack any data concerning symptom duration or symptom history.
To describe and compare the relationships between 2 measures of depression-assessed in the form of depression symptom severity and reported treatment history-with atherosclerosis risk factors and major clinical events in a sample of women with suspected myocardial ischemia.
Follow-up study of women who completed a diagnostic CAD protocol, including cardiac symptoms, coronary angiography, ischemic testing, and assessments of depression symptom severity and reported treatment history.
The Women's Ischemia Syndrome Evaluation (WISE), a National Heart, Lung, and Blood Institute (NHLBI)-sponsored multicenter study assessing cardiovascular function using state-of-the-art techniques in women referred for coronary angiography to evaluate chest pain or suspected myocardial ischemia.
Five hundred five women (mean age, 53.4 years) enrolled in WISE and followed up for a mean of 4.9 years.
Incidence of cardiac events, including myocardial infarction, stroke, and heart failure, and total mortality.
Relative to those with no or less stable depression symptoms, women with elevated depression symptoms and a reported treatment history showed higher rates of smoking, hypertension, and poorer education and an increased incidence of death and cardiac events (multivariate-adjusted risk ratio, 3.1; 95% confidence interval, 1.5-6.3; P = .001).
Among women with suspected myocardial ischemia, a combination of depressive symptom severity and treatment history was a strong predictor of an elevated CAD risk profile and increased risk of cardiac events compared with those without depression or with only 1 of the 2 measured depression markers. These findings reinforce the importance of assessing mental health factors in women at elevated CAD risk. Focusing only on baseline depression symptom severity may provide an incomplete picture of CAD risk.
Archives of General Psychiatry 09/2006; 63(8):874-80. · 12.02 Impact Factor
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Leslee J Shaw,
C Noel Bairey Merz,
Carl J Pepine,
Steven E Reis,
Vera Bittner,
Kevin E Kip,
Sheryl F Kelsey,
Marian Olson,
B Delia Johnson, Sunil Mankad,
Barry L Sharaf,
William J Rogers,
Gerald M Pohost,
George Sopko
[show abstract]
[hide abstract]
ABSTRACT: Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, < 50% 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.
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 (P < 0.0001). 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 (P < 0.0001). 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 (P < 0.0001). Drug treatment was highest for those with nonobstructive or 1-vessel CAD (P < 0.0001). 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; P = 0.001). 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 (P = 0.0003).
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 08/2006; 114(9):894-904. · 14.74 Impact Factor
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B Delia Johnson,
Leslee J Shaw,
Carl J Pepine,
Steven E Reis,
Sheryl F Kelsey,
George Sopko,
William J Rogers, Sunil Mankad,
Barry L Sharaf,
Vera Bittner,
C Noel Bairey Merz
[show abstract]
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ABSTRACT: Women with chest pain but without obstructive coronary artery disease (CAD) are considered at low risk for cardiovascular (CV) events, but half continue to experience debilitating chest pain over many years. This study compared CV outcomes in women with persistent chest pain (PChP) vs. those without PChP.
We studied 673 Women's Ischaemia Syndrome Evaluation (WISE) participants with chest pain undergoing coronary angiography for suspected myocardial ischaemia and at least 1 year of follow-up. PChP was defined as self-reported continuing chest pain after 1 year. Events occurring after that year were recorded for a median of 5.2 years. We compared CV event rates for women with and without PChP in subgroups with and without obstructive CAD. The median age was 58 years, 20% were racial minorities, 45% had PChP, 39% had obstructive CAD. Among women without CAD, those with PChP had more than twice the rate of composite CV events (P = 0.03), that included non-fatal myocardial infarctions (P = 0.11), strokes (P = 0.03), congestive heart failure (P = 0.38), and CV deaths (P = 0.73), compared with those without PChP. In women with CAD, there was no difference in composite CV events in those with and without PChP (P = 0.72).
Among women undergoing coronary angiography for suspected myocardial ischaemia, PChP in women with no obstructive CAD predicted adverse CV outcomes. Such women might benefit from additional evaluation and aggressive risk factor modification therapy.
