|Year : 2017 | Volume
| Issue : 1 | Page : 7-11
Influence of hypertension and diabetes mellitus in pattern of coronary artery disease in women
Biji Soman MBBS, MRCP (UK), D.Card 1, Muneer A Rahaman MD, D.Card 2, Govindan Vijayaraghavan MD, DM, FRCP (London), FRCP (Edin) 3
1 Consultant Cardiologist, Department of Cardiology, Sree Uthram Thirunal Royal Hospital, Medical College, Kerala, India
2 Cardiologist, Department of Cardiology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
3 Vice Chairman and Head, Department of Cardiology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
|Date of Web Publication||26-Dec-2016|
Meditrina Hospital, Pallikkal P.O., Kottarakara - 691 566, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Coronary artery disease (CAD) among women is an ignored entity in India. The aim of this study was to evaluate the role of hypertension (HT) and diabetes mellitus (DM) on the extent of CAD in women, admitted with ischemic chest pain.
Materials and Methods: We conducted a retrospective analysis of the data of female patients admitted with chest pain suspected of cardiac origin and then underwent diagnostic coronary angiography. We obtained the ages, blood pressures, blood sugar levels, and angiographic findings of these patients after analyzing the patient records and reviewing the coronary angiograms.
Results: We studied 163 female patients with a mean age of 58 ± 10.5 years. Of them, 71 (43.5%) had HT, 46 (28%) had DM, and 46 patients (28%) had neither HT nor DM. DM prevalence was higher (12/25, 48.0%) among women with ST-segment elevation myocardial infarction (STEMI) as compared to those with non-STEMI (6/26, 23.1%) or unstable angina (28/112, 25.0%; P = 0.06). In contrast, a higher proportion of the women with unstable angina had neither HT nor DM. Coronary angiography revealed a significant CAD in 86 (52.8%) women. Of them, 34 had DM (odds ratio: 3.542, 95% confidence interval [CI]: 1.669-7.516, P = 0.001) and forty had HT (odds ratio: 1.290, 95% CI: 0.693-2.404, P = 0.422) while12 had neither of the two risk factors. Triple vessel disease was more common in women >50 years of age, but the relationship between risk factors and CAD remained same in both the age groups.
Conclusion: We conclude that increasing age along with DM is major risk factors for CAD among women. However, while older women tend to present with more extensive CAD, presentation with noncritical CAD or normal coronaries and muscle bridge is more common in younger women with suspected acute coronary event.
Keywords: Coronary artery disease, diabetes mellitus, hypertension, women
|How to cite this article:|
Soman B, Rahaman MA, Vijayaraghavan G. Influence of hypertension and diabetes mellitus in pattern of coronary artery disease in women. J Clin Prev Cardiol 2017;6:7-11
|How to cite this URL:|
Soman B, Rahaman MA, Vijayaraghavan G. Influence of hypertension and diabetes mellitus in pattern of coronary artery disease in women. J Clin Prev Cardiol [serial online] 2017 [cited 2019 Apr 21];6:7-11. Available from: http://www.jcpconline.org/text.asp?2017/6/1/7/196643
| Introduction|| |
Coronary artery disease (CAD) is a curse of the modern era, more so in the developing countries. Nearly, 80% of the deaths attributed to cardiovascular diseases (CVDs) occur in the developing countries. Heart disease is the leading cause of death among women, more than all forms of cancer put together.  Not much is known about the disease pattern, in spite of the increasing incidence of CAD among women. The studies have been carried out in the west regarding the risk factors of CAD in women, but no significant data are available in the Kerala population. The aim of this study was to analyze the influence of hypertension (HT) and diabetes mellitus (DM) on CAD in women in Kerala.
| Materials and Methods|| |
We studied 163 consecutive female patients admitted from January 2014 onward, to cardiac Intensive Care Unit at our center, with the complaints of chest pain suspected of cardiac origin and presenting with evidence of ischemia in electrocardiogram. CAD was diagnosed after reviewing hospital records and evaluating detailed clinical history at presentation, structured clinical examination, ECG, and biomarkers at presentation. All patients underwent diagnostic coronary angiography. We analyzed the age, blood pressures, blood sugar, and angiographic findings.
