1 Abstracts of the Second International Conference on Women, Heart Disease, and Stroke February 16-19, 2005 Royal Pacific Resort at Universal Orlando, a Loews Hotel Orlando, Florida Jointly sponsored by the American Heart Association, the Centers for Disease Control and Prevention, American College of Cardiology Foundation, the World Heart Federation, the National Heart, Lung, and Blood Institute, and the Heart and Stroke Foundation of Canada The sponsors gratefully acknowledge the educational grants that support the conference by: Bayer HealthCare LLC Pfizer, Inc. Kos Pharmaceuticals, Inc. AHA Pharmaceutical Roundtable Guidant Corporation Archer Daniels Midland Company The Public Health Agency of Canada The sponsors gratefully acknowledge the educational grants that support the conference by the following scientific councils of the American Heart Association: High Blood Pressure Research Council Cardiovascular Radiology and Intervention Council Stroke Council Clinical Cardiology Council Epidemiology and Prevention Council Arteriosclerosis, Thrombosis, and Vascular Biology Council Cardiopulmonary, Perioperative, and Critical Care Council Cardiovascular Surgery and Anesthesia Council The conference program has also been endorsed by these scientific councils of the American Heart Association: Cardiovascular Disease in the Young Council Cardiovascular Nursing Council Kidney in Cardiovascular Disease Council Visit the American Heart Association Web site for details: My.americanheart.org (click on Conference and Education tab.) Phone:
2 Oral Presentations E-41 Oral Presentations Gender, Depressive Symptoms and Quality of Life: Is There a Relation? Emir Veledar, Jerome Abramson, Viola Vaccarino, Emory Univ, Sch of Medicine, Atlanta, GA; Pamela Hartigan, Yale Univ, Sch of Medicine, West Haven, CT; Carol Lewis, Emory Univ, Sch of Medicine, Atlanta, GA; Teo Koon, Mc Master Univ, Sch of Medicine, Ontario, Canada; William Boden, Univ of Connecticut Sch of Medicine, Hartford, CT; Robert O Rourke, Oregon Health & Science Univ, Portland, OR; John Spertus, Univ of Missouri, Kansas City, MO; William Weintraub; Emory Univ, Sch of Medicine, Atlanta, GA Background: Limited evidence suggests that depressive symptoms may be at least as important as traditional risk factors in the prediction of the health status of cardiac patients. We sought to determine the gender differences and relative importance of depressive symptoms vs. traditional risk factors or measures of disease severity on health status in a large sample of cardiac patients. Methods: Our study was based upon cross-sectional baseline data from 1707 cardiac patients (1463 males and 243 females) who participated in the Courage Trial. Depression was assessed using the Mood Screen Form and dichotomized into depression (at least 1 symptom) or no depression. The Seattle Angina Questionnaire (SAQ) was used to assess perceived health status. Physical factors and other risk factors that were assessed included age, gender, white race, BMI, number of diseased vessels, LAD, prior PCI, previous bypass surgery, EF, CCS class, CHF, living alone, diabetes, hypertension, renal disease, previous stroke, physical activity, and physical exam data. Linear regression was used to analyze depression as a predictor of SAQ subscales after adjustment for physical and other risk factors. Results: Depression was associated with physical limitation, disease perception, age, being alone, female gender, and number of diseased vessels. Linear regression showed that depression was one of the most significant predictors of health status, independent of the extent of disease and other cardiac risk factors and was ranked very high among predictors of all SAQ subscales. Although there were no gender differences in angina frequency (p 0.062), angina stability (p ) and disease perception (p ), women had lower treatment satisfaction (p ) and viewed themselves as having greater physical limitation (0.0173), perhaps because they had higher depression levels (p ). Conclusion: Difference in depression levels is strongly associated with gender and heath status among cardiac patients, independent of the degree of cardiac disease and other risk factors. Clinicians should strongly consider gender related variation in depression levels when managing the health status of cardiac patients. 1 Depressive Symptomatology among Cardiac Patients: The Role of Illness Perceptions and Gender Sherry L Grace, York Univ, Toronto, Canada; Suzan Krepostman, Univ Health Network, Toronto, Canada; Dina Brooks, Univ of Toronto, Toronto, Canada; Heather Arthur, McMaster Univ, Hamilton, Canada; Pat Scholey, Trillium Health Cntr, Mississauga, Canada; Neville Suskin, London Health Sciences Cntr and Univ of Western Ontario, London, Canada; Susan Jaglal, Univ of Toronto, Toronto, Canada; Beth L Abramson, St. Michael s Hosp Cardiac Prevention Cntr and Univ of Toronto, Toronto, Canada; Donna E Stewart; Univ Health Network and Univ of Toronto, Toronto, Canada Depression is prevalent among CVD patients, particularly women, and is related to both CVD onset and outcome. Illness perceptions regarding the causes of CVD, its course, consequences and controllability are related to emotional distress, including depressive symptomatology. This study examined CVD illness perceptions and how they relate to such symptomatology among women and men acute coronary syndrome patients at 2 hospitals in Toronto, Ontario were approached for this cross-sectional component of a larger longitudinal study. 661 consented to participate (504 men, 157 women; 75% response rate). Participants completed a survey including sociodemographic items, the Hospital Anxiety and Depression Scale, and the Illness Perception Questionnaire. Women participants were significantly older, had lower income, and were less often married (ps.001). Women reported significantly greater depressive symptomatology than men (p.05). Women perceived a significantly more chronic course (p.001) and more cyclical episodes (p.05) than men, while men perceived greater personal control (p.001), and treatability (p.05) than women. Participants perceived diet, heredity and stress as the greatest CVD causes, with men more likely to blame diet, smoking (ps.01), and alcohol (p.001), and women more likely to blame heredity (p.01). The data were analyzed separately by sex using SPSS UNIANOVAs, controlling for known correlates. For women, (F 4.34, p.001; adj R %), greater depressive symptomatology was significantly related to being unmarried (p.05), lower activity status (p.001), and perceiving a chronic time course (p.01). For men, (F 6.57, p.001; adj R %), greater depressive symptomatology was significantly related to being non-white (p.05), lower activity status (p.001), and 3 illness perceptions, namely perceiving a chronic course (p.05), greater consequences (p.001) and lower treatability (p.05). Women are more likely to attribute CVD to causes beyond their control, and to perceive CVD as a chronic, untreatable condition compared to men. Illness perceptions were related to depressive symptomatology, which suggests that interventions to reframe these perceptions may be warranted to improve emotional health. 3 Marital Status, Marital Strain and the Risk of Coronary Heart Disease or Total Mortality: The Framingham Offspring Study 4 Gender Differences in the Prevalence and Effect of Depression Post Unstable Ischemic Syndrome Tasneem Z Naqvi, Asim Rafique, James Mirocha, Syed S Naqvi; Cedars Sinai Med Ctr, West Hollywood, CA Background: Women have a higher in hospital and 1 year mortality post acute myocardial infarction (AMI). We examined the influence of gender on the prevalence of depression and rate of recurrent acute ischemic cardiac events following unstable angina (UA) or AMI Methods Patients were mailed a Zung Self Assessment Questionnaire 2 weeks post discharge for UA or AMI and followed for months. Depression was diagnosed based on Zung score of 50. Results. A total of 944 pts were surveyed 716 males, (75.8%) years, 228 females (24.2%), years. 103 women (45%), and 249 men (35%), 50 were depressed, p Figure shows the prevalence of depression by age and gender. When gender, age, diabetes, hypertension, history of prior MI and smoking were placed in a multivariable regression model, gender, diabetes, prior MI and smoking remained significant predictors of depression. (p 0.04 for each variable). Readmissions occurred in 26% depressed women compared to 22% depressed men, p 0.27, during follow up period. Conclusion Female gender is a significant predictor of depression post UA and AMI irrespective of age, diabetes, prior MI and smoking. Routine screening for presence of depression needs to be performed in women who present with UA or AMI. 2 Elaine D Eaker, Eaker Epidemiology Enterprises, LLC, Chili, WI; Lisa M Sullivan, Boston Univ Sch of Public Health and Framingham Heart Study, Boston, MA; Margaret Kelly-Hayes, Boston Univ Sch of Medicine and Framingham Heart Study, Boston, MA; Ralph B D Agostino, Sr., Boston Univ Sch of Public Health and Framingham Heart Study, Boston, MA; Emelia J Benjamin; Boston Univ Sch of Medicine and Framingham Heart Study, Boston, MA Objective. Previous research has demonstrated that there may be associations between measures of marital strain and prognosis related to coronary heart disease, but few studies have addressed the predictive value of marital strain for definite incident coronary heart disease (CHD) or all-cause mortality. The objective of this study was to determine if marriage and marital strain are related to the development of CHD or total mortality in men and women participating in the Framingham Offspring Study. Methods. Using a prospective community cohort design, measures of marital status, marital strain, and risk factors for CHD and mortality were collected at the baseline examination from 1984 to Participants included 1,769 men and 1,913 women, 18 to 77 years of age (mean 49 years). The analyses involving marital strain consisted of 1,493 men and 1,501 women married or living in a marital situation at baseline. The outcomes of interest were the ten-year incidence of definite coronary heart disease and total mortality. Results. For both men and women younger age, higher education, and lower systolic blood pressure, were related to traditional measures of marital disagreements (p 0.01 for all groups). After adjusting for age, systolic blood pressure, body mass index, cigarette smoking, diabetes and the ratio of total/high-density cholesterol, married compared to unmarried men were about half as likely to die during the follow-up (RR 0.54; 95% C.I.: 0.34,0.83). Contrarily, marital status was not related to either incident CHD or total mortality in women. Compared to women who did not, women who reported self-silencing during conflict with their spouse had four times the risk of dying over the follow-up (RR 4.01; 95% C.I.: 1.75,9.20). Men reporting that their wives work was disruptive to their lives were 2.7 times more likely to develop CHD (RR 2.71; 95% C.I.: 1.22, 6.03) over the follow-up. Conclusion. To our knowledge, this is the first study to observe that measures of marital strain are related to mortality in women and the development of CHD in men. If replicated, such findings would encourage medical care providers to identify these characteristics in their patients for discussion and possible referral for counseling. Employment Status and Risk of Ischemic Stroke among Women 5 April P Carson, Kathryn M Rose, Diane Catellier, Univ of North Carolina, Chapel Hill, NC; Ana V Diez Roux, Univ of Michigan, Ann Arbor, MI; Carles Muntaner, Univ of Maryland, Baltimore, MD; Sharon B Wyatt; Univ of Mississippi Med Cntr, Jackson, MS The influx of women into the workforce during the 20th century spurred research into the potential health effects of working outside of the home. Several studies have reported that
3 E-42 Circulation Vol 111, No 4 February 2005 homemakers have poorer health profiles and increased risks of mortality and coronary heart disease than women employed outside of the home. However, the relation between women s employment status and stroke has not been investigated. The aim of the current study was to investigate this association among 7,281 black and white women (1,913 homemakers; 5,368 employed outside of the home), ages years, in the Atherosclerosis Risk in Communities Study. Between 1987 and 2001, 206 incident ischemic stroke events occurred. Cox proportional hazards regression was used to assess the association between employment status and risk of stroke. In crude analysis, women employed outside of the home had a lower risk of stroke (hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.52,0.94). Adjustment for age, race/center, education, income and marital status attenuated the association (HR 0.78, 95% CI 0.55, 1.10), while additional adjustment for HDL and LDL cholesterol, body mass index, smoking status, drinking status, diabetes, systolic blood pressure, and use of hypertension medications accounted for the remaining association (HR 0.97, 95% CI 0.68, 1.38). Effect modification by marital status and race was suggested in the analysis, but could not be fully explored due to the small number of stroke events. In conclusion, women employed outside of the home had a modestly lower risk of stroke than homemakers that was accounted for by socio-demographic factors and traditional stroke risk factors. Future research efforts should investigate additional attributes of the work experience and potential associations with varied health outcomes among women. Impact of Meditation upon Endothelial Function in African American Adolescent Females Frank A Treiber, Surender Malhotra, Vernon Barnes; Georgia Prevention Inst, Augusta, GA Objective: Diminished endothelium- dependent vasodilation to reactive hyperemia(edad) is an index of endothelial dysfunction,an early event in the atherogenic process. In youth and adults,decreased EDAD of femoral or brachial arteries has been associated with increased resting BP, hypercholesterolemia, essential hypertension and coronary artery disease. African- Americans(AAs) exhibit decreased EDAD compared to European Americans. Transcendental Meditation ( TM ) has been shown to decrease BP in AA prehypertensive youth and hypertensive adults.the objective of this study was to determine the impact of TM on EDAD in prehypertensive adolescent AA females. Methods: Thirty six AA females ( 16.2 years ;20 health education controls,16 TM) with high normal systolic BP(i.e., 85th -95th percentile on three occasions) were randomly assigned to either four-month TM or health education controls groups. Echocardiographically - derived measures of EDAD were collected at pre-,postintervention and at a four-month follow up. Subject s right brachial artery was scanned in longitudinal section using a Hewlett-Packard 5500 with a 7.5MHz ultrasound vascular transducer for two minutes following four minutes of arterial occlusion induced by inflating the BP cuff to 200mmHg. EDAD was calculated as % change from baseline diameter to maximum post cuff release diameter. Results: The TM and health education control groups did not differ significantly at post intervention.the TM group improved significantly at the 4 month followup evaluation ( 4.4% vs-.50%,p.03). Conclusion:TM appears to have a beneficial impact upon endothelial function in AA females at increased risk for CVD.If replicated in other at risk groups and/or in CVD patients,meditation may prove to be a beneficial adjunct to lifestyle and/or pharmacologic based approaches for the prevention and /or treatment of CVD and its clinical manifestations. Gender Differences in Management and Outcome of Acute ST-Elevation Myocardial Infarction Sofia Sederholm Lavesson, MD, Ulf Stenestrand, MD, PhD, Dept of Medicine and Care, Div of Cardiology, Linköping, Sweden; Lars Wallentin, MD, Prof, Uppsala Clinical Reserch Cntr, Uppsala, Sweden; Eva Swahn, MD, Prof; Dept of Medicine and Care, Div of Cardiology, Linköping, Sweden Background: Previous studies have suggested that women with acute myocardial infarction receive less intensive treatment than men and that they have a poorer prognosis. There is still no agreement if this is due to higher age and co-morbidity or if there exists a specific sex factor. The aim of this study was to assess sex-differences in acute reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) treated at cardiac intensive care units (CCUs), and to assess the short and long term mortality. Any found differences should then be adjusted for confounding factors. Methods: RIKS-HIA contains data including 100 variables for each patient admitted to the CCUs in Sweden. Data for this study was collected between The study population consists of patients with STEMI. Primary endpoints were reperfusion therapy, in-hospital, 30-day and 1-year mortality. Adjustments for age and other covariates were done with logistic regression analyses. Results: The study population consisted of men (65%) and 9455 women (35%), mean age 67 and 73 years respectively. Women had more often diabetes or hypertension but were more seldom smokers, had an earlier MI or had undergone CABG or PCI. Acute reperfusion therapy was given to 71% of the men compared to 62% of the women. The in-hospital mortality was 16% for women and 9% for men. The corresponding numbers for 1-year mortality was 25% and 16%, respectively. After adjustment for covariates, there were still differences between the genders in reperfusion therapy as well as in mortality (table 1). Conclusion: Women with STEMI get less acute reperfusion therapy than men, even after correcting for age and co-morbidity. They have higher short and long term mortality, especially in-hospital mortality. The difference between the genders cannot fully be explained by differences in age and co-morbidity, thus there may exist a specific sex factor yet not known. 