European Heart Journal 07/2006; 27(12):1408-15. · 10.48 Impact Factor
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Gretchen L Gierach,
B Delia Johnson,
C Noel Bairey Merz,
Sheryl F Kelsey,
Vera Bittner,
Marian B Olson,
Leslee J Shaw, Sunil Mankad,
Carl J Pepine,
Steven E Reis,
William J Rogers,
Barry L Sharaf,
George Sopko
[show abstract]
[hide abstract]
ABSTRACT: We evaluated whether the relationship between hypertension, other cardiac risk factors, and coronary artery disease (CAD) is modulated by menopausal status and/or age.
The relative contribution of age versus menopausal status in the development of CAD in women remains unclear.
We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and traditional cardiac risk factors for CAD in premenopausal (n = 123) and postmenopausal (n = 482) women undergoing coronary angiography for suspected ischemia. To assess the relative contribution of age versus menopausal status, we fit a hypertension-menopausal status interaction term and adjusted for age.
There were similar relationships with regard to traditional coronary risk factors and angiographic CAD in premenopausal versus postmenopausal women, with few exceptions. Twenty percent of premenopausal women had angiographic CAD versus 31% of postmenopausal women (p = 0.02). Premenopausal women had lower mean (standard deviation) SBP (132 [25] vs. 139 [20] mm Hg; p < 0.0001) and lower PP (54 [18] vs. 62 [18] mm Hg; p < 0.0001) compared to postmenopausal women; however, multivariable analyses revealed that SBP was a risk factor for CAD in premenopausal (p = 0.002) but not postmenopausal women (p = 0.13), and regression slopes were significantly different (p = 0.04). This interaction effect remained after age adjustment, suggesting independent risk contribution from both age and menopausal status. A similar slope difference was observed for PP (p = 0.03) but not for DBP.
Among women undergoing angiography for suspected ischemia, elevated SBP and PP are potent risk factors in premenopausal women. The results suggest that identification of hypertension in premenopausal women dictates additional CAD risk factor assessment and management.
Journal of the American College of Cardiology 03/2006; 47(3 Suppl):S50-8. · 14.16 Impact Factor
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Leslee J Shaw,
C Noel Bairey Merz,
Carl J Pepine,
Steven E Reis,
Vera Bittner,
Sheryl F Kelsey,
Marian Olson,
B Delia Johnson, Sunil Mankad,
Barry L Sharaf,
William J Rogers,
Timothy R Wessel,
Christopher B Arant,
Gerald M Pohost,
Amir Lerman,
Arshed A Quyyumi,
George Sopko
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ABSTRACT: Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.
Journal of the American College of Cardiology 03/2006; 47(3 Suppl):S4-S20. · 14.16 Impact Factor
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C Noel Bairey Merz,
Leslee J Shaw,
Steven E Reis,
Vera Bittner,
Sheryl F Kelsey,
Marian Olson,
B Delia Johnson,
Carl J Pepine, Sunil Mankad,
Barry L Sharaf,
William J Rogers,
Gerald M Pohost,
Amir Lerman,
Arshed A Quyyumi,
George Sopko
[show abstract]
[hide abstract]
ABSTRACT: Coronary heart disease is the leading cause of death and disability in the U.S., but recent advances have not led to declines in case fatality rates for women. The current review highlights gender-specific issues in ischemic heart disease (IHD) presentation, evaluation, and outcomes with a special focus on the results derived from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. In the second part of this review, we will assess new evidence on gender-based differences in vascular wall or metabolic alterations, atherosclerotic plaque deposition, and functional expression on worsening outcomes of women. Additionally, innovative cardiovascular imaging techniques will be discussed. Finally, we identify critical areas of further inquiry needed to advance this new gender-specific IHD understanding into improved outcomes for women.
Journal of the American College of Cardiology 03/2006; 47(3 Suppl):S21-9. · 14.16 Impact Factor
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Leslee J Shaw,
Marian B Olson,
Kevin Kip,
Sheryl F Kelsey,
B Delia Johnson,
Daniel B Mark,
Steven E Reis, Sunil Mankad,
William J Rogers,
Gerald M Pohost,
Christopher B Arant,
Timothy R Wessel,
Bernard R Chaitman,
George Sopko,
Eileen Handberg,
Carl J Pepine,
C Noel Bairey Merz
[show abstract]
[hide abstract]
ABSTRACT: Our objective was to determine the prognostic value of estimated metabolic equivalents (METs) based on self-reported functional capacity by the Duke Activity Status Index (DASI) in symptomatic women.