JNC VII criteria for HT were used to make a diagnosis of HT. All women with blood pressure ≥149/90 mmHg were considered to be hypertensive  or those with lower BP but already on antihypertensive medications. Diagnosis of DM was based on the blood sugar values and as per criteria given by the World Health Organization,  fasting blood glucose of ≥126 mg/dL, or women already on blood sugar lowering drugs.
Elective coronary angiography was performed through standard femoral or radial artery approach. Angiographic data were analyzed by two independent cardiologists. Diameter stenosis of >50% severity in at least one of the major epicardial coronary arteries was considered as significant CAD.
Patients with more than one risk factors (i.e., both HT and DM), renal failure, or with contraindications for coronary angiography were excluded from the study.
Results were expressed as mean ± standard deviation for numerical variables and percentages for categorical variables in the forms of tables. All statistical analyses were performed using Statistica version 8 software (Statsoft, DELL). P < 0.05 was considered statistically significant.
| Results|| |
A total of 163 women were studied with a mean age of 58 ± 10.5 years. Age distribution and the risk factor profile of the study population are presented in [Table 1]. Of the 163 subjects, 71 (43.5%) had HT, 46 (28%) had DM, and 46 patients (28%) had neither HT nor DM. The prevalence of both HT and DM increased with age, peaking in the eighth decade (HT 55.5% and DM 33.3%).
Twenty-five (15.3%) of all women had presented with ST-segment elevation myocardial infarction (STEMI), another 26 (16.0%) with non-STEMI (NSTEMI), and the remaining 112 (68.7%) with unstable angina [Table 2]. DM prevalence was higher (12/25, 48.0%) among women with STEMI as compared to those with NSTEMI (6/26, 23.1%) or unstable angina (28/112, 25.0%; P = 0.06). In contrast, a higher proportion of the women with unstable angina had neither HT nor DM (34.8%, P = 0.007 for comparison with other groups).
Of the 163 women included in this study, 86 (52.8%) were found to have significant CAD. Majority of the patients with CAD were in the sixth decade-only 12 (14%) were below 50 years while 23 (27%) were in their 50's, another 31 (36%) in the sixth decade, and 20 (23%) were septuagenarians [Table 3].
|Table 3: Age-wise coronary artery disease pattern of the study population |
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[Table 4] describes the relationship between the major cardiovascular risk factors and the presence of significant CAD in the study population. Both HT and DM were more common among patients with CAD as compared to those without significant CAD, but the difference was statistically significant only for DM (HT - 46.5% vs. 40.3%, odds ratio: 1.29, 95% confidence interval [CI]: 0.693-2.40, P = 0.42; DM - 39.5% vs. 15.6%, odds ratio 3.54, 95% CI: 1.669-7.516, P = 0.0007). The absence of both these risk factors was strongly associated with the absence of significant CAD (odds ratio: 0.21, 95% CI: 0.096-0.438, P < 0.0001).
|Table 4: Relationship between risk factors and coronary artery disease in the study population |
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To determine the impact of age on the relationship between the risk factors and the presence of CAD, we divided the study population into two groups - those <50 years of age (n = 41) and those ≥50 years of age (n = 122). Although there was no significant difference in the prevalence of individual risk factors, greater proportion of women <50 years presented with neither HT or DM (41.5% vs. 23.8%, P = 0.029). As expected, significantly, larger proportion of the women >50 years of age were found to have significant CAD on coronary angiography (60.7% vs. 29.3%, P = 0.0005). The prevalence of triple vessel disease was particularly higher in the older age group, whereas myocardial bridge was more common in the younger age group [Table 5]. In both the age groups, the presence of DM was strongly associated with CAD, whereas the absence of both HT and DM had a strong negative association [Table 6].
|Table 5: Risk factor profile and angiographic profile of the women with coronary artery disease by age group |
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|Table 6: Association between risk factors and the presence of coronary artery disease in younger and older patient subgroups |
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| Discussion|| |
Since 2003, in the United States, the death rate secondary to CAD has declined by 38.0%.  In contrast to the United States and other developed countries, cardiovascular mortality is currently responsible for twice as many deaths in the developing countries. , CAD in women presents late but has a stormier course with worse prognosis.