6 7 TABLE 1. ACUTE REPERFUSION THERAPY MORTALITY IN STEMI, WOMEN TO MEN. LOGISTIC REGRESSION ANALYSES Crude OR (95% CI) Adjusted OR (95% CI) Acute reperfusion therapy 0.69( ) 0.83( ) In-hospital mortality 1.89( ) 1.23( ) 30-day mortality 1.79( ) 1.16( ) 1-year mortality 1.73( ) 1.10( ) Gender Differences in Treatment and Outcomes for Q-wave Acute Myocardial Infarction Allan Anderson, Hosp at Med City Dallas, Dallas, TX; George Palmer, Central Florida Regional Hosp, Sanford, FL; Lynn Tarkington, Margaret Lanham, Salvatore Battaglia, HCA, Inc., Nashville, TN; Steven Culler, Edmund Becker, Emory Univ, Atlanta, GA; April Simon; Cardiac Data Solutions, Inc., Atlanta, GA Objective: Significant differences in Q-wave AMI treatments and outcomes have been documented between men and women. The objective of this study is to determine if the level of cardiac services available at the hospital where the patient presents impacts women s clinical outcomes and/or revascularization. Methods: Using the HCA Casemix Database, an administrative database of all consecutive patients at all HCA hospitals, patients admitted with a primary diagnosis of Q-wave AMI from thru and were not transferred into the facility from another acute care hospital were analyzed. Patient characteristics, comorbidities, treatments, and outcomes were identified using ICD-9 codes. Univariate and logistic regression analyses, controlling for 23 characteristics and co-morbidities, were used to analyze mortality and AMI treatments: medical management, thrombolytics, PCI, and CABG. Hospitals were differentiated into 3 types: heart surgery hospitals (HSH), cath lab only hospitals (CLOH), or no heart surgery or cath lab hospitals (NHSCH). Findings: There were 55,003 Q-wave AMI patients (34.6%, N 19,034 women) with 78.5% (N 43,180) presenting to HSH, 19.5% (N 10,722) presenting at CLOH, and 2% (N 1,101) presenting to NHSCH. Univariate results show mortality rates for women significantly higher than men (13.4% vs. 6.8%, p 0.001) with overall mortality rates improving as the level of hospital service increased. Logistic regression results controlling for age, co-morbidities, and type of hospital demonstrated that men were significantly less likely to die (OR 0.71) and more likely to be transferred for further treatment (OR 1.24), receive thrombolytics (OR 1.16), receive PCI (OR 1.12), and/or receive CABG (OR 1.64) than women. Conclusions: Women with Q-wave AMI continue to have significantly worse mortality rates and receive less revascularization than men even after controlling for age, co-morbidities and the type of hospital to which they present. Further research needs to examine how women with Q-wave AMI can obtain clinical parity with men. Predictors of Excess Mortality Post Myocardial Infarction in Females: A Prospective Observational Study. Johanne Neill, Colum G Owens, Jennifer Adgey, Professor; Royal Victoria Hosp, Belfast, United Kingdom Background: Recent research suggests that women have a higher early mortality post acute myocardial infarction (AMI) than men. Potential factors to explain this disparity include a delay to presentation, less aggressive medical and interventional strategies, and more severe disease at coronary catheterization in women. We aimed to assess these factors in our patient population. Methods: Consecutive patients (n 214) presenting to coronary care in the Royal Victoria Hospital between Jan 2003 and Jan 2004 with ischaemic type chest pain and AMI (troponin T 0.09ng/ml) were recruited. The following were recorded: demographics; risk factors; delay factors in presentation and treatment; coronary artery disease (CAD) extent; infarction site and left ventricular function; treatment (thrombolytic therapy, glycoprotein IIbIIIa inhibition, percutaneous intervention, and coronary artery bypass grafting). The primary endpoint was three month mortality. Results: Of the 214 patients recruited 30% (64/214) were female. Mean age among females was 73 (SD 10.8) and 63 (SD12.2) for males (p 0.001). There was no significant difference between the groups for delay in presentation or treatment and risk factors were similar. Men and women had similar CAD extent and frequencies of LV impairment (EF 45%). Infarction site distribution was similar in the two groups. Incidence of triple vessel disease was 36% (15/42) in females and 40% (48/121) in males. (p NS). Women were equally likely to proceed to aggressive revascularization strategies (50% 32/64 vs 55% 82/150). Independent predictors of 3 month mortality by multiple regression analysis were age 75 (Wald 4.46, p 0.035) and LV impairment (Wald 11.39, p 0.001). Whilst a trend towards excess 3 month mortality among females (14.1% 9/64 vs 6.7% 10/150 in men) was observed, this did not reach statistical significance probably due to small numbers (p 0.07). Conclusions: No gender difference in delay factors in presentation and treatment nor in management strategy was observed. Females trended towards an excess three month mortality post AMI compared with males. As LV impairment was comparable, the trend identified is mainly due to older age at presentation in females. 10 Mortality in Women After Coronary Artery Bypass Surgery Really is Higher Karin H Humphries, Univ of British Columiba, Vancouver, Canada; Min Gao, BC Cardiac Registry, Vancouver, Canada; Aihua Pu, Univ of British Columiba, Vancouver, Canada; Samuel V Lichtenstein, St. Paul s Hosp, Vancouver, Canada; Christopher R Thompson; Univ of British Columiba, Vancouver, Canada Evidence of gender differences in post-cabg mortality is conflicting, probably reflecting patient selection. We undertook a population-based analysis of all patients undergoing CABG in the 8 9
4 Oral Presentations E-43 province of British Columbia (BC) between 1991 and 2002 to evaluate gender differences in mortality. Methods: Demographic, clinical and procedural data were obtained from the BC Cardiac Registry, a prospective registry of all cardiac procedures done in BC. Deaths were obtained from the provincial vital statistics database. The effect of gender on 30-day mortality was modeled using logistic regression, adjusted for age, comorbidities, ejection fraction, prior surgery, number of diseased vessels and surgery year. Results: Women comprised 20.0 % of all BC patients who underwent an isolated CABG procedure (n 21,157) and were older than men ( years vs , p 0.001). Irrespective of age women had higher mortality rates than men (figure). Overall, 3.7% of women and 2.0% of men died within 30 days of CABG (p 0.001). Women were more likely to present with CHF, DM, and hypertension, but had higher ejection fractions, fewer diseased vessels and fewer prior revascularizations. After adjustment for baseline differences, women were still more likely to die than men (OR 1.6; 95% CI 1.3, 2.0). Mortality declined significantly over this 12-year period (p 0.001) in both men and women. Conclusions: In a population-based cohort of patients undergoing isolated CABG, women were 60% more likely to die within 30 days even after accounting for disease burden and coronary anatomy. Women benefitted equally from the decline in mortality over time, despite consistently higher comorbid disease. 100 days. Inadequate therapy consisted of the following ordered scnearios: no high-dose statin prescribed within 100 days prior to the LDL OR no statin begun within 6 months of the LDL OR no increase in statin dosage within 6 months if the patient was already on a statin OR no repeat LDL 130 mg/dl within 6 months. Comparisons adjusted for age, insulin use, number of visits, hypertension, ischemic coronary disease, congestive heart failure, and stroke, and clustering of patients within site. Results Men and women veterans had similar odds of lipid measurement, but women had higher lipid levels and were less likely to receive a high-dose statin. Women veterans were more likely to have inadequate therapy before adjustment, but not after adjustment (Table). Female managed care enrollees were less likely to have their lipids measured. Once lipids were measured, women were similarly likely to be prescribed a high-dose statin and to receive adequate therapy as men (Table). Conclusions Women with diabetes have greater lipid levels than men with diabetes in both the VA and managed care. Quality initiatives in the VA should target advancement of therapy in patients with diabetes, while initiatives in managed care should focus on initial measurement of lipids in patients with diabetes. ASSOCIATION BETWEEN GENDER AND LIPID MANAGEMENT. REFERENT GROUP IS MEN. Unadjusted OR, (95% CI) Veterans Adjusted OR (95% CI) Unadjusted OR (95% CI) Managed care Adjusted OR (95% CI) LDL not measured 1.1 ( ) 1.1 ( ) 1.5 ( ) 1.5 ( ) LDL 130 mg/dl 1.5 ( ) 1.3 ( ) 1.3 ( ) 1.3 ( ) LDL 130 mg/dl 1.5 ( ) 1.3 ( ) 1.2 ( ) 1.2 ( ) and no high-dose statin LDL 130 mg/dl 1.3 ( ) 1.2 ( ) 1.3 ( ) 1.3 ( ) and inadequate therapy 11 Reduced Treatment Success in Lipid Management Among Women with Coronary Heart Disease or Risk Equivalents: Results of a National Survey Kevin C Maki, Radiant Development, Chicago, IL; Neil J Stone, Northwestern Memorial Hosp, Chicago, IL; Christie M Ballantyne, Baylor College of Medicine, Houston, TX; Mary R Dicklin, Radiant Development, Chicago, IL; Benjamin J Ansell, Univ of California at Los Angeles, Los Angeles, CA; Michael H Davidson; Radiant Development, Chicago, IL The National Cholesterol Education Program (NCEP) Evaluation ProjecT Utilizing Novel E-Technology (NEPTUNE) II was designed to assess cholesterol treatment success among patients receiving lipid therapy. US physicians (n 376) who are high prescribers of lipid-modifying medications enrolled 10 or 20 consecutive patients (February-September 2003). Data were entered into the NEPTUNE II software on a Personal Digital Assistant and uploaded to a central database via the Internet. Of the 4885 patients evaluated, 2103 (43%) were women of predominantly Non-Hispanic white race/ethnicity (1629/2103 [78%]) with a mean age of 60 y. Low-density lipoprotein cholesterol (LDL-C) goal (NCEP Adult Treatment Panel III [ATP III]) achievement was similar between men and women in the 0 1 risk factor category (449/505 [89%] for women and 311/354 [88%] for men) and 2 risk factor category (437/580 [75%] for women and 559/738 [76%] for men). A smaller percentage of women than men achieved goal in the coronary heart disease and risk equivalents (CHD RE) category (513/1018 [50%] vs. 1016/1690 [60%], p ). Logistic regression analyses were performed to examine the association between gender and achievement of LDL-C treatment goal among patients with CHD RE, and to evaluate potential confounding by other significant predictors of treatment success including age, smoking status, hypertension, compliance with dietary therapy, triglyceride level, lipid-modifying therapy, and physician specialty (table). Thus, female gender was associated with lower likelihood of NCEP ATP III LDL-C treatment goal achievement among those with CHD RE, and this relationship remained significant after adjustment for other significant predictors of treatment success. Logistic Regression Analyses Female vs. Male (referent) Odds Ratio (95% Confidence Interval) P-value Age-adjusted (0.56, 0.77) Multivariate (0.63, 0.88) Are Lipids Managed Differently in Women and Men? An Examination of Veterans and Managed Care Enrollees Catherine Kim, Eve A Kerr, Steven J Bernstein, Sarah L Krein; Univ of Michigan, Ann Arbor, MI Objective To examine gender differences in lipid management among people with diabetes. Design Observational cohort from administrative data Setting/Participants Veterans (n 22,034) or managed care enrollees (n 2,589) with diabetes in 2000 and Methods We compared men and women on several measures of lipid management, including: 1) measurement of low-density lipoprotein (LDL) over the first 18 months of the 2-year study period, 2) among those with an LDL measured, an LDL 130 mg/dl, 3) an LDL 130 mg/dl without high-dose statin treatment within the last 100 days of the study period, and 4) an LDL 130 mg/dl without appropriate monitoring or adjustment ( inadequate therapy ) over the last Disparities in Multiple Cardiovascular Risk Factors among Women, United States, 2003 Donald K Hayes, Clark H Denny, Janet B Croft, Aparna Sundaram, Nora L Keenan, Kurt J Greenlund; Cntrs for Disease Control and Prevention, Atlanta, GA Objective: To examine racial/ethnic and socioeconomic disparities for multiple cardiovascular risk factors among women in the United States. Background: Modifiable risk factors such as high blood pressure, high cholesterol, diabetes, tobacco use, obesity, and physical inactivity are targets for primary and secondary prevention because women with multiple risk factors are at increased risk for heart disease and stroke. Methods: Data from the 2003 Behavioral Risk Factor Surveillance System, a telephone survey of health behavior in US adults, were used to assess the prevalence of multiple (i.e., 2) risk factors in 153,466 women. The age adjusted prevalence of multiple risk factors and race/ethnic and socioeconomic disparities were analyzed. Results: Among all women, 7.0% reported diabetes; 20.7% were current smokers; 24.3% had elevated blood pressure; 24.4% had high cholesterol; 26.0% were obese; 26.0% were physically inactive; 69% reported at least one risk factor. Overall, 36.4% of women had 2 risk factors. The age-adjusted prevalence of multiple risk factors was greater among Blacks (percent 95%CI %), Native Americans ( %) and Hispanics ( %) compared to Whites ( %); Asians ( %) had a lower prevalence. Employment and greater levels of education and household income were associated with a lower prevalence of multiple risk factors. After adjustment for age, income, education, and employment, the odds of multiple risk factors remained higher in Blacks (OR 1.76, 95%CI ) than in Whites but was no longer significant for other race/ethnic groups. Conclusions: Over one-third of US women reported having 2 or more risk factors for heart disease and stroke. Socioeconomic factors accounted for much of the disparity in multiple risk factor status between race and ethnic groups except among Blacks. Prevention programs targeting the reduction of disparities associated with multiple risk factors are critical to decreasing the burden of heart disease and stroke in U.S. women. Prevalence of Cardiovascular Risk Factors in Russian Women Rimma Potemkina; State Rsch Cntr for Preventive Medicine, Moscow, Russian Federation Background: Life expectancy at birth of Russian women is lowest in the Europe and CVD mortality of Russian women is highest in the Europe. Evidence-based CVD prevention and control at the regional and national level should be based on reliable information including data of the behavior risk factor (BRF) surveillance system. Aim of the study: Development of Russian Behavioral Risk Factor Surveillance System for evaluation of the prevalence of the behavior risk factors in Russian population the different geographic and administrative settings. Material and methods: Standard survey questionnaire includes demographics, education, health status, health care accessibility, height and weight, smoking habit, fruit and vegetable consumption, physical activity pattern, blood pressure and cholesterol awareness, alcohol consumption, CVD and diabetes awareness, oral health, women health (mammography) and seat-belt use data. Package of standard guidelines on BRFS planning, conducting and data analysis has been developed by State Research Centre for Preventive Medicine (SRCPM) team and disseminated in the Russian regions. Random samples varied from 1500 to 2800 of each have been examined in six Russian regions using face-to-face interview and telephone interview in Result: Response rate varied from 69 93% in the regions. Analysis on the prevalence of main BRF factors with age-sex adjusted indicators in the different geographic and administrative settings has shown that the main risk factors are highly prevalent: smoking prevalence in women during last decade is increasing and get up to 32%; overweight (BMI 25) - up to 60% in women; low-level fruit and vegetable consumption (less 14
5 E-44 Circulation Vol 111, No 4 February 2005 then 400g/day) - up to 80%; high blood pressure - up to 45% ; alcohol abuse (more then 20g/day) - up to 4% in women. Conclusions: Standard methodology for BRFS conducting in Russia has been elaborated. High prevalence of main BRF in women in different regions requires stronger links between monitoring and surveillance data/information and health policy and program development at the Federal and Regional levels. 15 Evidence of a Greater Relative Risk for Coronary Heart Disease from Heavy Smoking amongst Women in the Asia Pacific Cohort Studies Collaboration Mark Woodward, Tai H Lam, Il Suh, Dongfeng Gu, Federica Barzi, Anthony Rodgers; The George Institute for International Health, Sydney, Australia Background: Although some previous studies of CHD have found that relative risks for smoking are higher amongst women, and a plausible biological explanation for this has been suggested, the evidence is by no means consistent. Methods: An individual participant meta-analysis of 562,338 people (35% women) from 40 cohort studies in Australia, mainland China, Hong Kong, Japan, Korea, New Zealand, Singapore, Taiwan and Thailand. Mean daily cigarette consumption and smoking status at baseline related to incident CHD (fatal or non-fatal) over a median of 6.8 years, using Cox survival models stratified by study and adjusted for age and systolic blood pressure. Results: Women (7%: 13,996 of 195,683) were much less likely to be smokers than men (54%: 196,875 of 366,655), largely due to wide disparities in Asian countries. Female smokers had a lower average daily cigarette consumption than male smokers (15 v 16); again the difference was larger in Asia: 10 v 16. During follow-up there were 1126 coronary events for women and 2850 for men. Hazard ratios (95% confidence intervals) for CHD comparing smoking less than a pack, a pack and more than a pack a day to never-smokers, respectively, were, for women: 1.28 ( ), 2.52 ( ) and 2.38 ( ); for men: 1.36 ( ), 1.33 ( ) and 1.70 ( ). These differences in the effect of smoking by gender were statistically significant (p 0.02). No gender difference was found (p 0.95) in the beneficial effects of quitting: ex-smokers had a hazard ratio (95% confidence interval) of 0.71 ( ) for women and 0.71 ( ) for men, compared to current smokers. Conclusions: Women have greater relative risks from smoking 20 or more cigarettes per day than men. Given that women have a shorter duration of smoking than men, the results here based upon average daily smoking will underestimate the true gender differential. The rise in female smoking across the world, particularly at young ages, thus suggests a huge increase in coronary disease to come. This will not only have devastating consequences for women and their families, but will also limit the ability of women to realize their potential as leaders in economic development. Tobacco control strategies with an emphasis on female issues are essential. Moderate Renal Dysfunction Increases the Risk of Cardiovascular Death among Treated Hypertensive Women Susan M Hailpern, Hillel W Cohen; Albert Einstein College of Medicine, Bronx, NY Background: Cardiovascular disease (CVD) is a major cause of death for patients with end-stage renal failure and recent evidence suggests that excess CVD risk may begin early in the course of chronic kidney disease. Objective: To assess the association of moderate renal dysfunction (MRD: creatinine clearance ml/min) with the risk for CVD death in treated hypertensive women, we examined the experience of hypertensive female participants in the Worksite Hypertension Control Program. Subjects with pre-existing renal disease were excluded, as were those with missing baseline creatinine clearance, creatinine clearance 30 ml/min, and those with a follow-up less than 180 days, leaving a study sample of n 3762 with a mean age years. CVD death outcomes were defined as those with ICD9 codes thru and were ascertained from the National Death Index. Creatinine clearance was estimated by the Cockcroft-Gault equation. Renal function was dichotomized as MRD (30 60 ml/min) and normal. Cox proportional hazards models were constructed with MRD and the following CVD risk factors: age, ethnicity, systolic blood pressure, cholesterol, fasting glucose, body mass index, blood urea nitrogen, smoking, and a previous history of cardiovascular disease, diabetes, and prior anti-hypertensive treatment. Results: MRD was present in 445 (11.8%) of the women. During a median follow-up of 9.5 years (range ) 105 CVD deaths occurred. Subjects with MRD had higher CVD mortality rates than those with normal renal function (6.93/1000 person-years vs. 2.56; p 0.001). Adjusting for CVD risk factors, MRD showed a significant positive association with CVD (HR 1.69; CI: 1.006, 2.837; p 0.047). Conclusions: These results suggest that MRD is an independent predictor of CVD death among treated hypertensive women. Furthermore, the data suggest that renal function assessment could be a useful additional tool for risk stratification among women treated for hypertension. 16 age and MET achieved was created and applied to a referral population of 4471 symptomatic women who underwent symptom-limited stress testing. Kaplan-Meier survival curves compared survival by difference between the observed and predicted MET categories. Results: The linear regression equation for predicted METs-for-age in the asymptomatic women was MET (Age), P (Fig 1). Those achieving 85% age-predicted MET resulted in a hazards ratio of death twice that of those achieving 85% age-predicted MET in the asymptomatic cohort (P 0.001). These results were confirmed in symptomatic women (Fig 2). Conclusion: We have established a nomogram for METs based on age, with validation of in asymptomatic and symptomatic women. These findings should be incorporated to any exercise stress test, providing additional prognostic information for risk stratification. The implications for clinical practice and health care policy are far-reaching. 