Functional capacity is an important component affecting the predictive value of exercise testing, yet current guidelines offer limited assistance regarding identification of functional impairment and choice of pharmacologic stress testing.
A total of 914 women underwent clinically indicated coronary angiography and completed the 12-item DASI questionnaire; a subgroup of 251 women also underwent exercise testing. Cox proportional hazards modeling was used to estimate five-year death or myocardial infarction by DASI scores. In a secondary analysis, additional events included unstable angina, heart failure, or stroke at five years.
Average DASI-estimated functional capacity was 5.7 +/- 4.2 METs and, for exercising women, 6.0 +/- 2.6 METs. In the 914 women, event-free survival ranged from 83% to 95% in subgroups with < or =4.7 to >9.9 METs (p = 0.009); 67% of the events occurred in women scoring < or =4.7 METs (p = 0.003). Event rates were similar by exercise and DASI MET values. In women with DASI-estimated METs < or =4.7 (n = 75), ischemia occurred less (39% vs. 64%, p < 0.0001), and exercise testing results were more often indeterminate (<85% predicted maximum heart rate = 37% vs. 6%, p = 0.001) as compared to women achieving >4.7 METs.
Among women with suspected myocardial ischemia, functional impairment estimated by the DASI correlates with indeterminate exercise test results and is associated with an adverse prognosis. Use of the DASI before exercise testing can risk stratify symptomatic women and may improve the identification of higher-risk, functionally impaired subjects that would benefit from pharmacologic stress imaging and targeted risk management.
Journal of the American College of Cardiology 02/2006; 47(3 Suppl):S36-43. · 14.16 Impact Factor
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Robert W W Biederman,
Mark Doyle,
June Yamrozik,
Ronald B Williams,
Vikas K Rathi,
Diane Vido,
Ketheswaram Caruppannan,
Nael Osman,
Valerie Bress,
Geetha Rayarao,
Caroline M Biederman, Sunil Mankad,
James A Magovern,
Nathaniel Reichek
[show abstract]
[hide abstract]
ABSTRACT: In compensated aortic stenosis (AS), cardiac performance measured at the ventricular chamber is typically supranormal, whereas measurements at the myocardium are often impaired. We investigated intramyocardial mechanics after aortic valve replacement (AVR) and the effects relative to the presence or absence of coronary artery disease (CAD+ or CAD-), respectively.
Twenty-nine patients (46 to 91 years, 10 female) with late but not decompensated AS underwent cardiovascular MRI before AVR (PRE), with follow-up at 6+/-1 (EARLY) and 13+/-2 months (LATE) to determine radiofrequency tissue-tagged left ventricle (LV) transmural circumferential strain, torsion, structure, and function. At the myocardial level, concentric LV hypertrophy regressed 18% LATE (93+/-22 versus 77+/-17 g/m2; P<0.0001), whereas at the LV chamber level, ejection fraction was supranormal PRE, 67+/-6% (ranging as high as 83%) decreasing to 59+/-6% LATE (P<0.05), representing not dysfunction but a return to more normal LV physiology. Between the CAD+ and CAD- groups, intramyocardial strain was similar PRE (19+/-10 versus 20+/-10) but different LATE, with dichotomization specifically related to the CAD state. In the CAD- patients, strain increased to 23+/-10% (+20%), whereas in CAD+ patients it fell to 16+/-11% (-26%), representing a nearly 50% decline after AVR (P<0.05). This was particularly evident at the apex, where CAD- strain LATE improved 17%, whereas for CAD+ it decreased 2.5-fold. Transmural strain and myocardial torsion followed a similar pattern, critically dependent on CAD. AVR impacted LV geometry and mitral apparatus, resulting in decreased mitral regurgitation, negating the double valve consideration.