Women in India with CAD are a neglected lot, primarily because of lack of awareness about the disease, and the continuing myth that CAD is the disease of men. Women's Ischemia Syndrome Evaluation Study and other similar studies have demonstrated that women and men with heart disease tend to differ in their presenting symptoms, access to investigations, treatment, and overall prognosis.  Despite the emergence of knowledge regarding sex differences in CAD, women continue to be under-represented in research on heart disease.  Only limited information is available on CAD in females from our country, ,,, though several studies have reported that Indians have high incidence of CAD. ,, In our study, an increase in the incidence of CAD with age was observed, and the maximum number of cases were seen in the seventh decade. Among premenopausal women, endogenous estrogen confers protection from CAD while in the postmenopausal women, the atheroma load increases and risk of CAD doubles. ,
The studies have reported that the presence of obstructive CAD is less likely among women when compared with men who undergo coronary angiography. , Normal or nonobstructive CAD during coronary angiography is more commonly seen in younger premenopausal women, who may not have the conventional cardiac risk factors. 
HT is associated with a two to threefold increased risk for CAD in women.  HT confers a fourfold risk of CAD in females versus threefold in males.  National Health and Nutrition Examination Survey data show that, over 65 years of age, HT is more common among women.  In our study, 46 (28. 22%) women were diabetic. DM was a major risk factor for CAD among our population. In 2002, the National Cholesterol Education Program report designated diabetes as a coronary heart disease equivalent.  DM is a stronger CAD risk factor in women than in men. ,,, The INTERHEART Study demonstrated stronger association of diabetes with myocardial infarction among women compared with men.  Diabetes negates the protective effect of endogenous estrogen on the premenopausal women,  it also equalizes the CAD risk between premenopausal diabetic women and nondiabetic men of same age.  Diabetes exerts its increased CVD risk through multiple pathways and mechanisms which include endothelial dysfunction, increased vascular oxidative stress, and abnormalities of platelet function, coagulation, fibrinolysis, and lipoproteins.  Several studies have identified the increased risk of coronary heart disease mortality in diabetic women when compared with diabetic men.  Various studies such as GUSTO-I,  GISSI-2 trials,  VALIANT trial,  and the OASIS registry  demonstrated that diabetics women with CAD had far worse outcome, not only when compared to nondiabetics but also when compared with diabetic men. ,
The limitations of this study are that it was a retrospective study, and a single tertiary care hospital population was included in the study. Hence, it may not represent the general population of Kerala.
| Conclusion|| |
We conclude that increasing age along with DM are the major risk factors for CAD among women. However, while older women tend to present with more extensive CAD, presentation with noncritical CAD or normal coronaries and muscle bridge is more common in younger women with suspected acute coronary event.
We would like to thank and acknowledge the contribution of Ms. Greeshma C. Raveendran, biostatistician, in helping us with the advanced statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al.
Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation 2016;133:e38-360.
National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Classification of Blood Pressure. Bethesda (MD): National Heart, Lung, and Blood Institute (US); August, 2004. Available from: https://www. ncbi.nlm.nih.gov/books/NBK9633/. [Last accessed on 2016 Nov 07].
World Health Organization. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia: Report of a WHO/IDF Consultation. Geneva: World Health Organization; 2006.
National Center for Health Statistics. Mortality Multiple Cause Micro-data Files, 2013: Public-use Data File and Documentation: NHLBI Tabulations. Available from: http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm#Mortality_Multiple. [Last accessed on 2015 May 19].
Gaziano TA. Cardiovascular disease in the developing world and its cost-effective management. Circulation 2005;112:3547-53.
Fuster V, Voute J, Hunn M, Smith SC Jr. Low priority of cardiovascular and chronic diseases on the global health agenda: A cause for concern. Circulation 2007;116:1966-70.
Pepine CJ. Ischemic heart disease in women. J Am Coll Cardiol 2006;47:S1-3.
Kim ES, Carrigan TP, Menon V. Enrollment of women in National Heart, Lung, and Blood Institute-funded cardiovascular randomized controlled trials fails to meet current federal mandates for inclusion. J Am Coll Cardiol 2008;52:672-3.