18 Women s Knowledge and Awareness of Own Cardiovascular Risk Factors: Accuracy of Self Reported Normality vs Clinical Findings M Teresa Lira, Sonia Kunstmann, Chilean Society of Cardiology, Santiago, Chile; J Carlos Molina, Univ of Chile, Santiago, Chile; Luis Villarroel, Catholic Univ, Santiago, Chile; Daniela Gaínza; Univ of Los Andes, Santiago, Chile Self Reported Cardiovascular Risk Factors (CRF) had become a common method of massive populations surveys. However this could underestimate persons real risk by the report of normal values that do not match with clinical findings (false negative). Objectives: To determine women s knowledge and awareness about own Blood Pressure (BP) Total Cholesterol (TC) and Blood Sugar (BS) and the accuracy of their self reported normal values compared with clinical findings. To analyze gender influence among these variables. Method: A total of healthy adults from the RICAR Project, 6320 women and 5870 men, aged y. (mean age y), answered a questionnaire about their own BP, TC and BS. Those who knew their parameters were asked if they had normal or abnormal values. Using standardized methods we measured Systolic (SBP) and Diastolic Blood Pressure (DBP), Total Cholesterol (TC) and 4 hours Post Prandial Blood Sugar (PPBS). Abnormal values were defined by international guidelines (SBP 140 mmhg, DBP 90 mmhg TC 200 mg/dl and PPBS 140 mg/dl). Results: The over-all educational level was: 12.9% (1573) primary, 48.6% (5924) secondary and 38.6% (4693) technical or professional level. Educational profile differs between women and men (women vs men): primary 15.4% vs 9.5%, secondary 47.2% vs 50.5%, technical or professional 37.4 vs 40.1% (p ). Conclusions: Knowledge and awareness of own BP, TC and BS were suboptimal in both sexes. Despite women in this group had less educational level, they had significant more knowledge and awareness about their CRF; also their self reported CRF prevalence was significantly more accurate than in men, except for TC that had similar percentages of false negatives in both sexes. Knowledge of own BP Knowledge of own TC Knowledge of own BS False Negative of Normal SBP False Negative of Normal DBP False Negative of Normal TC False Negative of Normal BS Women Men P value 2544 of % 1425 of % p of % 969 of % p of % 686 of % p of ,5% 200 of ,8% p of % 205 of ,4% p of ,9% 192 of % ns 26 of % 30 of 99 30,3% p The Prognostic Value of Exercise Capacity in Women: Nomogram for the Female Population Martha Gulati, Rush Univ Med Cntr, Chicago, IL; Leslee J Shaw, Cedars Sinai Med Cntr, Los Angeles, CA; Morton F Arnsdorf, Ronald A Thisted, Univ of Chicago, Chicago, IL; C. N Merz, Cedars Sinai Med Cntr, Los Angeles, CA; Arfan J Al-Hani, St. James Hosp, Chicago Heights, IL; Henry R Black; Rush Univ Med Cntr, Chicago, IL Background: Recent studies have demonstrated that exercise capacity (ExC) is an independent predictor of mortality in women. Determination of normative values of ExC for age in women has not been well-established. A nomogram for ExC was established from an asymptomatic cohort of women who underwent stress testing. Its prognostic value was further validated in a population of symptomatic women. Methods: 5721 asymptomatic women from the St. James Women Take Heart Project underwent a symptom-limited stress test using the Bruce Protocol. Deaths were identified prospectively over 9 years. ExC was measured in metabolic equivalents (MET). Linear regression estimated ExC achieved by age. A nomogram for calculating ExC from Integrating Gender-Based Analysis into Policy, Evidence and Practice for Cardiovascular Health: A Canadian Perspective Sari Tudiver, Jean A Kammermayer; Health Canada, Ottawa, Canada The 2000 Victoria Declaration on Women, Heart Diseases and Stroke called attention to the broad range of biological and social determinants of cardiovascular disease, including conditions of gender inequity. Recommendations focussed on the different levels and types of policy and action needed by governments, non-governmental organizations, researchers, and others to ensure equity in health status both between women and men, and among women themselves in all countries. This involves the development of broad social and economic policies as well as effective programs and services for primary prevention, screening, diagnosis, treatment, rehabilitation and support that are attentive to the differing social roles and realities of women and men. There are many challenges in developing and implementing such gender-sensitive policies and programs, including the identification, gathering and analysis of appropriate evidence as well as addressing the complexities of policy making,
6 Oral Presentations E-45 overcoming institutional resistance and challenging accepted paradigms. Through its Women s Health Strategy (1999) and Gender-based Analysis Policy (2000), Health Canada has an explicit commitment to apply gender-based analysis to programs and policies in the areas of health system modernization, population health, risk management, direct services and research. outcomes. GBA is an analytic framework for exploring sex and gender differences across the life cycle, addressing the complex interactions between the genetic, biological and physiological characteristics and the socially constructed roles, relationships, values, attitudes and forms of power commonly attributed to men or women. At Health Canada, training, resource development and funding of gender-sensitive social policy research are components of this approach. The proposed presentation will describe how the application of Health Canada s Gender-based Analysis Policy (2000) can enhance our understanding of the determinants of cardiovascular health/disease and explore the challenges to more effectively link evidence, policies and practice to improve cardiovascular disease. Age of Smoking Initiation among Adult Women Susan M Hailpern, Albert Einstein College of Medicine, Bronx, NY; Deborah Viola; New York Med College, Valhalla, NY Background: Smoking is the single most preventable cause of death in the United States, and a major risk factor for heart disease among women. Recent tobacco control efforts have shifted away from adult smoking cessation programs to adolescent prevention programs. Objective: To examine whether prevention of adolescent smoking prevents the onset of smoking among adult women, our study investigated the age of smoking initiation among adult women. Factors associated with adult smoking initiation were compared to those associated with smoking initiation in adolescence and those of non-smokers. Methods: Study subjects were female participants in the 2002 NHIS survey between the ages of 18 and 28 (mean age years) who gave an age or non-response to the question about age at smoking initiation (n 3042). Age at smoking initiation was dichotomized at 18 years and 18 years, representing adolescence and adulthood. Smoking initiation was defined according to CDC guidelines (lifetime use 100 cigarettes). Logistic regression models were constructed with race, alcohol use, income, educational level, and geographic region of residence. Results: Among the 31.07% (945 of 3042) who reported smoking, 34.18% (323 of 945) initiated smoking after the age of 18 years. Analysis of the smoking cohort finds that by age 28, nearly half initiated smoking at 18 years (p for trend 0.001). Compared to non-smokers, adult initiators were more likely to consume moderate-to-large amounts of alcohol (OR 2.17; CI: 1.55,3.04; p 0.001), reside in the Midwestern US (OR 2.22; CI: 1.40, 3.53; p 0.002), and were less likely to have a college education (OR 0.50; CI: 0.34, 0.75; p 0.001). Compared to adolescent smokers, adult initiators were more likely to be non-white (OR 2.79; CI: 1.94, 4.04;p 0.001), have a college education (OR 3.03; CI: 1.86, 4.966; p 0.001), and reside in the non-northeastern region of the US (OR 1.84; CI: 1.16, 2.90; p 0.01). Conclusions: Prevention of adolescent smoking uptake may not prevent the onset of smoking in adult women. Additional efforts are needed to prevent smoking uptake in adulthood for smoking related heart disease prevention among women. Knowledge of factors related to adult smoking uptake could help inform public health decision makers. How to do Prevention in Immigrant Women Margarethe Hochleitner, Angelika Bader; Innsbruck Univ Hosp, Innsbruck, Austria Austria has a more-or-less state-run health care system that covers not only all Austrian citizens but all persons in Austria, and therefore also all immigrants. Cost contributions are marginal. In our state, Tyrol, about 5% of the population are Turkish immigrants. Despite the fact that the WHO estimates that Turkish women have the greatest heart risk in Europe, our heart disease prevention programs do not reach female Turkish immigrants. We thus saw the need to offer a special program for Turkish women: We established that our state has 28 mosques and five different mosque organizations and drew up a complete Turkish-language program with an explanatory letter addressed to the particular hodjas requesting that invitations to our events be distributed at the Friday prayer session. We offered each of the 28 mosques a lecture on heart risk factors, information material as well as measurement of blood pressure, cholesterol, blood glucose, Body Mass Index and medical consultation (all in Turkish). As part of this program 878 questionnaires were completed: 54.1% of the women reported knowing that cardiovascular disease is the primary cause of death, while 41.3% did not even know their blood pressure, 49.7% about diabetes mellitus and 57.4% about their cholesterol status. In conclusion, the mosque program showed that Turkish immigrant women are indeed willing to participate in prevention programs, but apparently not jointly with Austrian women. It is remarkable that every second woman gave cardiovascular disease as the main cause of death. However, the small number of women who knew their heart risk data, despite the fact that all are covered by a comprehensive, practically free health care system, shows that health programs for female Turkish immigrants need to be tailored to the cultural and language situation of these women. 22 A Community Heart Health Screening Program Healthy Heart Society of British Columbia Targets Women at Risk for Heart Disease Joyce Resin; Healthy Heart Society of BC, Vancouver, Canada is an evidence-based multi-disciplinary toolkit to identify those most at risk for heart disease, and to assess the level and nature of their risk. It includes ready-made resources for health professionals who wish to offer community-based primary prevention and screening services. uses a 54 question Cardiovascular Risk Assessment (CRA) designed by the Stanford Heart Network (SHN). Since 2002, approximately 8,000-10,000 people have participated in events across British Columbia. Of those who have completed a CRA (Jan 02 - Aug 04), 64% are women (2170 of 3376). SHN data indicates that at least 76% of women (1639 of 2137) are at increased, high or very high risk of heart disease (33 women did not indicate their age, so risk could not be assessed). has been embraced by workplaces, health organizations, and ethnic communities - all with increasing numbers of female participants. Two populations in BC who are actively utilizing are the Aboriginal and Indo-Canadian communities. Through the program s non-threatening approach and its ethnic sensitivity, its appeal is growing in the Aboriginal communities of BC. As a result, more First Nations women are learning to pay closer attention to their health and are playing a more active role in supporting the heart health of their communities. Indicators of possible improvements in Aboriginal women s health include improved nutrition through the development of community gardens, and increased participation in walking programs linked to promotes capacity building in communities and encourages partnerships with local businesses, community centres, churches and other interest groups. Through the expanded use of as a screening initiative, collection of heart-health data offers information relating to the community s heart health status. Finally, encourages participants to take ownership of their heart health, and supports a self-management approach to health and well-being. Our presentation will describe the program and its benefits and will demonstrate how it might be adapted to other populations. Shortened Delay from Acute Myocardial Infarction Symptom Onset to Emergency Room Presentation Associated with Public Health Campaign Targeted to Women Suzanne Hughes, Bobbie Gross; Akron General Med Cntr, Akron, OH In February 2003, our 537-bed adult tertiary-care teaching hospital launched a public education campaign to raise community awareness about women s risk of heart disease. Our messaging focused on 3 themes: the scope of the problem that CVD is women s greatest health threat, the importance of prompt action when acute cardiac symptoms occur (stressing that women s symptoms may differ from men s), and the importance of knowing your numbers - cholesterol profile, blood pressure, body mass index, and blood sugar. The message was disseminated in face-to face community events, in meetings of women s service and social organizations, and at brown bag presentations at area businesses. The message was also delivered via print and broadcast media in radio and television interviews of the nurse coordinator and physician spokespersons, in advertisements of special events in the local newspaper, in regular mailing of hospital calendars, and in a quarterly newsletter we developed and mailed to over 3,000 women in our database. One of several vehicles utilized to measure the campaign s effectiveness was the analysis of the data compiled for the National Registry of Myocardial Infarction (NRMI). We used this data to evaluate the % of acute myocardial infarction patients who reached our emergency department (ED) within 4 hours of symptom onset, comparing pre and post program launch. Two hundred twenty-three patients AMI patients were entered into the NRMI database in In the rolling year ending June , 50% of women reached the ED within 4 hours of symptom onset. In the rolling year ending September 30, the % reaching our ED within 4 hours had increased to 62.5% and in the rolling year ending December , the % of women arriving within 4 hours had risen to 75%. For the same periods, the percentage of males reaching the ED within 4 hours was 61%, 65%, and 62% respectively. Conclusion: The percentage of women who reached the ED within 4 hours of symptom onset of acute myocardial infarction increased from 50% to 75% during the period of a public health campaign designed to raise awareness of prevalence, symptoms and risk factors for heart disease in women. This increase was noted in the presence of unchanged data in male patients over the same time period. Palpitations: Underappreciated Women s Health Problem? Steven M Schwartz, Oakwood Hosp and Med Cntr, Dearborn, MI; Hannah Lipman, Univ of Michigan Med Cntr, Ann Arbor, MI; Cynthia Pagano, Lifewatch, Buffalo Grove, IL; Danelle Glasburg, Lifewatch, Buffalo Grove, IL; Michael Lehmann; Univ of Michigan Med Cntr, Ann Arbor, MI Palpitations are common in medical practice and may reflect clinically significant underlying arrhythmias. We investigated demographic differences (i.e. sex and age) of patients evaluated for palpitations in detected atrial fibrillation/flutter (AFF) or supraventricular tachycardia (SVT) (N 7098). We found a significant difference in the sex distribution (by age group) (df2), p.01, presented in Table 1. The prevalence of AFF and SVT on EM recording by sex was significantly different (df1), p.0001, presented in Table 2. Summary: Women were overly represented in the youngest age strata while men were overly represented in the oldest age strata. Clinically significant rhythms in women were more likely to be SVT and more likely to be AFF in men. Age strata indicated that women 65 were more likely to have AFF (22%) and younger women more likely to have SVT (16%). Men were more likely to display AFF in the two older cohorts (23% and 22% respectively). SVT in the youngest male cohort was only 10%. Rate-duration criteria for triggering physician notification were met in 45% of AFF patients and 31% of SVT patients, with more women meeting these criteria for SVT (54%) and more men meeting these criteria for AFF (57%) ( (df1), p.01). Conclusions: Among patients with palpitations undergoing EM, women outnumber men (by 3-fold) across age strata. A significant subset of both women and men displayed clinically important tachyarrhythmias although men and women displayed significantly different tendencies towards AFF and SVT respectively. These observations broaden the concept of sex differences in manifestation of cardiac symptoms. Table yrs yrs. 65 yrs. Women 1423(78%) 2409(75%) 1474(73%) Men 409(22%) 826(26%) 557(27%) Table 2 Women Men AFF 422(8.5%) 214(12.5%) SVT 728(14.7%) 221(12.9%) 23 24