In AS patients after AVR, reverse remodeling of the supranormal systolic function parallels improvement in cardiovascular MRI-derived regression of LV hypertrophy and LV intramyocardial strain. However, discordant effects are evident after AVR, driven by CAD status, suggesting that the typical AVR benefits are experienced disproportionately by those without CAD and not by those obliged to undergo concomitant coronary artery bypass grafting/AVR.
Circulation 09/2005; 112(9 Suppl):I429-36. · 14.74 Impact Factor
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Oscar C Marroquin,
Kevin E Kip,
Suresh R Mulukutla,
Paul M Ridker,
Carl J Pepine,
Tjendimin Tjandrawan,
Sheryl F Kelsey, Sunil Mankad,
William J Rogers,
C Noel Bairey Merz,
George Sopko,
Barry L Sharaf,
Steven E Reis
[show abstract]
[hide abstract]
ABSTRACT: Coronary artery microvascular dysfunction is prevalent in women with chest pain in the absence of obstructive coronary artery disease (CAD) and is manifested by attenuated coronary flow reserve (CFR). Markers of inflammation and endothelial cell activation have been found to be elevated in patients with chest pain but without CAD. The relationship between inflammation, endothelial activation, and CFR is not known.
Ninety-four women with chest pain in the absence of obstructive angiographic CAD underwent catheterization-based assessment of CFR and measurement of levels of inflammatory markers (n = 78) and endothelial cell activation in the NHLBI WISE study.
Coronary flow reserve did not correlate with levels of C-reactive protein (high-sensitivity C-reactive protein) (rs = -0.07, P = .53), interleukin (IL)-6 (rs = -0.12, P = .31), IL-18 (rs = 0.14, P = .23), tumor necrosis factor alpha (rs = -0.09, P = .43), transforming growth factor beta1 (rs = 0.02, P = .84), and soluble intracellular adhesion molecule-1 (rs = 0.04, P = .68). Median levels of markers of inflammation and endothelial cell activation did not differ between the 57 women with abnormal CFR (< 2.5) and the 37 women with normal coronary microvascular function (high-sensitivity C-reactive protein 0.32 vs 0.25 mg/dL, P = .80; IL-6 2.89 vs 2.39 pg/mL, P = .63; IL-18 218 vs 227 pg/mL, P = .59; tumor necrosis factor alpha 2.7 vs 2.4 pg/mL, P = .43; transforming growth factor beta1 9928 vs 12436 pg/mL, P = .76; soluble intracellular adhesion molecule-1 286 vs 287 pg/mL, P = .95). Multivariable models demonstrated no evidence of associations between markers of inflammation and of endothelial cell activation and CFR.
Coronary microvascular dysfunction is not associated with markers of inflammation and endothelial cell activation in women with chest pain in the absence of obstructive CAD. These results suggest that inflammation and endothelial cell activation may not play a pathophysiological role in coronary microvascular dysfunction.
American heart journal 07/2005; 150(1):109-15. · 4.65 Impact Factor
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[show abstract]
[hide abstract]
ABSTRACT: Magnetic resonance imaging (MRI) is gaining importance in cardiology as the noninvasive test of choice for patients with a multitude of cardiovascular problems. Recently, cardiovascular MRI has emerged as an important noninvasive diagnostic modality in the assessment of coronary artery disease. Because of its superior spatial resolution, integration of qualitative and quantitative methodology, and excellent reproducibility, MRI has advantages over conventional noninvasive modalities currently used in the evaluation of coronary artery disease. This article reviews the rapidly expanding recent literature that has now established cardiovascular MRI as an ideal choice in the evaluation of myocardial ischemia (including dobutamine cine MRI and vasodilator perfusion MRI techniques). We further discuss the role of delayed contrast-enhanced MRI and low-dose dobutamine cine MRI for evaluation of myocardial viability. Comparisons with more established techniques, such as dobutamine stress echocardiography, single-photon emission computed tomography perfusion imaging, and positron emission tomography, are reviewed.