Enas EA, Senthilkumar A, Juturu V, Gupta R. Coronary artery disease in women. Indian Heart J 2001;53:282-92.
Dave TH, Wasir HS, Prabhakaran D, Dev V, Das G, Rajani M, et al.
Profile of coronary artery disease in Indian women: Correlation of clinical, non-invasive and coronary angiographic findings. Indian Heart J 1991;43:25-9.
Gupta R, Puri VK, Narayan VS, Saran PK, Dwivedi SK, Singh S, et al
. Cardiovascular risk profile in Indian women. Indian Heart J 1999;51:679.
Dhar M, Dwivedi S, Agarwal MP, Rajpal S. Clinical profile of coronary artery disease in women. Indian J Cardiol 2006;9:18-23.
Castelli WP, Kanel WB. Cardiovascular disease in women. Am J Obstet Gynecol 1988;138:153.
Stampfer MJ, Colditz GA, Willett WC, Manson JE, Rosner B, Speizer FE, et al.
Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the nurses' health study. N Engl J Med 1991;325:756-62.
Stampfer MJ, Colditz GA. Estrogen replacement therapy and coronary heart disease: A quantitative assessment of the epidemiologic evidence. Prev Med 1991;20:47-63.
Sharaf BL, Pepine CJ, Kerensky RA, Reis SE, Reichek N, Rogers WJ, et al.
Detailed angiographic analysis of women with suspected ischemic chest pain (pilot phase data from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation [WISE] study angiographic core laboratory). Am J Cardiol 2001;87:937-41.
Kennedy JW, Killip T, Fisher LD, Alderman EL, Gillespie MJ, Mock MB. The clinical spectrum of coronary artery disease and its surgical and medical management, 1974-1979. The coronary artery surgery study. Circulation 1982;66(5 Pt 2):III16-23.
Bugiardini R, Bairey Merz CN. Angina with "normal" coronary arteries: A changing philosophy. JAMA 2005;293:477-84.
Bettegowda S. Clinical profile of ischemic heart disease in women with special reference to the risk factors. Sch J Appl Med Sci 2014;2:3020-5.
Wenger NK. Coronary heart disease: The female heart is vulnerable. Prog Cardiovasc Dis 2003;46:199-229.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.
Oomman A, Sathyamurthy I, Ramachandran P, Verghese S, Subramanyan K, Kalarickal MS, et al.
Profile of female patients undergoing coronary angiogram at a tertiary centre. J Assoc Physicians India 2003;51:16-9.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937-52.
Jousilahti P, Vartiainen E, Tuomilehto J, Puska P. Sex, age, cardiovascular risk factors, and coronary heart disease: A prospective follow-up study of 14,786 middle-aged men and women in Finland. Circulation 1999;99:1165-72.
Sowers JR. Diabetes mellitus and cardiovascular disease in women. Arch Intern Med 1998;158:617-21.
Lee WL, Cheung AM, Cape D, Zinman B. Impact of diabetes on coronary artery disease in women and men: A meta-analysis of prospective studies. Diabetes Care 2000;23:962-8.
Mak KH, Moliterno DJ, Granger CB, Miller DP, White HD, Wilcox RG, et al.
Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction. GUSTO-I investigators. Global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries. J Am Coll Cardiol 1997;30:171-9.
Zuanetti G, Latini R, Maggioni AP, Santoro L, Franzosi MG. Influence of diabetes on mortality in acute myocardial infarction: Data from the GISSI-2 study. J Am Coll Cardiol 1993;22:1788-94.
Aguilar D, Solomon SD, Køber L, Rouleau JL, Skali H, McMurray JJ, et al.
Newly diagnosed and previously known diabetes mellitus and 1-year outcomes of acute myocardial infarction: The valsartan in acute myocardial infarction (VALIANT) trial. Circulation 2004;110:1572-8.
Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, et al.
Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: Results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) registry. Circulation 2000;102:1014-9.
Kannel WB. Metabolic risk factors for coronary heart disease in women: Perspective from the Framingham study. Am Heart J 1987;114:413-9.
Barrett-Connor EL, Cohn BA, Wingard DL, Edelstein SL. Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo study. JAMA 1991;265:627-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]