7 E-46 Circulation Vol 111, No 4 February Improved Survival among Women with AV Node Ablation and Atrial Fibrillation Participating in the Left Ventricular-Based Cardiac Stimulation Post AV Node Evaluation (PAVE) Study Anne B Curtis, MD, Univ of Florida, Gainesville, FL; Chunlei Ke, Ph. D., Nicole Harbert, MPH, RD; St. Jude Med, Sylmar, CA Background: The PAVE trial was the first prospective, randomized, patient-blinded study evaluating biventricular (BV) pacing vs. right ventricular (RV) pacing after ablate and pace therapy for atrial fibrillation (AF). Patients were randomized to either BV pacing or single site RV pacing therapy. The primary endpoint was exercise performance measured by distance walked in 6 minutes. Safety data was also collected in the form of adverse events and deaths. A sub-study was performed to determine gender differences in mortality and the 6 minute walk. Methods: Within this sub-study, 252 patients (163 men with mean age of 68 yrs and 82.8% (135 of 163) NYHA class II and III, 89 women with mean age of 72 yrs and 88.8% (79 of 89) NYHA class II and III) were randomized to BV or RV pacing and underwent an attempted implant. Patients completed the 6 minute walk test at pre-implant, 6 weeks and 6 months. ANCOVA analysis was conducted to investigate whether gender affected the benefit of BV therapy on the 6-minute walk distance. Proportional hazard models were employed to assess the gender effect on the risk for mortality. Results: The BV group demonstrated significant improvement over the RV group in the 6-minute walk distance at 6-months, but the improvement was not significantly different for women and men. Within the BV and RV groups, women (W) had greater improvement than men (M) at 6 months (BV: W: 88.6m vs. M: 79.6m, RV: W:74.3 m vs. M:54.0m.). During the study, 8.9% (13 of 146) of BV patients and 17.9% (19 of 106) of RV patients died. The deaths consisted of 5.6% (5 of 89) women and 16.6% (27 of 163) men. The benefit of BV over RV in terms of mortality was not different for women and men. However, when treatment effect was adjusted to account for the non-random distribution of gender in the BV and RV groups, women had a significantly lower risk for mortality than the men (p 0.029, hazard ratio: 0.35 with 95% CI (0.13, 0.90)). The significantly lower risk in favor of women still held after patients baseline demographic variables, medical history and medications were controlled. Conclusion: The benefit of the BV therapy over RV was seen independent of patients gender. However, women appeared to perform better than men in the 6 minute hall walk and experienced a significantly lower risk for mortality. 26 Gender Gap in Implantable Cardioverter Defibrillator Therapy: Impact of a Guidelines Based Electronic Medical Record System in Patients with Ischemic Cardiomyopathy A A Seals, Jill Mitchem, Scott Baker, Bashar Saikaly, Trevor Greene, Carl Thurmond, William Platko; Baker and Gilmour Cardiovascular Institute, Jacksonville, FL In patients with ischemic cardiomyopathy (ICM), recent studies have demonstrated important indications for implantable cardioverter defibrillators (ICD). Unfortunately, an overall underutilization of ICDs has been reported in ICM pts, as well as a gender difference with female ICM pts significantly less likely to receive an ICD. Application of an electronic medical record (EMR) system has been shown to improve physician compliance with guidelines, but has not previously been reported in ICM pts with respect to ICD implants. Methods: We analyzed the incidence of ICM (prior MI and/or ischemic heart disease and LVEF 35%) and ICD implants in a cardiology practice experienced with an advanced EMR system (Misys). The EMR program incorporated software algorithms based on ACC/AHA guidelines, and was utilized in all pts. The EMR clinic data was compared to a large national database (ACTion Registry, Guidant). Results: The ACTion registry included analysis of 540,995 pts, 8190 confirmed with ICM. ICD implants were performed in 3360/8190 (41%) pts; 552/1836 (30%) of the female and 2808/6354 (44%) of the male pts (gender difference 14%, p.001). In the EMR based practice, analysis was completed in 6398 pts, with 131 pts confirmed with ICM. Overall, ICD implants were performed in 72/131 (55%) ICM pts; significantly increased compared to the national database (55% vs. 41%, p.01). The gender difference persisted in the EMR practice with 9/22 (41%) female and 63/109 (58%) male ICM pts receiving ICD implants (p.05). However, in comparison to the national database, female ICM pts in the EMR clinic were significantly more likely to receive ICD implants (41% vs. 30%, p.05). Conclusions: (1) In a large national database of ICM patients, there is an underutilization of ICD in all patients, as well as a significant gender difference with women less likely to receive ICD therapy. (2) An advanced EMR system appears to improve overall utilization of ICD therapy in all patients, and in comparison to the national database, significantly improves the percent of women patients receiving appropriate ICD therapy. (3) Although the EMR system improved overall compliance with ACC/AHA guidelines, significant gender differences persist with respect to appropriate ICD implants in ICM patients. Gender Differences among Pacing and Internal Cardiac Defibrillator Therapies with and without Resynchronization Robert Fishel, JFK Med Cntr, Atlantis, FL; Allan Anderson, Med City Dallas Hosp, Dallas, TX; Lynn Tarkington, HCA, Inc, Nashville, TN; Margaret Lanham, Salvatore Battaglia, HCA, Inc., Nashville, TN; Steven Culler, Edmund Becker, Emory Univ, Atlanta, GA; April Simon; Cardiac Data Solutions, Inc., Atlanta, GA 27 Objective: The objective of this study was to evaluate the use of CRT in patients with documented CHF and/or bundle branch block (BBB). Methods: Using the HCA Casemix Database, an administrative database of all consecutive patients admitted to any HCA hospital, patients with a primary procedure of pacemaker (PPM), CRT-P, internal cardiac defibrillator (ICD), or CRT-D and a diagnosis of CHF and/or BBB from thru were studied. Patient characteristics, co-morbidities, procedures and complications were identified by ICD-9 codes. Univariate and logistic regression analyses controlling for 20 patient characteristics and co-morbidities were used to analyze gender differences on 5 clinical outcomes: mortality, post-operative stroke, post-operative infection, ICD mechanical malfunction, and PPM mechanical malfunction, as well as the device received. Findings: A total of 10,931 patients received devices with 4,138 (37.9%) being women. Device distribution was: 50.5% (5,521/ 10,931) PPM, 29.1% (3,185/10,931) ICD, 16.0% (1,747/10,931) CRT-D, and 4.4% (478/ 10,931) CRT-P. Women received 52% of PPM, 33% of CRT-P, 22.4% of ICD, and 21.2% of CRT-Ds. Logistic regression results regarding device utilization are reported in table. After controlling for device, diagnoses (including MI), age, and co-morbidities, there were no significant differences in the five clinical outcomes measured. Conclusions: There are significant differences in device use among men and women, after controlling for relevant patient characteristics including CHF and/or BBB. Men appear to be preferentially treated more aggressively with implantable devices (ICD, CRT-D, and CRT-P). There were no significant differences in immediate clinical outcomes regardless of gender, after controlling for relavant patient characteristics and type of device implanted. Further research needs to investigate if these differences in devices impacts long-term outcomes of women. ODDS RATIO MEN/WOMEN BBB Only CHF Only BBB and CHF PPM CRT-P NS 1.39 NS ICD CRT-D Trends in the Incidence of Stroke in Women in Auckland, New Zealand during Lorna C Dyall, Dr, Kristie N Carter, Ms, Craig S Anderson, Prof, Auckland Univ, Auckland, New Zealand; Ruth Bonita, Dr; World Health Organization, Geneva, Switzerland Background and purpose: Patterns and distribution of stroke in women is needed to increase our understanding of aetiology and prevention in our ageing population. This study aimed to determine the trends in the incidence of stroke in women from three population-based registers in Auckland, New Zealand, covering a 20 year period, , , and Methods: The three studies employed similar methodology and case finding methods and are recognized as meeting certain ideal criteria for stroke incidence studies. All first-ever and recurrent strokes in people (aged 15 years) were identified in the population of Auckland, a total of 596,580 in 1981, 721,458 in 1991, and 897,882 in 2001 according to each Census. The WHO standard world population was used for direct age standardization of annual rates (per 100,000). Rates are reported with 95% confidence intervals (CI). Results: The proportion of women with strokes was unchanged over the study periods and men had higher rates across all but the oldest age-group ( 85 years). Compared with a consistent decline in rates in men, standardised stroke incidence in women was relatively stable across the three study periods ( , 133 [95% CI ]; , 143 [95%CI ]; and , 124 [95%CI ]). However, a significant decline of 14% (95%CI 2% 29%) in rates of first-ever stroke was found between and in women. Moreover, there were large declines in incidence rates in European women over the three studies, with increasing trends in event rates in Pacific women. Conclusions: There has been a modest decline in stroke incidence in women in Auckland over the past 10 years, which may reflect some success from primary prevention strategies. However, the stable attack rates and increasing rates in ethnic minority groups are cause for concern. Trends in Fatal and Non-fatal Strokes among Women Aged >85 Years during in Finland Veikko Salomaa, Pia Pajunen, Rauni Pääkkönen, National Public Health Institute KTL, Helsinki, Finland; Helena Hämäläinen, Social Insurance Inst, Turku, Finland; Ilmo Keskimäki, National Rsch and Development Cntr for Welfare and Health, Helsinki, Finland; Tiina Laatikainen, National Public Health Institute KTL, Helsinki, Finland; Marja Niemi, National Rsch and Development Cntr for Welfare and Health, Helsinki, Finland; Pekka Puska; National Public Health Institute KTL, Helsinki, Finland Background and Purpose In Finland the size of the female population 85 years of age increased by 50% between (from 40,693 in 1991 to 61,086 in 2002). In this study we analysed the trends in fatal and non-fatal strokes during in women 85 years of age in Finland. Methods The Finnish Hospital Discharge Register were linked to the National Causes of Death Register to produce a Cardiovascular Disease Register, which includes data on 32,877 stroke events (ICD-10 codes I60-I64, excluding I63.6) in women aged 85 in Trends in incidence and mortality rates were estimated using log-linear regression models assuming Poisson distribution for the annual numbers of events. The statistical analyses were carried out with software from the SAS institute. The methods are described in more detail at Results Age-standardized incidence of first-ever stroke declined annually by 1.9 % (95% CI, -2.3% to -1.5%) from 3,738/ in 1991 to 3,029/ in 2002 (rates are 3-year moving averages). The average annual change in total stroke mortality was -2.1% (-2.6% to -1.6%) during the study period. However, the decline in total stroke mortality was explained by 2.5% (-3.0% to -2.0) decline in the mortality of ischemic strokes as the mortality of hemorrhagic strokes increased annually by 1.9% (0.04% to 3.4%). The 28-day case-fatality of stroke declined by 1.9% (-2.5% to -1.3%) from 48% in 1991 to 40% in The absolute number of stroke events increased by 41% from 2,102 in 1991 to 2,963 in Conclusions The incidence and mortality of first-ever stroke declined in women 85 years during However, the absolute number of stroke events increased by 41% in these very elderly women reflecting a 50% increase in the size of the female population 85 years of age between in Finland
8 Oral Presentations E Predicting Ten-Year Stroke Risk among Women Aged 55 to 84 Years in the United States Amy Z Fan, Carmen Harris, Zhi-Jie Zheng, Sarah Yoon, Janet B Croft; Cntrs for Disease Control and Prevention, Atlanta, GA Objectives. We assessed the 10-year stroke risk probability among older U.S. women using the Framingham stroke risk appraisal function that was developed among adults aged years. Methods. NHANES III ( ), a cross-sectional, national survey of the noninstitutionalized U.S. population, includes a home interview and a physical examination in mobile examination centers. In order to apply the Framingham stroke risk appraisal function, we selected women (n 2392, representing 22 million US women) aged years, free of self-reported stroke in the survey, and with electrocardiogram (ECG) data available. Stroke risk factors included age, cigarette smoking, systolic blood pressure, antihypertensive medication use, and diabetes mellitus. Left ventricular hypertrophy by ECG and self-reported prior coronary heart disease, chronic heart failure, and intermittent claudication were also included in the risk profile. Weighted probability estimates for a future stroke ( standard errors) were obtained with SUDAAN 8.0. Results. Overall, the 10-year stroke probability was 8.9% ( 0.2%) for stroke-free US women aged years. Stroke risk increased with age (55 64 yrs: 4.2% 0.2%; yrs: %; yrs: %). Non-Hispanic blacks (11.8% 0.8%) had higher predicted 10-year stroke risk than non-hispanic whites (8.8% 0.2%) and Mexican Americans (8.0% 0.4%). The differences in stroke risk are largely attributed to the differential distributions of risk factors and the risk weight carried by each risk factor. Conclusion: The estimated 10-year stroke risk was 8.9% among stroke free US women aged years. However, since history of atrial fibrillation was an exclusion criterion for ECG recording in NHANES III and atrial fibrillation is an important stroke risk factor, the actual stroke risk is likely to be higher in the general population. Further studies should evaluate whether the Framingham stroke risk appraisal function is applicable to other ethnic groups and, if not, seek to establish ethnic-specific stroke risk appraisal functions. Impact of Baby Boomer Women on Hospitalizations for Coronary Heart Disease and Stroke in the United States Hylan D Shoob, Janet B Croft; Centers for Disease Control and Prevention, Atlanta, GA Baby Boomers, a generation of 80 million persons born between 1946 and 1964, comprise almost one-third of the US population. This study provides a national perspective on the current impact of Baby Boomer women on coronary heart disease (CHD) and stroke in the US by comparing National Hospital Discharge Survey data in older Baby Boomers, aged years in 2000 ( birth cohort) with women aged years in 1980 ( cohort) and 1990 ( cohort). CHD included all first-listed hospital diagnoses with ICD9-CM codes or 429.2; stroke included codes or Estimated numbers and age-specific prevalences (per 100,000 US civilian population) were compared between women aged years during each survey year. Among all US hospitalizations for CHD in women, almost 102,000 (11.3%) in 2000, over 80,000 (10.0%) in 1990, and over 85,000 (10.7%) in 1980 were observed in the year-old age group; age-specific prevalence (per 100,000 women) of CHD hospitalization was lower in 2000 (536.1) than in 1990 (628.5) or 1980 (726.2). Among all hospitalizations for stroke in women, almost 32,000 (7.6%) in 2000, over 17,000 (4.9%) in 1990, and over 14,000 (4.5%) in 1980 occurred at ages years; age-specific prevalence was higher in 2000 (167.7) than in 1990 (136.2) or 1980 (122.9). Among women patients aged years, transfer to a short-term or long-term care facility occurred among 16.4%, 7.6%, and 3.7% of those with CHD and 13.2%, 14.8%, and 8.9% of those with stroke in 2000, 1990, and 1980, respectively. Baby Boomers had a greater impact on CHD and stroke patient populations in 2000 relative to that of year-olds in 1980 and Because the first wave attains age 65 in 2011, aging of this large cohort is a public health issue. The value of prevention, detection, treatment, and control of risk factors in Baby Boomers is critical to prevent the future health care needs, resources and costs associated with care and disability deaths] suggested no significant differences in cardiovascular mortality between women with endometrial cancer and those in the general population. Diabetes related mortality among women with endometrial cancer was significantly higher than in the general population based on a SMR (95% confidence interval) of 2.64 ( , 209 deaths). Conclusions: This pattern of cardiovascular and diabetes-related mortality is similar to that observed among women with polycystic ovary syndrome. It is possible that exposure to unopposed endogenous estrogen could protect women with polycystic ovary syndrome and endometrial cancer from cardiovascular disease, despite higher prevalence of diabetes and other cardiovascular risk factors. Further studies are required to allow adjustment for potentially important confounding factors. 33 Gender and Outcome Relationship in Contemporary Percutaneous Coronary Intervention: Continuous Increased Risk of Adverse Outcomes in Women Even in the Era of New Technology. Prerana Manohar, Ann Schaefer, Spectrum Health Butterworth, Grand Rapids, MI; Dean E Smith, Univerisity of Michigan, Ann Arbor, MI; David Share, Blue Cross Blue Shielf of Michigan, Detroit, MI; Eva Kline-Rogers, Univ of Michigan, Ann Arbor, MI; Richard McNamara, Spectrum Health Butterworth, Grand Rapids, MI; Mauro Moscucci; Blue Cross Blue Shield of Michigan Cardiovascular Consortium, Univ of Michigan, Ann Arbor, MI Background. Prior studies have shown a relationship between female gender and adverse outcomes of percutaneous coronary interventions (PCI). Whether this relationship still exist with contemporary PCI and in the era of coronary stents and of glycoprotein receptor blockers remains to be determined. Methods. Data were prospectively collected from 22,725 consecutive PCI in a multicenter regional consortium (Blue Cross Blue Shield of Michigan Cardiovascular Consortium, BMC2) between 1/2002 and 12/2003. Clinical outcomes evaluated included in-hospital death, vascular complications, transfusion, post procedure myocardial infarction (MI), contrast nephropathy, stroke and a combined major cardiovascular adverse event endpoint including MI, death, stroke, emergency CABG and repeat PCI at the same site. Results. When compared with men, women undergoing PCI were older (66.9 vs 61.9 year, p ), and had a higher frequency of comorbidities including diabetes, CHF, renal insufficiency, peripheral vascular disease, valvular heart disease and COPD (all p 0.05). After adjustment for baseline demographics, comorbidities, clinical presentation and lesion characteristics, female gender was associated with an increased risk of death in the hospital, vascular complication, blood transfusion, contrast nephropathy, stroke and MACE (Table). Conclusion. Female gender continues to be associated with an increased risk of adverse outcomes following contemporary PCI. Technological advancements have not offset the relationship between gender and outcomes of PCI. Outcome Adjusted OR 95% CI P Death Vascular complication Transfusion MI Stroke Emergency CABG MACE Contrast Nephropathy Cardiovascular Disease Mortality among Women with Endometrial Cancer: A Retrospective Cohort Study Based in Scotland. Sarah Wild, Jenny Bryden, Robert Lee, Univ of Edinburgh, Edinburgh, United Kingdom; Jennifer Bishop, Alan Finlayson, David Brewster; NHS National Services Scotland, Edinburgh, United Kingdom Background : Endometrial cancer is associated with a variety of factors that affect risk of cardiovascular disease (CVD). Cardiovascular disease mortality after diagnosis of endometrial cancer has not previously been described. The objective of this study was to compare mortality from cardiovascular disease among women with a history of endometrial cancer with that of women in the general population. Methods : We performed a retrospective cohort study of women registered with endometrial cancer in Scotland between 1981 and 2000 with linkage to national mortality data for the period Standardised mortality ratios (SMRs) for ischaemic heart disease and cerebrovascular disease as underlying cause of death and diabetes as underlying or contributory cause of death adjusted for age, calendar period and socio-economic status were estimated. Mortality among the general population of women in Scotland for the same period was used as the standard. Results: There were 7202 registrations of endometrial cancer in Scotland between 1981 and 2000 and a total of 47,935 women-years of follow-up to death or the end of Five year survival for the cohort was 63% using Kaplan-Meier estimates. SMRs (95 % confidence intervals) for ischaemic heart disease [1.07 ( ), 381 deaths] and for cerebrovascular disease [0.99 ( ), 34 Women Benefit from Earlier Invasive Risk Stratification in Acute Coronary Syndrome Mouaz Al-Mallah, Rasha Bazari, Michael Hudson, Noel Gutierrez, Hrishikesh Iyengar, Sanjaya Khanal; Henry Ford Heart and Vascular Institute, Detroit, MI Background: Invasive risk stratification in patients with acute coronary syndromes (ACS) has been shown to improve outcomes. However, it is unclear whether women benefit equally from early invasive risk stratification. We investigated whether the time to coronary angiography affects survival of female patients admitted with ACS. Methods: Patients admitted to the coronary intensive care unit with ACS between 1/1/97 and 12/31/00 and undergoing coronary angiography during same hospitalization were divided into three groups based on the time to angiography: same day, 1 2 days and 2 days. The baseline clinical features, angiography results and outcomes were compared between the angiography groups. Results: Of the total 836 patients who fulfilled the inclusion criteria, 350(41%) were women. Fewer women underwent early coronary angiography within 2 days (63% vs. 74%, p 0.001) compared to men. Three year mortality rates in women undergoing angiography on the same day, 1 2 days and 2-days were 6.8%, 6.7% and 20% respectively (p 0.001) Kaplan Meier survival curves are shown below (Log rank p ). Using multivariate analysis, angiography beyond 48 hours was the most significant predictor of mortality among women (OR 3.7, 95% CI ,p 0.001) after adjusting for confounding variables. Conclusion: Earlier invasive risk stratification within 2 days of presentation in women with ACS has a substantial survival benefit. Gender should not be a reason to defer early coronary angiography in these patients.