Current Atherosclerosis Reports 04/2005; 7(2):108-14. · 2.66 Impact Factor
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B Delia Johnson,
Leslee J Shaw,
Steven D Buchthal,
C Noel Bairey Merz,
Hee-Won Kim,
Katherine N Scott,
Mark Doyle,
Marian B Olson,
Carl J Pepine,
Jan den Hollander,
Barry Sharaf,
William J Rogers, Sunil Mankad,
John R Forder,
Sheryl F Kelsey,
Gerald M Pohost
[show abstract]
[hide abstract]
ABSTRACT: We previously reported that 20% of women with chest pain but without obstructive coronary artery disease (CAD) had stress-induced reduction in myocardial phosphocreatine-adenosine triphosphate ratio by phosphorus-31 nuclear magnetic resonance spectroscopy (abnormal MRS), consistent with myocardial ischemia. The prognostic implications of these findings are unknown.
Women referred for coronary angiography for suspected myocardial ischemia underwent MRS handgrip stress testing and follow-up evaluation. These included (1) n=60 with no CAD/normal MRS, (2) n=14 with no CAD/abnormal MRS, and (3) n=352 a reference group with CAD. Cardiovascular events were death, myocardial infarction, heart failure, stroke, other vascular events, and hospitalization for unstable angina. Cumulative freedom from events at 3 years was 87%, 57%, and 52% for women with no CAD/normal MRS, no CAD/abnormal MRS, and CAD, respectively (P<0.01). After adjusting for CAD and cardiac risk factors, a phosphocreatine-adenosine triphosphate ratio decrease of 1% increased the risk of a cardiovascular event by 4% (P=0.02). The higher event rate in women with no CAD/abnormal MRS was primarily due to hospitalization for unstable angina, which is associated with repeat catheterization and higher healthcare costs.
Among women without CAD, abnormal MRS consistent with myocardial ischemia predicted cardiovascular outcome, notably higher rates of anginal hospitalization, repeat catheterization, and greater treatment costs. Further evaluation into the underlying pathophysiology and possible treatment options for women with evidence of myocardial ischemia but without CAD is indicated.
Circulation 06/2004; 109(24):2993-9. · 14.74 Impact Factor
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Anthony P Morise,
Marian B Olson,
C Noel Bairey Merz, Sunil Mankad,
William J Rogers,
Carl J Pepine,
Steven E Reis,
Barry L Sharaf,
George Sopko,
Karen Smith,
Gerald M Pohost,
Leslee Shaw
[show abstract]
[hide abstract]
ABSTRACT: Recently revised American College of Cardiology/American Heart Association guidelines have suggested that exercise test scores be used in decisions concerning patients with suspected coronary artery disease (CAD). Pretest and exercise test scores derived for use in women without known CAD have not been tested in women with a low prevalence of CAD.
Within the Women's Ischemia Syndrome Evaluation (WISE) study, we evaluated 563 women undergoing coronary angiography for suspected myocardial ischemia. The prevalence of angiographic CAD was 26%. Overall, 189 women underwent treadmill exercise testing. Prognostic end points included death, myocardial infarction, stroke, and revascularization.
Each score stratified women into 3 probability groups (P <.001) according to the prevalence of coronary disease: Pretest: low 20/164 (12%), intermediate 53/245 (22%), high 75/154 (49%); Exercise test: low 11/83 (13%), intermediate 22/74 (30%), high 17/32 (53%). However, the Duke score did not stratify as well: low 7/46 (15%), intermediate 36/126 (29%), high 6/17 (35%); P =.44. When pretest and exercise scores were considered together, the best stratification with the exercise test score was in the intermediate pretest group (P <.03). The Duke score did not stratify this group at all (P =.98). Pretest and exercise test scores also stratified women according to prognostic end points: pretest--low 7/164 (4.3%), intermediate 28/245 (11.4%), high 27/154 (17.5%), P <.01; exercise test--low 4/83 (4.8%) and intermediate-high 17/106 (16%), P =.014.
Both pretest and exercise test scores performed better than the Duke score in stratifying women with a low prevalence of angiographic CAD. The exercise test score appears useful in women with an intermediate pretest score, consistent with American College of Cardiology/American Heart Association guidelines.
