This Article  • Full text  • PDF  • Correction  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (42)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Men's Health  • Men's Health, Other  • Women's Health  • Women's Health, Other  • Prognosis/ Outcomes  • Alert me on articles by topic  Social Bookmarking   What's this?

Harry Hemingway, FRCP; Alison McCallum, MB,BS; Martin Shipley, MSc; Kristiina Manderbacka, PhD; Pekka Martikainen, PhD; Ilmo Keskimäki, MD, PhD

JAMA. 2006;295:1404-1411.

Context  Stable angina pectoris in women has often been considered a "soft" diagnosis, with less-severe prognostic implications than in men, but large-scale population studies are lacking.

Objective  To determine sex differences in the incidence and prognosis of stable angina in a large ambulatory population.

Design  Prospective cohort study using linked national registers.

Setting  All municipal primary health care centers, hospital outpatient clinics, occupational health care services, and the private sector in Finland.

Participants  Among ambulatory patients aged 45 to 89 years who had no history of coronary disease, we defined new cases of "nitrate angina" based on nitrate prescription (56 441 women and 34 885 men) or "test-positive angina" based on abnormal invasive or noninvasive test results (11 391 women and 15 806 men). Potentially eligible patients were evaluated between January 1, 1996, and December 31, 1998. Follow-up ended in December 2001.

Main Outcome Measures  Coronary mortality at 4 years (n = 7906 deaths) and fatal and nonfatal myocardial infarction at 1 year (n = 3129 events).

Results  The age-standardized annual incidence per 100 population of all cases of angina was 2.03 in men and 1.89 in women, with a sex ratio of 1.07 (95% confidence interval [CI], 1.06-1.09). At every age, nitrate angina in women and men was associated with a similar increase in risk of coronary mortality relative to the general population. Women with test-positive angina who were younger than 75 years had higher coronary-standardized mortality ratios than men; for example, among those aged 55 to 64 years, it was 4.69 (95% CI, 3.60-6.11) in women compared with 2.40 (95% CI, 2.11-2.73) in men (P<.001 for interaction). There was a strong, graded relationship between amount of nitrates used and event rates; women using higher doses of nitrates had prognoses comparable with those of men. Among patients with diabetes and test-positive angina, age-standardized coronary event rates were 9.9 per 100 person-years in women vs 9.3 in men (P = .69), and the fully adjusted male-female sex ratio was 1.07 (95% CI, 0.81-1.41).

Conclusions  Women have a similarly high incidence of stable angina compared with men. Furthermore, stable angina in women is associated with increased coronary mortality relative to women in the general population and, among easily identifiable clinical subgroups, has similarly high absolute rates of prognostic outcomes compared with men.

Author Affiliations: Department of Epidemiology and Public Health, University College London Medical School, London, England (Dr Hemingway and Mr Shipley); and Outcomes and Equity Research, National Research and Development Centre for Welfare and Health (Drs McCallum, Manderbacka, and Keskimäki), and Population Research Unit, Department of Sociology, University of Helsinki (Dr Martikainen), Helsinki, Finland.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Ethnic differences in long-term improvement of angina following revascularization or medical management: a comparison between south Asians and white Europeans
Zaman et al.
J Public Health (Oxf) 2009;31:168-174.
ABSTRACT | FULL TEXT  

States, rates and traits: prognosis research and chronic stable angina
Hemingway
Heart 2009;95:439-440.
FULL TEXT  

Improving long-term outcomes following coronary artery bypass graft or percutaneous coronary revascularisation: results from a large, population-based cohort with first intervention 1995-2004
Blackledge and Squire
Heart 2009;95:304-311.
ABSTRACT | FULL TEXT  

Impact of Depression on Sex Differences in Outcome After Myocardial Infarction
Parashar et al.
Circ Cardiovasc Qual Outcomes 2009;2:33-40.
ABSTRACT | FULL TEXT  

Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study
Sekhri et al.
BMJ 2008;337:a2240-a2240.
ABSTRACT | FULL TEXT  

Presentation of stable angina pectoris among women and South Asian people
Zaman et al.
CMAJ 2008;179:659-667.
ABSTRACT | FULL TEXT  

Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity
Hemingway et al.
ANN INTERN MED 2008;149:221-231.
ABSTRACT | FULL TEXT  

Contribution of novel biomarkers to incident stable angina and acute coronary syndrome: the PRIME Study
Empana et al.
Eur Heart J 2008;29:1966-1974.
ABSTRACT | FULL TEXT  

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris
Sekhri et al.
BMJ 2008;336:1058-1061.
ABSTRACT | FULL TEXT  

Angina Pectoris: Reversal of the Gender Gap
Bittner
Circulation 2008;117:1505-1507.
FULL TEXT  

Prevalence of Angina in Women Versus Men: A Systematic Review and Meta-Analysis of International Variations Across 31 Countries
Hemingway et al.
Circulation 2008;117:1526-1536.
ABSTRACT | FULL TEXT  

Women and coronary disease
Andreotti and Marchese
Heart 2008;94:108-116.
FULL TEXT  

Gender and images of heart disease in Scandinavian drug advertising
Riska and Heikell
Scand J Public Health 2007;35:585-590.
ABSTRACT  

Effects of Ad5FGF-4 in Patients With Angina: An Analysis of Pooled Data From the AGENT-3 and AGENT-4 Trials
Henry et al.
J Am Coll Cardiol 2007;50:1038-1046.
ABSTRACT | FULL TEXT  

Management of cardiovascular risk in the peri-menopausal woman: a consensus statement of European cardiologists and gynaecologists
Collins et al.
Eur Heart J 2007;28:2028-2040.
ABSTRACT | FULL TEXT  

Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution
Timmis et al.
Heart 2007;93:786-791.
ABSTRACT | FULL TEXT  

How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients
Sekhri et al.
Heart 2007;93:458-463.
ABSTRACT | FULL TEXT  

Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study
Griffin et al.
BMJ 2007;334:624-624.
ABSTRACT | FULL TEXT  

Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Rosamond et al.
Circulation 2007;115:e69-e171.
FULL TEXT  

Stable angina who needs revascularisation?
DTB 2007;45:12-16.
ABSTRACT | FULL TEXT  

Effect of Patient-Specific Ratings vs Conventional Guidelines on Investigation Decisions in Angina: Appropriateness of Referral and Investigation in Angina (ARIA) Trial
Junghans et al.
Arch Intern Med 2007;167:195-202.
ABSTRACT | FULL TEXT  

The Year in Epidemiology, Health Services Research, and Outcomes Research
Krumholz and Masoudi
J Am Coll Cardiol 2006;48:1886-1895.
FULL TEXT  

Systematic review: prognosis of angina in primary care
Jones et al.
Fam Pract 2006;23:520-528.
ABSTRACT | FULL TEXT  

Survival after resection for primary lung cancer.
Treasure and Utley
Thorax 2006;61:649-650.
FULL TEXT  

JournalScan
Malik
Heart 2006;92:862-864.
FULL TEXT  

Stable Angina Is as Prevalent and Serious in Women as in Men
JWatch Emergency Med. 2006;2006:4-4.
FULL TEXT  

Four Studies on Cardiac Health in Women
Journal Watch Cardiology 2006;2006:6-6.
FULL TEXT  

Women's Health--Advances in Knowledge and Understanding
DeAngelis and Glass
JAMA 2006;295:1448-1450.
FULL TEXT