9 E-48 Circulation Vol 111, No 4 February 2005 Delay-Times and Rate of Acute Reperfusion Therapy in ST-elevation Myocardial Infarction Differ between Men and Women Sofia Sederholm Lavesson, MD, Ulf Stenestrand, MD, PhD, Dept of Medicine and Care, Div of Cardiology, Linköping, Sweden; Lars Wallentin, MD, Prof, Uppsala Clinical Rsch Cntr, Uppsala, Sweden; Eva Swahn, MD, Prof; Dept of Medicine and Care, Div of Cardiology, Linköping, Sweden Background: Women with AMI receive less thrombolysis and acute PCI than men. A common explanation is that this is due to more complications in women. We wanted to assess if differences in delay-times existed and if they correlated to the differences in rate of thrombolysis or PCI. Methods: RIKS-HIA contains data including 100 variables for patients admitted to the CCU s in Sweden. Data for this study was collected between The study population consisted of patients with first time ST-elevation myocardial infarction. Key times are shown as mean values analysed with student t-test as well as in median values analysed with Mann Whitney U-test. Differences in rate of thrombolysis and acute PCI were assessed with chi-squared tests. Adjustments for covariates were done with logistic regression analyses. Results: The patient population consisted of men (65%) and 9455 women (35%) with mean ages of 67 and 73 yrs, respectively. Women had more often diabetes or hypertension than men, but less often an earlier AMI or had undergone PCI or CABG. Thrombolysis was given to 58% of the women and to 64% of the men. The corresponding numbers for acute PCI were 8% and 12%, respectively, and for all kinds of acute reperfusion therapy 62% and 71%, respectively. Women had longer delay-times than men regarding thrombolysis but not regarding PCI (table 1). Logistic regression analyses for thrombolysis gave a crude OR of 1.30 that was reduced to 1.16 after adjustment for age and co-morbidity and to 1.11 when symptom-to-door-time or 12 hrs was also included. The corresponding numbers for PCI were 1.63, 1.25 and 1.24, respectively. Conclusion: Women with STEMI wait longer before they seek medical care than men. This affects their chance of receiving thrombolysis, but not PCI. At the hospital they have to wait longer than men to receive thrombolysis, but not PCI. The reason for this is unknown, but probably both the female patient and the doctor underestimate women s risk of having an AMI. KEY TIMES IN PATIENT WITH STEMI, GENDER DIFFERENCES. Symptomto-ER time Symptomtothrombolysis time Symptomto-PCI time ER -to- CCU time ER-tothrombolysis time ER-to- PCI time Means (hrs:min) Men Means (hrs:min) Women p- values Medians (hrs:min) Men Medians (hrs:min) Women 35 p- values 5:21 6: : :10 3: :30 2: :18 5:15 NS 4:00 4:00 NS 0:58 1: :30 0: : :45 0: :34 2:17 NS 1:23 1:15 NS 36 Lower Access to Revascularization among Women with Acute Myocardial Infarction in New York City Jing Fang, Albert Einstein College Med, Bronx, NY; Robert W Gern, Montefiore Med Cntr, Bronx, NY; Michael H Alderman; Albert Einstein College Med, Bronx, NY Although coronary revascularization has become increasingly common among patients with acute myocardial infarction (AMI), use continues to differ by gender - women use less than men. To determine whether the lower use of revascularization among women is due to less likely to be admitted to hospitals with revascularization service or due to less procedure performance among women even though they have already been admitted to such hospitals, we used New York City (NYC) hospital discharge data from the New York State Department of Health to assess the use of revascularization among patients with AMI during 1995 to During this period, there were 127,624 AMI patients (54,155 women) in NYC. Compared with men, women were older (73 vs 65 years, p 0.001), more likely to be non-white (32 vs 29%, p 0.001), to have Medicare (55 vs 38%, p 0.001) and Medicaid (14 vs 12%, p 0.001). Women were also more likely to have hypertension (61 vs 51%, p 0.001), diabetes (31 vs 29%, p 0.001), congestive heart failure (40 vs 29%, p 0.001) and cardiogenic shock (4 vs 3%, p 0.01), and to be admitted to hospital emergently (84 vs 79%, p 0.001). The overall revascularization rate in the city was 30% and was higher among men than women (36 vs 23%, p 0.001). Even though women were more likely to live in the neighborhoods with hospitals capable of revascularization (30 vs 28%, p 0.001), they were less likely to be admitted to such hospitals (49 vs 56%, p 0.001). Moreover, among those who were admitted to such hospitals, women were less likely to be revascularized than men (47 vs 62%, p 0.001). Logistic regression analysis, accounting for other sociodemographic and clinical characteristics, revealed that the odds ratio of being admitted to revascularization hospitals for women compared to men was 0.82, 95%CI , p Among patients in such hospitals, the odds ratio of revascularization of women compared to men was 0.77, 95%CI , p Thus, to improve the access to revascularization among women with AMI, more aggressive methods are needed to improve the ambulance delivery service going directly to revascularizing hospitals; to improve the distribution of those facilities in the city; as well as to increase the rate of performance of this procedure among women in such hospitals. The Effect of Gender on Saphenous Vein Graft Patency: Analysis from a Randomized Clinical Trial Nimesh D Desai, Eric A Cohen, Stephen E Fremes; Sunnybrook and Women s College HSC, Toronto, Canada Objectives: Women are known to experience poorer outcomes after coronary bypass surgery than men. Women also are less likely to receive multiple arterial grafting. The purpose of the current investigation was to determine the influence of gender on vein and arterial graft patency in the current using angiographic data from a multicenter randomized clinical trial. Methods: The Radial Artery Patency Study was a randomized clinical trial in which 561 patients were randomized to receive radial artery or saphenous vein grafts to either the right or circumflex coronary territories in addition to a left internal mammary graft to the anterior wall. Recruitment for this trial closed in After one postoperative year, 440 patients underwent coronary angiography of their study radial and vein bypass grafts. Radial grafts had 92.8% patency while saphenous veins had 86.4% patency, p We performed regression modeling using generalized estimating equations to determine risk factors for radial artery and saphenous vein occlusion. Results: 13.4% of patients enrolled in this trial were females. Women were less likely to be smokers, but had a higher prevalence of hypertension, hypercholesterolemia, diabetes, and a higher mean age. Saphenous vein occlusion rates were 24.5% for females and 12.8% for males, p Radial artery occlusion rates were 8.3% for females and 8.2% for males. Using multivariate modelling, the only significant predictor of vein graft patency was female gender (OR 2.1, 95% CI 1.1 to 4.8). Multivariate predictors of radial artery patency included less than 90% target vessel stenosis (i.e. competitive flow from native vessel) (OR 2.6, 95% CI 1.4 to 4.7), history of peripheral or cerebral vascular disease (OR 2.6, 95% CI 1.1 to 6.8), and perioperative vasoconstrictor use (OR 2.2, CI 1.0 to 4.8). Gender was not a predictor of radial artery graft failure. Conclusions: Female gender was independently associated with early vein graft occlusion despite adjustment for other traditional atherosclerosis risk factors. This data suggests preferential use of multiple arterial grafts may improve graft patency women. Radial Artery Grafts in Women: Utilization and Results Jennifer S Lawton, Hendrick B Barner, Marci S Bailey, Nader Moazami, Michael K Pasque, Marc R Moon, Ralph J Damiano, Jr.; Washington Univ in St. Louis, St. Louis, MO Objectives The operative mortality in women undergoing coronary artery bypass grafting (CABG) is twice that of men. Despite a known survival benefit with the use of the left internal mammary artery, this arterial graft is used less frequently in women. The use of the radial artery (RA) graft may limit early mortality and morbidity following CABG. This study evaluated the use of the radial artery graft in women at one institution. Methods Between 1997 and 2002, 2633 patients underwent isolated CABG at our institution. Of those 2633 patients, 1087 received at least one radial artery graft. A smaller cohort of 207 patients had intraoperative radial artery diameter and flow measurements. Preoperative demographic data, radial artery utilization, radial artery size, radial artery flow, and outcome were evaluated. Results Of 862 (33%) women who had isolated CABG, only 301 (35%) received a radial artery graft versus 44% of men (786/1771, p 0.001). Five-year survival was significantly less in women who received a radial artery graft when compared to men (Figure 1, p 0.001). Radial artery size and flow were significantly less in women. Among the patients who underwent postoperative cardiac catheterization, the rate of radial artery occlusion was not different between women and men (2 women and 2 men, p 0.59). Conclusions Women received fewer radial artery grafts when compared to men. Radial artery size and flow rate was significantly less in women. Five-year survival in all patients who received a radial artery graft was significantly better in men when compared to women
10 Oral Presentations E-49 Underuse of Aspirin in Postmenopausal Women with Cardiovascular Disease: The Women s Health Initiative Observational Study Jeffrey S Berger, David L Brown, Beth Israel Med Cntr, New York, NY; Gregory L Burke, Wake Forest Univ Sch of Medicine, Winston-Salem, NC; Robert D Langer, Univ of California, San Diego, San Diego, CA; John B Kostis, Robert Wood Johnson, Univ of Medicine and Dentistry, New Jersey, New Brunswick, NJ; Albert Oberman, Univ of Alabama at Birmingham, Birmingham, AL; Nathan Wong, Univ of California, Irvine, College of Medicine, Irvine, CA; Sylvia Wassertheil-Smoller; Albert Einstein College of Medicine, Bronx, NY Background: Guidelines mandate the use of mg of aspirin to reduce morbidity and mortality in patients with established CVD. Nevertheless, there is limited data on compliance with the guidelines regarding the use of aspirin and its dose among postmenopausal women with CVD. Methods: The Women s Health Initiative Observational study followed 8,928 women with preexisting CVD for an average of 4.1 years across 40 centers in the United States (US). Aspirin dose and use was ascertained at baseline. Predictors of aspirin use were assessed by developing a propensity model with a logistic regression equation including multiple baseline covariates. Results: Among 8,928 patients with preexisting CVD, 4,101 (46%) were on low dose aspirin therapy. Only 43% (593/1,364) of women with a prior stroke were on aspirin therapy. Among 2,230 patients with a documented MI, 1,199 (54%) reported use of aspirin. Independent clinical predictors of aspirin use included prior revascularization (OR, 3.38 CI, , P 0.01), history of hypercholesterolemia (OR, 1.55 CI, , P 0.01), previous MI (OR, 1.28 CI, , P 0.01) and stroke (OR, 1.17 CI, , P 0.031). Demographic predictors of aspirin use included increasing age (OR, 1.02 CI, , P 0.01) and college education (OR, 1.39 CI, , P 0.01). Negative predictors of aspirin use included black race (OR, 0.66 CI, , P 0.01), Medicaid insurance (OR, 0.59 CI, , P 0.01), and residence in the South (OR, 0.87 CI, , P 0.05) or West (OR, 0.87 CI, , P 0.04) compared to the Northeast US. Among 4,101 aspirin users, 1,224 (30%) were on 75 81mg and 2,877 (70%) were receiving 325mg. Older age and college education were correlates of treatment with 81mg of aspirin, whereas prior revascularization and MI were correlates of treatment with 325mg. Conclusion: Despite substantial evidence that aspirin therapy reduces mortality, there is significant underuse of aspirin in postmenopausal women with CVD. This is most pronounced in blacks, patients with Medicaid insurance, and patients residing in the Southern or Western US. Continued efforts should be made to optimize the use of aspirin therapy among women with preexisting CVD. Gender and Peri-Procedural Stroke and Death Following Carotid Artery Stenting: An Update from the CREST Lead-In Phase Virginia J Howard, Univ Alabama Birmingham, Birmingham, AL; Helmi L Lutsep, Oregon Health and Science Univ, Portland, OR; Thomas G Brott, Jamie N Roberts, Mayo Clinic Jacksonville, Jacksonville, FL; George Howard, Univ Alabama Birmingham, Birmingham, AL; Robert W Hobson, II; UMDNJ-New Jersey Med Sch, Newark, NJ BACKGROUND AND PURPOSE: Case series and regional registries of carotid endarterectomy have reported higher perioperative stroke and death rates for women compared to men. The potential for this same relationship with carotid artery stenting (CAS) was examined in the Lead-In phase of the multicenter Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST.) METHODS: CREST, supported by the NIH-NINDS, is a randomized clinical trial comparing the efficacy of carotid endarterectomy (CEA) and carotid stenting (CAS) in preventing stroke, myocardial infarction, and death in the peri-procedural period and ipsilateral stroke over the follow-up period. The effort includes a lead-in credentialling phase of symptomatic ( 50% stenosis) and asymptomatic ( 70% stenosis) patients. Patients were treated with aspirin and clopidogrel before and 30-days after CAS and examined by a neurologist pre-procedure, at 24-hours, and at 30-days. The occurrence of stroke and death was determined by an independent clinical events committee. The association of gender and peri-procedural stroke and death was examined. RESULTS: In the first 519 lead-in patients undergoing CAS (33% symptomatic, 67% asymptomatic) for whom 30-day data were available, the 30-day stroke and death rate for women was 2.9% (5/172) (95% CI: 0.9,6.7) compared to 4.0% (14/347) (95% CI: 2.2,6.7) for men. The difference in stroke and death rate was not significant, and there were no significant differences by gender after adjustment for symptomatic status, presence of high risk comorbid conditions, use of embolic protection device, or percent stenosis. As of September 28, 2004, 357 (35 %) of the 1,027 lead-in patients are women. Accrual is ongoing and the presentation will update these early results. CONCLUSION: Preliminary results from the CREST lead-in case series do not provide evidence that women have a higher peri-procedural stroke and death rate following CAS compared to men. The potential differential peri-procedural risk by gender will be prospectively addressed in the randomized phase. In contrast to the other major CEA trials, CREST has a goal of recruiting 40% women and is powered to address differential efficacy between women and men. 41 Late Peri/Postmenopause and Lower Estrogen Levels are Associated with Larger Common Carotid Adventitial Diameters among Women Enrolled in the Study of Women s Health Across the Nation (SWAN) Rachel P Wildman, Tulane Univ Sch of Public Health and Tropical Medicine, New Orleans, LA; Alicia B Colvin, Univ of Pittsburgh Graduate Sch of Public Health, Pittsburgh, PA; Lynda H Powell, Susan A Everson-Rose, Rush Univ Med Cntr, Chicago, IL; Karen A Matthews, Univ of Pittsburgh, Pittsburgh, PA; Janet M Johnston, Kim Sutton-Tyrrell; Univ of Pittsburgh Graduate Sch of Public Health, Pittsburgh, PA Aging and increased risk factors lead to dilation of the peripheral arteries, which can be quantified by peripheral adventitial diameter measurement. Greater basal dilation limits future dilation during adverse conditions. Little is known about the effects of sex hormones on basal vascular tone. This study assessed the cross-sectional relationship between common carotid artery (CCA) adventitial diameter, measured by B-mode ultrasound, and both menopausal status (n 373) and sex hormones (n 275) in Caucasian and African American women from the Pittsburgh and Chicago sites of SWAN, an ongoing multi-ethnic, multi-site longitudinal study of the menopausal transition. Sex hormones tested included estrogen; testosterone; follicle stimulating hormone; sex hormone binding globulin (SHBG); the free androgen index (FAI), a measure of testosterone not bound by SHBG; and androgen excess (FAI/log estrogen). The mean age of the women was 50.4 years and 45% were late peri/postmenopausal. Late peri/postmenopausal women had higher total cholesterol and LDL levels, and lower HDL levels (p 0.05 for all), as well as lower estrogen (p 0.001) and higher androgen excess levels (p 0.031) compared to pre/early perimenopausal women. CCA adventitial diameter was significantly larger among late peri/postmenopausal women compared to pre/early perimenopausal women even after multivariable adjustment for age, race-ethnicity, height, systolic blood pressure, body weight, lipid levels, socioeconomic status, and study site (6.84 mm vs mm, respectively; p 0.025). Unadjusted Spearman correlation coefficients showed that larger CCA adventitial diameter was associated with lower estrogen (r -0.17, p 0.004) and SHBG (r -0.18, p 0.002) levels, and higher free androgen index (r 0.17, p 0.004) and androgen excess (r 0.18, p 0.002) levels. After multivariable adjustment, the association with estrogen remained but androgen associations were attenuated (primarily due to body weight adjustment). These data suggest that declining estrogen levels during late peri/postmenopause may lead to substantial changes in the peripheral vasculature. The effects of declining estrogens and their interaction with cardiovascular treatments need to be further understood. Influence of Cardiovascular Risk Factors on Different Vascular Beds in Women Jan Pitha, M.D., Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Magdalena Lejskova, M.D., Silvia Zecova, M.D., Institute for Postgraduate Education, Prague, Czech Republic; Petr Stavek, PhD., Rudolf Poledne, PhD.; Institute for Clinical and Experimental Medicine, Prague, Czech Republic BACKGROUND: Different susceptibility of different vascular beds to particular atherogenic risk factors is still not well understood. The aim of this study was to assess an association between particular cardiovascular risk factors and subclinical atherosclerosis in carotid and femoral arteries in a representative population sample of women. METHODS: Population sample of 303 healthy women (age years) were examined. Regular risk factors were established (menopausal and smoking status, blood pressure; plasma concentrations of total, LDL, HDL cholesterol, triglycerides and C-reactive protein). In addition, parameter for the reverse cholesterol transport was calculated as atherogenic index of plasma: log (plasma triglycerides/ plasma HDL cholesterol). Subclinical atherosclerosis was measured in femoral and carotid arteries by highly sensitive ultrasound (Acuson XP/4, linear probe 7.0 MHz) using measurements of intima-media complex. Subclinical atherosclerosis/plaque was defined as local thickening of intima-media complex more than 1.2 mm at minimally two sites in femoral and/or common, internal and external carotid arteries. RESULTS: Subclinical plaques in peripherally located arteries were detected in 90 women (29.7 %). In 12 women plaques in only femoral arteries were detected (FEM); in 6 women plaques in only carotid arteries were detected (CAR). The only difference between these two groups was found in atherogenic index of plasma, which was significantly higher in women with isolated presence of plaques in femoral arteries (FEM: , CAR: , p 0.05). There were no significant differences between both groups in other risk factors under study (age, menopause, smoking, diabetes mellitus, blood pressure, plasma total, LDL, HDL cholesterol, triglycerides and C-reactive protein). CONCLU- SION: Atherosclerotic process in femoral arteries is associated with impaired reverse cholesterol transport in contrast to carotid arteries. This difference is not dependent on smoking. 43 Gender, Carotid Stenosis and Risk Factor Treatment in African-American Patients with CAD Shalini S Modi, M Kronenberg, Wayne State Univ, Detroit, MI; Luis C Afonso, Seemant Chaturvedi; Wayne State Univ, Detroit, Detroit, MI Objective: We sought to determine the relations among gender, carotid stenosis and adherence to therapeutic guidelines in a cohort of African American (AA) patients with documented coronary artery disease (CAD) in the ambulatory setting. We hypothesized that women with CAD were under-treated in relation to men. Methods: We evaluated a consecutive cohort of 120 patients seen in two outpatient Cardiology clinics. Inclusion criteria were CAD based on a clinical diagnosis of angina by a cardiologist or previous documentation of CAD. A previous history of TIA/stroke was an exclusion criterion. We recorded a baseline history, physical examination and lipid profile, and obtained carotid duplex scanning in 101/120 patients.chi Square analysis was used to judge group differences..results: The patients mean age was 60 with 52% (62/120) females. Cardiovascular risk factor distribution varied by gender, with significant differences in diabetes (females males, p 0.01) and smoking (males females, p 0.01). Age greater than 60yrs (21% vs.3%, p 0.01) and diabetes (22% vs. 5%, p 0.01) were predictors of unilateral carotid stenosis of 50%.At study entry, adherence to guidelines for medical therapy was relatively poor, since only 61% (20/33) females with CAD had LDL 100mg/dl while on statins, similar to males, 84% (21/25), p Only 45% (13/29) of female diabetics were treated with an ACE inhibitor/arb, similar to males, 38% (6/16), p 1. Only 45% (13/29) of female diabetics achieved Hb A1c 7 g/dl, similar to males, 31% (5/16), p 1. Only 74% (48/62) of females, reported use of antiplatelet agents, similar to males, 67% (39/58), p 1. Finally, only 44% (27/62) of females reported using -adrenergic blocking drugs, similar to males, 45% (6/58), p 1, in spite of documented CAD. Conclusions:Diabetics had more carotid stenosis of 50% severity, and there was a trend for females to have more carotid narrowing.contrary to popular belief, we did not find a significant gender difference in the use of these standard pharmacologic therapies. These results reiterate the need to implement strategies to improve the quality of care delivered in the outpatient setting to such high-risk patients. 42