American heart journal 06/2004; 147(6):1085-92. · 4.65 Impact Factor
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Christopher B Arant,
Timothy R Wessel,
Marian B Olson,
C Noel Bairey Merz,
George Sopko,
William J Rogers,
Barry L Sharaf,
Steven E Reis,
Karen M Smith,
B Delia Johnson,
Eileen Handberg, Sunil Mankad,
Carl J Pepine
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ABSTRACT: This study was designed to investigate the relationship between hemoglobin level (Hgb) and adverse cardiovascular outcomes in women with suspected ischemia.
Low Hgb levels correlate with increased cardiovascular morbidity and mortality in patients presenting with acute myocardial infarction (MI) or congestive heart failure (CHF). However, the prognostic significance of Hgb in women with suspected ischemia is unclear.
As part of the National Heart, Lung, and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE), we prospectively studied 936 women referred for coronary angiography to evaluate suspected ischemia. We compared Hgb levels with cardiovascular risk factors, core lab interpreted angiograms, inflammatory markers, and adverse cardiovascular outcomes.
Of women enrolled, 864 (mean age 58.4 +/-11.6 years) had complete Hgb, angiogram, and follow-up (mean 3.3 +/- 1.7 years) data. The mean Hgb was 12.9 g/dl (range 7.7 to 16.4 g/dl) and 184 women (21%) were anemic (Hgb <12 g/dl). Anemic women had higher creatinine and were more likely to be nonwhite and have a history of diabetes, hypertension, and CHF (p < 0.05). However, we found no difference in EF or severity of coronary artery disease. Anemic women had a higher risk of death from any cause (10.3% vs. 5.4%; p = 0.02) and total adverse outcomes (26% vs. 16%, p < 0.01). In a multivariable model, decreasing Hgb was associated with significantly higher risk of adverse outcomes (hazard ratio = 1.20, p = 0.002). Also, anemic women had shorter survival time free of adverse outcome (p < 0.001).
Our findings extend previous reports, linking lower hemoglobin levels with higher risk for adverse cardiovascular outcomes, to women evaluated for suspected ischemia in the absence of acute MI or CHF.
Journal of the American College of Cardiology 06/2004; 43(11):2009-14. · 14.16 Impact Factor
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ABSTRACT: This is a case of a 74-year-old male with known multiple peripheral aneurysms. The patient presented for resection of a right popliteal aneurysm. During a routine preoperative transthoracic echocardiography, we detected a cystic structure on the inferolateral aspect of the basal left ventricle and the left atrium along the atrioventricular groove. A CT scan confirmed this to be a left circumflex artery aneurysm. The patient subsequently died of a ruptured berry aneurysm and an intracranial bleed.
Echocardiography 05/2004; 21(3):265-7. · 1.24 Impact Factor
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ABSTRACT: We analyzed the impact of hormone replacement therapy (HRT) on psychological factors in white and black women. We hypothesized that both groups of women would have fewer symptoms of depression and lower hostility scores associated with HRT use.
The cohort included 463 postmenopausal women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. WISE is a four-center study of women with chest pain who underwent quantitative coronary angiography for suspected ischemia. The psychosocial indices included the Beck Depression Inventory (BDI) and the Cook Medley Hostility questionnaire measuring cynicism, hostility, and aggression.
There were no differences by race in use, duration, and type of HRT or presence of menopausal symptoms. There were differences by race in baseline psychological measurements, with black women exhibiting higher BDI scores and higher total Cook Medley scores (p = 0.03) than white women. Use of HRT was consistently associated with better psychological health in white women, with fewer symptoms of depression and lower aggression and cynicism scores (p < 0.04). Black women with menopausal symptoms who used HRT had significantly lower hostility (p < 0.01) and cynicism scores (p < 0.05) than black women who did not use HRT. The presence of menopausal symptoms and hysterectomy status were significant independent predictors of HRT use for both white and black women (p < 0.05).
We observed racial differences in associations between HRT use and psychological health. Within the white but not the black HRT users, there were fewer symptoms of depression and lower aggression and cynicism scores.
Journal of Women s Health 05/2004; 13(3):325-32. · 1.57 Impact Factor