11 E-50 Circulation Vol 111, No 4 February Poster Presentations Left Ventricular Geometry Predicts Mortality in Women with Preserved Systolic Function - An Echocardiographic Study in 17,851 Patients Gustavo A Cardenas, Richard V Milani, Carl J Lavie, Yvonne E Gilliland; Ochsner Clinic Foundation, New Orleans, LA Several studies have indicated that left ventricular hypertrophy (LVH) predicts morbidity and mortality. Recently, a common LV geometric pattern of concentric remodeling (CR), characterized by normal LV mass indexed to body surface area (LVMI) but increased relative wall thickness (RWT; 2 x posterior wall thickness/diastolic diameter 0.43), has been associated with increased morbidity and mortality. To our knowledge, however, the prognostic impact of CR has not been studied in a large cohort of women. We studied echocardiographic and clinical data in 17,851 consecutive female patients (mean age years) with preserved systolic function (ejection fraction 50%) referred for echocardiography and followed for 3.1 years for mortality determined by the National Death Index. LVH was defined as LVMI 104 g/m 2, and patients were classified as normal structure (no LVH and RWT 0.43), CR, eccentric LVH (EH; LVH with RWT 0.43) or concentric LVH (CH; LVH and RWT 0.43). Normal (52%) and CR (35%) were the most prevalent LV geometric patterns. Although patients with CR had significantly lower LVMI and higher EF than patients with normal structure, their mortality was more than double that of normals (p ) and was comparable to those with LVH (see table). Conclusions - Abnormal LV geometry is common in women with normal systolic function, being present in 48% of this population, with CR being the most common abnormal geometric pattern. Concentric remodeling is present in over one third of women referred for echocardiography and is associated with significantly increased mortality compared with normal LV structure and carries a prognosis comparable to frank LVH. Parameter Normals (n 9,612) CR (n 6,201) EH (n 863) CH (n 1,038) EF, % * * * RWT * * LVMI, g/m * * * Mortality, % * 7.8 * 10.2 * p compared with normals Arterial Wall Stiffness in Normal and Obese Female Caucasian South African Subjects Determined by Pulse Wave Velocity Helen Marcoyannopoulou Fojas, Evangelismos Univ Hosp, Athens, Greece; Johannes M Van Rooyen, Aletta E Schutte, Susan Jordaan, Hugo W Huisman, Colette Underhay, Nicolaas T Malan; Northwest Univ, Potchefstroom, South Africa PURPOSE: To compare the Pulse Wave Velocity (P.W.V.) using a non invasive method in normal and obese Caucasian South African females. METHOD: Arterial wall elasticity was determined indirectly by P.W.V. using an electronic device which recorded the left external carotid and left dorsalis pulses simultaneously with a single lead ECG. The time delay between the two pulses is computed automatically. A shorter time of PWV would indicate decreased arterial wall elasticity. MATERIALS: A group of one hundred and fifteen clinically asymptomatic female South African Caucasians were studied. All of them had normal ECG in sinus rhythm. Their ages ranged from 19 to 56 years (mean yrs.). Of this group, forty one were normal with a BMI ranging from 18.4 to (mean ); thirty two were overweight with a BMI ranging from to (mean ); and, forty two were obese with a BMI from to ( mean ). Taking the subjects altogether, the BMI ranged from to (mean ). No one of them was hypertensive. RESULTS: Among the normal subjects the mean time of PWV was sec.. Overweight subjects had a mean time of PWV of sec. Obese subjects had a mean time of PWV of sec. The difference between the overweight and obese subjects is not statistically significant. However, the difference between the normal individuals and the two groups (overweight and obese) combined is significant with a p value of DISCUSSION: This study shows that overweight and obesity are high risk factors in the development of cardiovascular disease. PWV is a very important preventive tool in detecting early changes in arterial wall elasticity among overweight and obese individuals before end organ damage occurs. PWV can detect very early changes in arterial wall elasticity among obese individuals while the process is still reversible so that weight loss can be beneficial. CONCLUSION: Arterial wall elasticity, as determined by Pulse Wave Velocity, is decreased in overweight and obese individuals. P3 Stroke, Myocardial Infarction and Total Mortality Rates by Coronary Artery Calcification Score Barbara L Naydeck, Diane Ives, Lewis H Kuller, Anne B Newman; Univ of Pittsburgh, Pittsburgh, PA CVD event risk using coronary calcification (CAC) measures for older women from a community-dwelling population have not been published. Within the Cardiovascular Health P1 P2 Study, electron beam tomography assessed CAC in 614 participants of mean age 80 4 years of whom 60% (367) were women. All were followed for 4.4 years for mortality, MI and stroke. Data were analyzed using CAC score quartiles (Table), and fewer women had scores in the upper quartiles (40% women versus 65% men, p.0001). Event rates increased across CAC quartiles (Table), and women with high CAC scores had high rates of death (p.030) and were particularly at high risk for stroke (p.034) compared to those with lower scores. Results for MI suggested high risk but were not significant. Assocations in men were weaker. A low level of CAC identified older women with very low short-term risk. The high rate of stroke among older women should be addressed when evaluating a high CAC score. Mortality CAC Total Stroke CAC Total MI CAC Total N Events MEN, N 247 Rate/100 person yrs WOMEN, N 367 N Events HR and 95% CI Adjusted for Age and presence of Clinical CVD Rate/100 person yrs Men Women referent 0.94 ( ) 1.35 ( ) 1.87 ( ) referent 1.00 ( ) 0.77 ( ) 1.45 ( ) referent 0.98 ( ) 1.42 ( ) 2.14 ( ) Is There a Parallel between Endothelial and Endocardial Function? Toni L Bransford, Amyn Malik, Natalia Florea, Daniel Duprez; Univ of Minnesota, Minneapolis, MN referent 1.77 ( ) 1.89 ( ) 2.80 ( ) referent 1.01 ( ) 3.22 ( ) 4.65 ( ) referent 4.17 ( ) 1.36 ( ) 7.90 ( ) Background: Endothelial and endocardial cells can release vasorelaxant substances and share common features as modulators of vascular tone and cardiac performance. It is unclear if there is homogeneity or heterogeneity between endothelial function and diastolic relaxation. Objective: This study aimed to examine the relationship between forearm-mediated vasodilation (FMD) as a marker for endothelial function and cardiac diastolic relaxation in apparently healthy normotensive subjects. Methods: In a group of 10 male and 10 female subjects (mean age 29 /-6 years), we performed brachial artery ultrasound following 3 minutes of cuff-induced brachial artery occlusion. We then performed 2D and Doppler echocardiography. The female subjects were studied during both the follicular and luteal phase of the menstrual cycle. Results: All subjects had normal systolic function (EF 55%) and normal diastolic function (mean E/A 1.8 /-.4, E 13.6 /-1.9). Mean FMD for the study group was %. Heart rate was 66 /- 13, and mean BP was 114 /-10/ 64 /- 7 mm Hg. There was a significant correlation between FMD and diastolic relaxation in men and women in the luteal phase of the menstrual cycle (r -.840, p.001). When FMD was included from women in the follicular phase of the menstrual cycle, the correlation was lost. Conclusions: Endothelial function is strongly related to endocardial function in men. In contrast, in women the relationship between endothelial function and endocardial function is highly determined by hormonal status. P5 Gender Differences in New Markers for Early Detection of Cardiovascular Disease in Asymptomatic Individuals Natalia Florea, Lynn Hoke, Paul A Sommers, Anne L Taylor, Jay N Cohn, Daniel Duprez; Univ of Minnesota, Minneapolis, MN Background. Female-specific recommendations for preventive cardiology require gender sensitive approach to risk factor modification. It is still unclear whether gender differences in new risk markers such as high-sensitivity C-reactive protein (hs-crp, a marker for vascular inflammation), and brain natriuretic peptide (BNP, a marker for left ventricular dysfunction), show the same trend as gender difference in classical risk factors. We examined gender differences in hs-crp and BNP in a primary prevention study population. Methods and Results. A total of 535 asymptomatic individuals (189 females and 346 males) were screened for established cardiovascular risk factors and new risk markers. Established risk factors included body mass index (BMI), blood pressure, total cholesterol, low-density cholesterol (LDL), and high-density cholesterol (HDL). New risk markers included hs-crp and BNP. Table 1 summarizes the results. Conclusions. The levels of classical risk factors were lower in females versus males. In contrast, hs-crp and BNP, new markers for cardiovascular risk, were higher in females. There is, therefore, an urgent need to establish specific reference values for new cardiovascular risk markers in females. P4
12 Poster Presentations E-51 TABLE 1 Variable Female, n 189 Male, n 346 P-value Age, years BMI, kg/m Mean Arterial Pressure, mmhg Total Cholesterol, mg/dl LDL Cholesterol, mg/dl HDL Cholesterol, mg/dl BNP, pg/ml hs-crp, mg/ml continuous data. Multiple logistic regression analysis was performed to assess the association between low BMD and the presence of BAC adjusted for age and ethnicity. Results: The prevalence of BAC, osteopenia, and osteoporosis was 39%, 46%, and 28% respectively. As compared to women without BAC, women with BAC were significantly more likely to be older, Hispanic, postmenopausal, diabetic and have low BMD (p 0.05). Furthermore, women with BAC were more likely to have osteopenia (OR 3.3, p 0.02) or osteoporosis (OR 4.8, p 0.001) compared to women without BAC. After adjustment for potential confounders, the association between low BMD and BAC remained significant (p 0.02). Conclusion: These data suggest that osteoporosis and arterial calcification are strongly correlated with each other among postmenopausal women. We conclude that low BMD may be an additional marker of, and be correlated with, subclinical vascular disease. Coronary CT Calcium Score and CV Risk Factors in Women Under 65 Clinton Greenston, Theodore J Angelopoulos, Joshua Lowndes, Linda Zukley, Thomas J Dube, Byron Yount, James M Rippe; Rippie Lifestyle Institute at Celebration Health, Celebration, FL Introduction: Cardiovascular Disease (CVD) is the number one killer of women in the U.S., but tends not to present clinically until the 7 th decade in women with moderate risks. Coronary CT calcification scores (CT-Ca) have been shown to predict CV events and knowledge of CT-Ca scores have been shown to aid in the assessment of CVD risk when used in combination with traditional risk factors (RF). This may be especially important in patients in the intermediate-risk category in whom clinical decision making is the most uncertain. Therefore the purpose of this study was to assess the extent that CT-Ca measured similar aspects of the CAD process as other RFs and has the power to influence clinical decision-making in middle age women with intermediate risks. Methods: Healthy women (n 69) without a history of CAD had their risk of CAD evaluated as part of a routine annual health assessment program. The assessment consisted of measurement of traditional RFs (fasting glucose, cholesterol and subfractions, smoking status etc), non-traditional RFs including C Reactive Protein (CRP), triacylglycerol and maximal cardiorespiratory fitness (VO 2max ) and CT-Ca was added at the physicians request based on intermediate risk. Results: Descriptive data on this cohort is shown in Table 1. None of the RFs measured correlated with CT-Ca. Furthermore, no CT-Ca score was 115 (moderate risk). Conclusion: There is considerable evidence that all the variables measured are important in the assessment of CVD risk. The lack of correlation of CT-Ca score with other established RFs suggest that CT-Ca measures a significantly different aspect of the atherosclerosic process. Our data show that it is rare for women under age 65 visiting our center to have abnormal CT-Ca scores even in the presence of intermediate CV risks. These data also suggest that CT-Ca may pick up early atherosclerosis in women who do not have traditional RF s. P6 Risk Stratification and Prognosis of Female Patients with Known or Suspected Coronary Artery Disease: A Stress Echocardiography Study Sripal Bangalore, Asif Malik, Amit Kamra, Devi Gopinath, Utpal Patel, Siu-Sun Yao, Farooq A Chaudhry; St Lukes Roosevelt Hosp, New York, NY Background: Stress Echocardiography (SE) is an established test for the risk stratification of patients with known or suspected CAD. However, literature on risk stratification, specifically in females is limited. Methods: We evaluated 764 consecutive female patients (60 13 years) undergoing stress echocardiography (34% treadmill, 66% dobutamine). LV was divided as per standard 16-segment model, 5-point scale for wall motion. Abnormal stress echo studies were defined as those with stress-induced ischemia (deterioration in wall thickening and excursion during stress, and increase in wall-motion score of grade). Using receiver operating characteristic curve (ROC) the cutoff for peak WMSI and EF were calculated. Followup (mean years) for confirmed myocardial infarction (n 11) and cardiac death (n 13) were obtained. Results: By univariate analysis, both peak wall motion score index (WMSI) (p ) and EF (p ) were significant predictors of cardiac events. Peak WMSI effectively risk stratified women into low (0.6%/year), intermediate (2.6%/year) and high (4.3%/year) risk groups (p for all the groups) (graph). EF was able to further substratify all the above groups into two subgroups- those with EF 45 and those with EF 45. Using logistic regression analysis, peak WMSI (RR 2.2, 95% CI 1.4 to 3.5, p 0.001) was an independent predictor of cardiac events. Conclusions: Stress echo yields appropriate risk stratification in female patients. A normal stress echocardiography study confers a benign prognosis (0.6%/year event rate). Peak WMSI 1.7 and EF 45 are independent marker of patients at high risk for adverse cardiac outcome. P9 CORRELATION WITH CA HEART SCORE Variable Mean S.D. Correlation p value n Ca Heart Score Age (years) n 69 Weight (lbs) n 69 BMI n 69 Waist (in) n 69 Resting SBP (mmhg) n 69 Resting DBP (mmhg) n 69 Glucose (mg/dl) n 68 Cholesterol (mg/dl) n 69 HDL (mg/dl) n 69 LDL (mg/dl) n 69 Triglycerides (mg/dl) n 69 VO2max (ml/kg/min) n 60 CRP (mg/l) n 66 Withdrawn P8 Low Bone Mineral Density is Associated with Breast Arterial Calcifications, a Potential Marker of Subclinical Vascular Disease Jhansi Reddy, Lori Mosca, Suzanne J Smith, Furcy Paultre, John P Bilezikian; Columbia Univeristy College of Physicians and Surgeons, New York, NY Background: Arterial calcification and increased risk of coronary heart disease (CHD) have been linked to osteoporosis, suggesting a common metabolic pathway. Breast arterial calcification (BAC) identified on routine screening mammography has been associated with an increased burden of atherosclerotic risk factors, angiographically defined CHD, and increased cardiovascular mortality. The purpose of this study is to determine if there is an association between low bone mineral density (BMD) and the presence of BAC on routine screening mammography among white and Hispanic women. Methods: We reviewed the charts of 229 women (56% Hispanic, 87% postmenopausal, mean age 64 years) who had undergone both mammography and BMD evaluation at Columbia University Medical Center between Mammograms were reviewed by a trained radiologist for the presence of arterial calcifications using standardized methods and then validated by a second radiologist (kappa 0.73, 95% CI ). BMD was measured using dual-energy x-ray absorptiometry and categorized as normal, osteopenia, or osteoporosis as defined by the World Health Organization. Comparisons were made using the chi-square test for categorical data and the Student s t-test for P7 P10 Estrogen Receptor- Polymorphism and Endothelial Fibrinolytic Regulation in Postmenopausal Women Greta L Hoetzer, Heather M Irmiger, Yoli Casas, Jared J Greiner, Brian L Stauffer, Christopher A DeSouza; Univ of Colorado, Boulder, CO Recent evidence suggests that genetic polymorphisms in the estrogen receptor (ER)- gene can influence cardiovascular health. For example, the length of the dinucleotide thymine and adenine [(TA) n ] repeat polymorphism, located in the regulatory region of the ER- gene, has been associated with an increased prevalence and severity of coronary artery disease (CAD) in men and postmenopausal women. It is possible that (TA) n length may negatively alter the influence of the ER- on the vasculature. Both clinical and epidemiological data indicate that impaired fibrinolysis is a major contributor to the development, progression, and severity of CAD. Accordingly, the aim of the present study was to determine whether (TA) n length is associated with endothelial tissue-type plasminogen activator (t-pa) release in healthy postmenopausal women. We hypothesized that the capacity of the endothelium to release t-pa is blunted in postmenopausal women with long (TA) n repeat alleles ( 18 repeats). Forty-two healthy postmenopausal women were studied: 10 with short (both alleles 18 (TA) n dinucleotide repeats; age 59 2 yr), 8 with long (both alleles 18 repeats; 59 3 yr) and 24 with mixed (one short and one long allele; 56 1 yr) allele genotypes. Net endothelial t-pa release was determined, in vivo, in response to intrabrachial infusions of bradykinin and sodium nitroprusside. t-pa release in response to bradykinin was highest in the short ( to ng/100 ml tissue/min) compared with the mixed ( to ng/100 ml tissue/min) and long ( to ng/100 ml tissue/min) allele groups. Importantly, the total amount of t-pa antigen released (area under the curve) was significantly higher ( 50%) in the short ( ng/100 ml tissue) compared with the mixed ( ng/100 ml tissue) and long allele ( ng/100 ml tissue) groups. Our results demonstrate that the long (TA) n dinucleotide repeat allele is associated with reduced endothelial t-pa release in healthy postmenopausal women. Blunted endothelial fibrinolytic capacity may underlie the increased CAD risk associated with the long (TA) n repeat ER- polymorphism.
13 E-52 Circulation Vol 111, No 4 February 2005 P11 Protection from Cardiovascular Reactivity to Stress in Women Conferred by a Beta-2 Adrenergic Receptor Gene Polymorphism Joseph C Poole, Harry C Davis, Harold Snieder, Frank A Treiber; Med College of Georgia, Augusta, GA Objective: Peripheral vasodilation is primarily mediated by the action of catecholamines at beta-2 adrenergic receptors (ADRB2). Alterations in the ADRB2 gene have been associated with increased risk for essential hypertension (EH), though these studies have largely ignored the role of potential moderating factors. Recent evidence suggests that the role of the sympathetic nervous system (SNS) in BP regulation varies by gender. The objective of this study was to determine the gender-specific impact of the ADRB2 G-654A polymorphism on hemodynamic function at rest and in response to a behavioral stressor. Methods: Study subjects included 245 African American (AA) and 273 European American (EA) young adults ( yrs). Hemodynamic measurements (i.e., systolic/diastolic BP, total peripheral resistance [TPR]) were completed at rest and during a 10 minute competitive video game challenge. Reactivity was defined as change scores (peak stressor value - pre-stressor value). The ADRB2 G-654A polymorphism was detected by polymerase chain reaction (PCR) technique. A-allele carrier rates for AAs and EAs were 44.4% (109 of 245) and 53.6% (146 of 273), respectively. A statistical model was built that included terms for main effects of genotype, gender, ethnicity and obesity (body mass index 85 th percentile) as well as the two- and three-way interaction terms involving ADRB2-654 carrier status. Results: Significant interactions involving gender and carrier status were observed, such that female carriers of the -654 A-allele exhibited significantly lower SBP, DBP, and TPR reactivity to the video game challenge compared to female non-carriers and males (all ps.004). Conversely, male carriers exhibited significantly higher reactivity (SBP, DBP, and TPR) compared to male non-carriers and females (all ps.004). Conclusion: The association of a presumably harmful polymorphism in the ADRB2 5 -gene regulatory region with female-specific cardioprotection under behavioral stress suggests the possibility for gender-dependent regulation of the ADRB2 gene. These findings demonstrate the importance of gender consideration when examining BP control-related genetic polymorphisms, especially in genes involved in SNS function. P12 A Haplotype of the Angiotensin-II Receptor Subtype-1 is Associated with Hypertension in Caucasian Women Ashok Kumar, Alicia Prater, Yanna Li, Sudhir Jain; New York Med College, Valhalla, NY Hypertension is a serious risk factor for myocardial infarction, heart failure, vascular disease, stroke, and renal failure. Previous studies have suggested that overexpression of the angiotensin receptor type-1 increases hypertension in female transgenic mice. We have therefore analyzed the role of single nucleotide polymorphisms (SNPs) in the 5 - flanking region of the human angiotensin receptor type-1 (hat 1 R gene) in hypertension. We have found that hat 1 R gene promoter contains a haplotype block of at least five SNPs consisting of T/A at -777, T/G at -680, A/C at -214, G/C at -213, and A/G at Our studies have shown that variants -777T, -680T, -214A, -213G, and -119A always occur together thus creating haplotypes I and II (representing haplotypes TTAGA and AGCCG respectively). We have analyzed the genomic DNA from 207 Caucasian subjects with hypertension (mean age: 59 plus/minus 10 years) and 240 Caucasian normotensive controls (mean age 58 plus/minus 10 years) and shown that haplotype-i of the hat1r gene is associated with hypertension in Caucasian women. We have also shown that transient transfection of reporter construct containing haplotype-i of the hat1r gene has increased promoter activity in adrenal cortical and VSMC as compared to haplotype-ii. Our gel shift assays have shown that transcription factor C/EBP binds more strongly to an oligonucleotide containing -119A as compared to -119G. When nucleoside A and G are present at -214 and -213 (haplotype-i), this sequence has homology with E-box (CANNTG). We have shown that transcription factor USF, which binds to the E-box and is involved in glucose and insulin induced expression of a gene, binds strongly to an oligonucleotide containing nucleosides A and G at -214 and -213 (haplotype-i). In conclusion, haplotype-i of the hat1r gene that has increased promoter activity in H295R cells is associated with hypertension in Caucasian women. Is Family History of Cardiovascular Disease a Stronger Risk Factor for Women? Maren T Scheuner, UCLA Sch of Public Health, Los Angeles, CA; William C Whitworth, Paula W Yoon; Cntrs for Disease Control and Prevention, Atlanta, GA Family history is an important risk factor for coronary heart disease (CHD) and stroke. Familial characteristics, such as age at diagnosis and number of affected relatives influence the magnitude of risk. We assessed the effect of family history on CHD and stroke risk in men and women. We examined family history of CHD and stroke among 4035 respondents to the HealthStyles 2003 national survey. Odds ratios for risk of CHD and stroke stratified by gender were calculated, adjusting for age, race and educational level. Respondents were 60% female, 72% white, and mean age was 48.8 yrs (SD, 14.4) with no gender differences in age or race. Frequency of CHD in males was 4.9% and 2.1% in females. Frequency of stroke was 2.2% in males and 2.6% in females. Frequency of family history of CHD (affected 1st and/or 2nd degree relatives) was similar in males and females, 50.4% and 53.2%, respectively. However, females were significantly more likely to report family history of stroke, 47.0% vs. 39.1%, p For males, CHD risk was increased 2.9-fold (95% CI, ) given 1st degree relatives with CHD and this risk did not increase substantially if both 1st and 2nd degree relatives had CHD (OR 3.1; 95% CI, ). For females, CHD risk was increased 4.9-fold (95% CI, ) given 1st degree relatives with CHD, and their risk increased 6.9-fold (95% CI, ) if both 1st and 2nd degree relatives had CHD. Males and females were about 2-fold more likely to have stroke given 1st degree relatives with stroke, and the risk did not increase significantly if both 1st and 2nd degree relatives had stroke. However, females with P13 family history of stroke had an increased risk of CHD, especially if 1st and 2nd degree relatives had stroke (OR 3.8; 95% CI, ). For males, there was no risk of CHD given family history of stroke. Family history is a prevalent and significant risk factor for CHD and stroke in women and men. However, family history of CHD and stroke appear to be more important CHD risk factors for women. Though comprehensive assessment of familial cardiovascular risk is essential for men and women, our results suggest women could benefit most from this type of risk assessment strategy, which could result in improved targeting of interventions for cardiovascular risk reduction. P14 Genotype-By-Sex Interactions Influence Serum Paraoxonase 1 Activity in Mexican Americans Deidre A Winnier, David L Rainwater, Shelley A Cole, Thomas D Dyer, Jean W MacCluer, Michael C Mahaney; Southwest Foundation for BioMed Rsch, San Antonio, TX Paraoxonase 1 (PON1), a high density lipoprotein-associated serum enzyme known to protect against cellular damage from toxic agents, may also have antioxidant properties. PON1 activity levels have been reported to differ in human and animal studies with females exhibiting higher basal levels and potentially increased response to inflammation. The genetics of normal variation in PON1 is poorly understood and no formal studies of sex-specific effects have been done. We measured PON1 activity in frozen serum for 1407 individuals in over 40 extended pedigrees from the San Antonio Family Heart Study (SAFHS). Mean of PON1 activity was nmol/min/l for females (n 835) and nmol/min/l for males (n 572). We used a maximum likelihood based, variance decomposition approach implemented in SOLAR to test for genotype-by-sex interaction on PON1 activity and to localize sex specific quantitative trait loci (QTL) which may influence PON1 activity. The sex-specific heritability estimates were equivalent in males and females (h and 0.81, respectively), and the sex-specific genetic and environmental variances were not significantly different (P 0.42). The residual additive genetic correlation ( G 0.84) between sexes is significantly different from 1 (P 0.028), indicating that different genes influence PON1 activity. In addition to the PON1 structural locus on 7q21 22, four other potential QTLs with LOD 1.50 were evaluated for sex specific effects: one each on chromosomes 12, 15, 17 and 19. Only the chromosome 17 QTL (LOD 2.51, P ; flanked by microsatellite marker loci D17S974 and D17S921) shows a significant (P 0.049) sex-specific effect on PON1 activity with QTL-specific heritabilities of for females and for males. This study represents the first formal statistical genetic test of genotype-by-sex interactions on normal quantitative variation in PON1 activity. From our results, we infer that different combinations of genes are responsible for the genetic variation in our population and that a QTL on chromosome 17 may exhibit significant sex-specific effects on this phenotype. Sex-specific genetic influences may help explain some of the well-established sex differences in cardiovascular disease risk. Role of Chromosome X for Hypertension in French Canadians Jiro Uwabo, Margaret Labuda, Yulin Sun, Rsch Cntr CHUM, Montreal, Canada; Daniel Gaudet, Complexe Hospieer dela Sagamie, Chicoutimi, Canada; Francis Gossard, Zdenka Pausova, Rsch Cntr CHUM, Montreal, Canada; Theodore Kotchen, Allen W Cowley, Med College of Wisconsin, Milwaukee, WI; Johanne Tremblay, Pavel Hamet; Rsch Cntr CHUM, Montreal, Canada Prevalence of hypertension (HT) increases at a greater rate in males than in females until the age of 55. After 55, the females BP increases rapidly and surpasses that of males. The difference of BP increase may be due to sex, hormonal or other factors. Turner syndrome is caused by complete or partial monosomy X, and it is significantly associated with early onset HT. Recently ACE2 gene was localized on X chromosome. All this suggests that X chromosome may play a significant role in the pathogenesis of hypertension. The aim of this study was to investigate a possible contribution of three X chromosome genes within Turner syndrome locus (ACE2, HSP 27 like gene between JM1 and CACN1F, OTC) to hypertension. We studied a French Canadian family cohort which including 774 individuals in 115 families ascertained by propositus sib-pair with HT and dyslipidemia. Subjects were stratified by age into the following groups young (below 40), middle (from 41to 54) and old (above 55) groups. Results: In the case of the ACE2 gene, allele 1 was found to be significantly over-represented in HT compared to NT subjects (p 0.02), Odds ratio (OR) of HT for carriers of allele 1 is 1.3 (95% CI ), OR of late-onset HT with allele 1 was 1.8 (95% CI p 0.03) and OR of early-onset HT with allele 1 was 1.6 (95% CI p 0.001). Female genotype 1 homozygotes had significantly higher day average sbp, with no difference in dbp, compared to combined heterozygotes and genotype 2 homozygotes (130 vs.121mmhg, p 0.03).In the case of HSP27 like gene, there were no significant difference in genotype frequencies between HT and NT. In age groups, OR of late-onset HT for carriers of genotype 1 was 2.1 (95% CI p 0.07) in female and OR of middle age group of onset HT for the carriers of genotype 1 was 2.1 (95% CI p 0.02) In male.in the case of OTC gene, all BP levels were higher among genotype 1 males comparing to genotype 2 carriers. The difference was strong among HT, especially sleeping sbp of 24h BP monitoring (10.4mmHg, p 0.001), and mean arterial BP (7.4mmHg, p 0.001) but not among NT, after correction for age and sex. In conclusion: these results suggest possible evidence for locus including three genes involved in development of HT with specific impact of age in each sex in French-Canadian. P16 Low Density Lipoprotein Lowering Efficacy of the Ezetimibe / Simvastatin Combination Tablet in a Large Cohort of Women Elizabeth Gallup, Radiant Rsch-Kansas City, Overlook Park, KS; Kathleen Colleran, Univ of New Mexico Health Science Cntr, Albuquerque, NM; Anne Goldberg, Washington Univ, St. Louis, MO; Michael Davidson, Radiant Rsch-Chicago, Chicago, IL; Arvind Shah, Merck Rsch Laboratories, Rahway, NJ; Darbie Maccubbin, Diane Tribble, Stephen Donahue, Merck Rsch Laboratories, Inc., Rahway, NJ; Enrico Veltri, Schering-Plough Rsch Institute, Kenilworth, NJ; Yale Mitchel; Merck Rsch Laboratories, Inc., Rahway, NJ Background: The importance of aggressively treating hypercholesterolemia in women has been widely acknowledged. The ezetimibe/simvastatin (EZE/SIM) combination tablet contains P15
14 Poster Presentations E-53 components that inhibit both the intestinal absorption and endogenous production of cholesterol, providing highly efficacious LDL-C lowering. We evaluated the lipid-modifying efficacy of EZE/SIM vs SIM monotherapy in a large cohort of women with primary hypercholesterolemia. Methods: This was a gender subgroup analysis of pooled data from 3 identically designed randomized, double-blind, placebo (Pbo)-controlled studies. After a 6- to 8-wk washout and 4-wk diet/pbo run-in, 3083 patients (1642 women and 1441 men) with LDL-C mg/dl and triglycerides (TG) 350 mg/dl were randomized in equal numbers to: EZE/SIM (10/10, 10/20, 10/40 or 10/80 mg); SIM alone (10, 20, 40 or 80 mg); EZE 10 mg; or Pbo for 12 wks. The primary endpoint was % change from baseline in LDL-C for pooled EZE/SIM vs pooled SIM alone. Results: Baseline LDL-C values for women and men were 178 and 176 mg/dl, respectively. For all efficacy endpoints, the treatment effects in women and men were similar and consistent with the combined cohort of subjects from the 3 studies. In women, pooled EZE/SIM significantly reduced LDL-C, non-hdl-c, apolipoprotein (apo) B, TG, and C-reactive protein (CRP) compared with pooled SIM alone (table). Increases from baseline in HDL-C were similar for both treatments. More women and men receiving EZE/SIM vs SIM alone achieved LDL-C levels of 70 mg/dl (39% vs 6% for women and 35% vs 6% for men; p for both) or 100 mg/dl (79% vs 44% for women and 78% vs 41% for men; p for both). Conclusion: EZE/SIM offers a highly efficacious lipid-altering option for the treatment of primary hypercholesterolemia in women. Women Subgroup Least Squares Mean (SE) % Change from Baseline P-value Pooled SIM Pooled EZE/SIM for Pooled Parameter (N ) (N ) Comparisons 2 LDL-C -38.1(0.6) -52.7(0.6) P Non-HDL-C -34.5(0.5) -48.2(0.5) P Apo B -30.4(0.5) -42.0(0.5) P TG (1.1) -25.8(1.0) P HDL-C 7.0(0.5) 7.5(0.5) NS CRP 1,3-17.7(2.4) -31.3(2.1) P median (SE for the median); 2 p-value for EZE/SIM vs SIM in whole cohort can be applied to women subgroup; 3 n ; NS not significant P17 Apolipoproteins: A Potential Target for Cardiovascular Risk Stratification in Postmenopausal Women with Components of the Metabolic Syndrome Marie-Edouard N Desvarieux, Robert R Sciacca, Columbia Univ Med Cntr, New York, NY; Fredi Kronenberg, Rosenthal Cntr, Columbia Univ Med Cntr, New York, NY; Elsa-Grace V Giardina; Cntr for Women s Health, Columbia Univ Med Cntr, New York, NY Background: Novel emerging risk factors such as apolipoprotein B (apob) and apolipoprotein A-1 (apoa-1) may add to our ability to predict adverse cardiovascular events in post menopausal (PMP) women. In particular, apoa-1 and apob may be more predictive than traditionally measured lipoproteins in PMP women. Methods: The study population consisted of 76 PMP volunteers free of cardiac disease and not taking hormone replacement therapy with a mean age of 57 5 years (57% White, 15% African American, and 28% Hispanic; 73% college graduates) who were months since their last menstrual period. Results: Mean values for the components of the metabolic syndrome (MS) included: systolic blood pressure mmhg; waist circumference 34 4 inches; fasting glucose mg/dl ; triglycerides (TG) mg/dl; and high-density lipoprotein mg/dl. Of the 76 subjects 13% had 3 or more MS components, 26% had 2 MS components, 36% had 1 MS component, and 25% had 0 MS components. Other measures included: BMI ; total cholesterol mg/dl; apob mg/dl; and apoa mg/dl. ApoB levels increased (r 0.53; p ) with the number of MS components, while apoa-1 levels decreased (r -0.32; p 0.005) with increasing number of MS components, which are known to predict cardiac mortality. The association of apob with MS components remained significant after removal of the components related to HDL and TG (r 0.28, p 0.017). Conclusions: PMP women with 3 or more components of the metabolic syndrome were more likely to have elevated apob and low apoa-1. These findings suggest that apolipoproteins are a potential target for cardiovascular risk stratification. P18 Triglycerides are Strongly Related to Vascular Stiffness in Healthy Women Warren W Davis, Atlanta VAMC, Decatur, GA; Ngoc-Anh Le, W. Virgil Brown, Atlanta VAMC and Emory Univ Sch of Medicine, Decatur, GA; David Herrington, Wake Forrest Univ Sch of Medicine, Winston-Salem, NC; Sunichi Homma, Columbia Univ Sch of Medicine, New York, NM; Lori Mosca, Columbia Univ Sch of Medicine, New York, NY; Barry Eggleston, Rho Inc, Chapel Hill, NC; Jeff Raines; Univ of Miami Sch of Medicine, Miami, HI Triglycerides are known to correlate more strongly with vascular disease in women than in men. To determine if there is evidence of differences in vascular function in healthy women and men with similar predicted risk using Framingham risk functions, 223 men (35 to 69 years) and women (45 to 79 years) were recruited within three predicted risk categories according to the NCEP guidelines. These included 111 men and 112 women with approximately equal numbers in 3 groups according to 10-year risk estimates of 10%, 10 to 20% and 20% or coronary disease risk equivalent. All patients completed an exercise stress test (treadmill with Bruce protocol) with ECG monitoring and ultrasound examination. Seven patients were excluded due to abnormalities. Nine additional patients taking lipid-lowering drugs and one with plasma triglycerides 1000 mg/dl were also excluded. All subjects were evaluated after an 8 to 12-hour fast with plasma analyses as well as measures of arterial compliance in the calf and separately in the thigh using a computer-controlled assessment of continuous pulse volume recording (VASOGRAM ). Lipoprotein measures included total cholesterol (C), triglycerides (TG), LDL-C and HDL-C, apolipoproteins (apo) AI, B, E, and apolipoprotein composition of isolated triglyceride-rich lipoproteins (d 1.020). In the women, TG correlated more strongly with increased vascular stiffness than any other measure: in thigh (r 0.39, p 0.001) and in calf (r 0.31, p 0.001). Other significant correlations were: non-hdl-c, apob and apociii, all indicators of increased TG rich lipoproteins. None of these measures correlated with vascular stiffness in men. A Prospective Study of Plasma Lipids and Hypertension in Women Howard D Sesso, Julie E Buring, Marilyn J Chown, J. Michael Gaziano; Brigham & Women s Hosp, Boston, MA Background: Although elevated lipids and hypertension both lead to cardiovascular disease, few data exist on the nature of the relationship between various lipid parameters and the development of hypertension. Methods: A prospective study of 16,142 middle-aged and older women who provided baseline bloods and had no history of either high cholesterol (no diagnosis or treatment) or hypertension (systolic blood pressure (SBP) 140 mmhg, diastolic blood pressure (DBP) 90 mmhg, and no history or treatment). Plasma lipid levels were measured, and baseline risk factors collected. During 9.8 years of follow-up, incident hypertension was defined as either a new physician diagnosis, the initiation of antihypertensive treatment, SBP 140 mmhg, or DBP 90 mmhg. Results: There were 4,253 women who developed incident hypertension. In adjusted models for lifestyle risk factors, the relative risks (RRs) of developing hypertension from the lowest (referent) to the highest quintile of baseline total cholesterol (TC) were 1.00, 0.97, 1.02, 1.11, and 1.19 (p, trend ); for LDL cholesterol, 1.00, 0.99, 1.04, 1.08, and 1.24 (p, trend ); for HDL cholesterol, 1.00, 0.82, 0.71, 0.65, and 0.58 (p, trend ); for triglycerides, 1.00, 1.10, 1.37, 1.52, and 2.00 (p, trend ); for non-hdl cholesterol, 1.00, 1.11, 1.22, 1.28, and 1.53 (p, trend ); and for the TC/HDL ratio, 1.00, 1.17, 1.27, 1.52, and 1.90 (p, trend ). Results were similar for Adult Treatment Panel III clinical cutpoints, and after the exclusion of obese or diabetic women. The RRs of developing hypertension were consistently stronger among women with an SBP of 120 mmhg and DBP of 75 mmhg for each lipid parameter. Conclusions: In this large cohort of women, dyslipidemia as reflected by levels of total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, non-hdl cholesterol, and the TC/HDL ratio was associated with the subsequent risk of developing hypertension. Serum Lipid Concentrations Differ by Gender and Age Sameline Grimsgaard, Anne Elise Eggen, Inger Njølstad, Maja-Lisa Løchen, Frode Skjold; Univ of Tromsø, Tromsø, Norway Little is known about how serum lipid concentrations differ by gender and age. This cross-sectional study describes gender and age differences in conc. of serum total cholesterol (TC), HDL-cholesterol (HDL-C) and triglycerides (TG). The Tromsø Study is a population based cohort study of chronic diseases and risk factors in the municipality Tromsø in North Norway. In 1994, all inhabitants above 24 years were invited to the fourth screening. Height, weight and serum lipids were measured, and men and women attended (77 %). Age related variation in mean TC conc. was stronger in women than in men. TC increased from 5.06 to 7.34 mmol/l in women aged 25 to 74 years and declined thereafter. Women older than 50 years had higher TC conc. than men. HDL-C conc. were higher in women and varied little over age groups. The TC/HDL-C ratio increased from 3.33 in the youngest, to 4.71 in the oldest women, compared to around 4.8 in men. In women, mean TG conc. increased from 1.15 to 1.91 mmol/l in the youngest to the oldest age groups. In men, TG conc. increased from 1.67 to 1.89 mmol/l in the youngest to age 45 years and declined thereafter. The correlation between TG and HDL-C decreased from to in women 25 to 74 years (p 0.05) and was rather stable around -0.3 in men. Adjustment for body mass index did not change the gender differences in lipid conc. Less than 1% used lipid-lowering drugs. Age related variations in lipid conc. were markedly different in the two genders. Findings indicate gender differences in lipid metabolism that may influence how serum lipids predict cardiovascular disease. Possible implications of this gender difference need to be addressed in clinical and epidemiological studies. P19 P20
15 E-54 Circulation Vol 111, No 4 February 2005 Female Gender is Associated with Increased Levels of Oxidized Low-density Lipoprotein in a Healthy Elderly Population P23 Nina Johnston, Tomas Jernberg, Agneta Siegbhan, Lars Wallentin; Medicine, Uppsala, Sweden Background: Oxidized low-density lipoprotein (OxLDL) is suggested to play a pivotal role in atherosclerosis and its clinical manifestations. Risk factors for elevated levels of circulating OxLDL are not well established. The purpose of this study was to investigate the influence of traditional risk factors on levels of OxLDL in a healthy elderly population. Study Population: 294 men and 137 women free of symtomatic cardiovascular disease, other established chronic diseases and without cardiovascular medications were studied. Method: OxLDL was measured by a sandwich ELISA utilizing a specific murine monoclonal antibody, mab-4e6 (Mercodia AB, Uppsala, Sweden). Results:The characteristics of the study population are shown in the table below (All values unless otherwise stated are median (25 th -75 th percentiles).**p 0.01, ***p (chi-square for proportions, Mann-Whitney U for continuous data) In a multiple regression analysis including the baseline characteristics in table 1, there was an independent positive association of OxLDL to total cholesterol and female gender and a negative association to HDL. Conclusion: In apparently healthy elderly population female gender is associated with higher levels of circulating OxLDL. Blood Lipids and Enzymes in Postmenopausal Women after Exercise: Influence of Cholesterol Status Stephen F Crouse, Texas A&M Univ, College Station, TX; Shelly D Weise, San Angelo State Univ, San Angelo, TX; Peter W Grandjean, Auburn, Auburn, AL; J. James Rohack, John W Womach; Texas A&M Univ, College Station, TX P21 Background: The effectiveness of lifestyle intervention strategies to improve blood lipids in women may be dependent on preexisting cholesterol concentrations. We characterized the effects of cholesterol status on blood lipid, lipoprotein-lipid, and lipid regulatory enzyme responses to a single session of aerobic exercise in physically active, postmenopausal women. Methods: Blood samples were obtained from twelve women with high cholesterol (HC, 200 mg/dl) and thirteen women with normal cholesterol (NC, 200 mg/dl), 24 hr before (PRE), immediately (IPE), 24 and 48 hr after an exercise session (treadmill walking at 70 % VO 2peak, 400 kcals). Results: Repeated measures analysis revealed: 1) Pre-exercise cholesterol differences did not influence the lipid or lipoprotein-lipid responses to exercise; 2) for both groups, triglyceride was significantly reduced (-8.5%) after exercise, 3) the concentration profile over time for high density lipoprotein-cholesterol was significant for both groups, first falling at IPE then rising back to PRE levels by 24 hr after exercise; 4) the lecithin:cholesterol acyltransferase activity (LCATA) exercise response was group dependent increasing modestly in the NC group at 24 and 48 hr; 5) lipoprotein lipase activity (LPLA) increased at IPE ( 17%) in the HC group only, then fell at 24 and 48 hr (-21%) compared to PRE; 6) cholesterol ester transfer protein activity was unchanged. Conclusions: In postmenopausal women, a single session of endurance exercise elicited a short-term, favorable decrease in TG independent of initial blood cholesterol concentrations. However, LCATA and LPLA postexercise changes were influenced by preexercise cholesterol status. P22 Awareness, Accuracy and Predictive Validity of Self-Reported Cholesterol Angela P Huang, Julie E Buring, Paul M Ridker, Robert J Glynn; Brigham and Women s Hosp, Harvard Med Sch, Boston, MA Background: Although current guidelines emphasize the importance of cholesterol knowledge, little is known about the accuracy of this knowledge, the factors that affect accuracy, and whether self-reported cholesterol is related to cardiovascular disease (CVD). Methods: Before randomization, the 39,876 female health professionals in the Women s Health Study with no prior CVD responded to a mailed questionnaire that asked for their cholesterol level, and 27,939 women also provided a blood sample. We assessed whether demographic and cardiovascular risk factors affect cholesterol knowledge and the accuracy of this knowledge. Accuracy was evaluated by examining the difference between reported and measured cholesterol. Additionally we examined the relationship of self-reported cholesterol with incident CVD in the next 10 years. Results: Compared to women who did not report their cholesterol levels, those who did (n 33,603, 84%) had higher levels of income, education and exercise, and were more likely to be married, normal weight, treated for hypertension and hypercholesterolemia, nonsmokers, moderate drinkers, or users of hormone replacement therapy. On average women underreported their cholesterol by 9.7 mg/dl (95% CI: ), and this difference had limited relationships with the covariates above (R ). Sensitivity and specificity between self-reported cholesterol and measured serum cholesterol 200mg/dL were 72% and 75%, respectively. With a higher 240mg/dL cut-off, sensitivity decreased to 39% and specificity increased to 93%. Self-reported cholesterol had a strong relationship with incident CVD that occurred in 741 women (23% increased hazard per 40 mg/dl increase, 95% CI: 15% 33%). Both self-reported and measured cholesterol independently predicted CVD. Conclusion: Self-reported cholesterol has a strong relationship with risk of CVD. However, self-reported cholesterol itself has only moderate ability to identify those with elevated levels. Moreover, women generally underestimate their cholesterol levels, and those at higher risk of CVD because of obesity, smoking, untreated hypertension or sedentary lifestyle have decreased knowledge of their levels, and would benefit most from intervention to improve knowledge. Men Women Age, years 64(58 70) 67(63 72)*** Body-mass index, kg/m ( ) 25.5( ) Systolic blood pressure, mmhg 140( ) 140( ) Diastolic blood pressure, mmhg 80(75 85) 80(75 85) Current smoker (n,%) 16(46) 10(14)** Total Cholesterol, mmol/l 5.5( ) 6.1( )*** HDL, mmol/l 1.3( ) 1.6( )*** LDL, mmol/l 3.3( ) 3.7( )*** Triglycerides, mmol/l 1.6( ) 1.4( ) Total cholesterol/hdl 4.1( ) 3.9( )*** OxLDL, U/L 50(42 62) 58(38 67)*** Prevalence of Lipid Triad, Lipoprotein (a) and C - Reactive Protein in a Screening Population of South Asian Women: Implications for Heart Disease in Asian American Women Raghu Kolluri, The Cleveland Clinic Foundation, Cleveland, OH; Amit Patel, Riverside Methodist Hosp, Columbus, OH; Kanny S Grewal; Mid Ohio Cardiology and Vascular Consultants, Columbus, OH OBJECTIVE: South Asian immigrants, including women in the USA and other western nations have higher prevalence of coronary artery disease despite having less obesity, hypertension and smoking. This paradox is postulated to result from a high prevalence of metabolic syndrome. We assessed the prevalence of dyslipidemia, including high risk LDL and HDL subfractions, as well as the emerging risk factors such as Lp(a), CRP, and homocysteine in a screening population of South Asians in an urban USA setting. METHODS: 189 subjects free of known CAD or lipid pharmacotherapy underwent arthropometric assessment, lipid NMR spectroscopy, and non-lipid risk factor screening. RESULTS: 79 women and 110 men (age 40 /- 12.7) were assessed. 91% of subjects were born in India. Smoking (4%) and hypertension (17%) were infrequent. Asian women not only have a high prevalence of traditional risk factors for CAD, but also have high prevalence of elevated Lp (a) and a very high prevalence of elevated CRP. Both CRP and Lp (a) had neither a strong positive nor negative correlation with total cholesterol, LDL, HDL or TG s. Conclusions: Due to the high prevalence of both traditional and non traditional risk factors, Asian Indian women are at higher risk of CAD. Since elevated CRP and Lp (a) are highly prevalent in Asian Indian women, they should be included in screening for CAD in this population. MEAN LEVELS AND PREVALENCE N 79 Mean SD Prevalence BMI ( 30.0) 12.4% Total cholesterol (TC) %(32of79) Total LDL %(31of79) Small dense LDL %(22of79) LDL particle number %(36of79) Total HDL % (22 of 79) Large HDL % (9 of 79) Triglyceride % (24 of 79) Lp (a) / % (18 of 79) CRP 4.09 / % (40 of 79) Homocysteine 9.12 / % (5 of 79) The Relationship between Vascular Calcification of the Breast Seen on Mammography and Coronary Artery Disease Mario R Castellanos, Mohammad Zgheib, Marwan Elya, Pascal Karam, Carolyn Raia, Kathleen Ahern, Mohammad Ali-El-Harakeh, Thomas Costantino, James Malpeso, Ali Homayuni, Shalom Buchbinder; Staten Island Univ Hosp, Brooklyn, NY Objective: Vascular calcifications are a common finding on mammography. Studies associate these breast arterial calcifications (BAC) with several CAD risk factors and more importantly, P24 P25
16 Poster Presentations E-55 BAC has been associated with an increased risk of subsequent cardiovascular death. In this study we examine if BAC on mammography can predict the presence CAD on angiography. Methods: Women that underwent angiography to evaluate CAD were recruited and interviewed. Two groups were formed: ( ) CAD and (-) CAD. Postive CAD included all degrees of luminal stenosis. Negative CAD was defined as completely normal arteries. Mammograms were reviewed by a breast-imaging specialist, blinded to CAD status. BAC was defined as linear calcium deposits greater than 1mm along the periphery of an artery in 2 or more vessels. Mammograms were scored by the total number of BAC. Results: A total of 139 subjects were included. The mean age was 63.1 years ( / ). There were 73 with ( )CAD and 66 with (-)CAD. The frequency of BAC in ( )CAD group was 26% (19/73) vs. 18% (12/66) in (-)CAD. The Chi Square was not significant at p.26. The mean age of the patients with BAC was 70.7 ( /-9.82) which was significantly higher than the group without, 59.7 ( /-10.1), t test p Therefore, subjects were divided into age less than 65 and above. Seventy-five patients were below 65 and there were 30 with ( )CAD none of them had BAC. Of the 45 with (-)CAD, 15.5% (7/45) had BAC, (p.02). In age 65 and over, BAC was seen in 19/44 with ( )CAD vs 5/21in the (-)CAD (p.12). Analysis examining CAD severity and BAC score, similarly, showed no correlation. Conclusion: Studies report that BAC is associated with CAD risk factors and increased cardiovascular death. Subsequently, BAC has been proposed to be a promising marker for detecting CAD during mammography. In our study, which accurately identified patient CAD status, we were unable to show a correlation between the presence of BAC and CAD. Even when severity of BAC was considered, BAC score was not associated with any degree of CAD, rather BAC seem to correlate more with age. In fact most patients younger than 65 with CAD had no BAC. Based on these results caution should be advised on using BAC to identify patients with CAD on mammography screening. Further studies are recommended. Withdrawn Predictors for Arterial Events in the Multiple Outcomes of Raloxifene Evaluation (MORE) Trial Claire S Duvernoy, Univ of Michigan, Ann Arbor, MI; Pandurang M Kulkarni, Sherie A Dowsett, Yiyong Fu, Cheryl A Keech; Eli Lilly and Company, Indianapolis, IN Background: In a post hoc analysis from the MORE trial, an osteoporosis treatment trial of postmenopausal women (PMW), raloxifene (RLX) was associated with a reduced incidence of arterial (CV) events in those at increased CV risk. Aim: To determine 1) the magnitude of the CV effects (i.e. predictive values [PVs]) of candidate risk factors for CV events in PMW with osteoporosis; and 2) whether RLX 60mg/d alters these PVs, using data from MORE. Materials & Methods: Baseline parameters collected in MORE were those associated with CV risk according to US guidelines. Logistic regression and stepwise procedures were used to obtain the best fitting multivariate model using placebo (PLC) data (N 2576). Any 2-way interactions significant at p 0.1 were tested further. Significant parameters in the PLC multivariate model were tested using RLX PLC data (N 5133) to determine RLX s effect on the PVs of these CV risk factors. Results: Overall, 178 CV events were reported (PLC 96, RLX 82). Baseline characteristics significant in the PLC multivariate model are tabulated. In the RLX group, prior CHD and HL were not predictive of CV events. Conclusions: Factors previously identified as predictive of CV events were confirmed in these osteoporotic PMW. Neither CHD nor HL were predictive in those women treated with RLX which suggests that RLX may reduce risk for CV events in those women with prior CHD and/or HL. Raloxifene Use in The Heart (RUTH) is an ongoing PLC-controlled trial to specifically assess RLX s effect on CV outcomes in PMW at increased CV risk. Table: Odds ratio (95% CI) for CV events in multivariate logistic model CV risk factor PLC RLX or RLX PLC a Age 1.1( ) 1.1( ) Prior CHD Y/N 6.2( ) 1.6( ) b Current Smoker Y/N 2.3( ) 2.2( ) Diabetes mellitus Y/N 3.1( ) 2.2( ) Hyperlipidemia (HL) Y/N 2.2( ) 1.0( ) b Hypertension Y/N 1.8( ) 2.4( ) a Raloxifene data (N 2557) if interaction of therapy*risk factor significant, raloxifene and placebo data otherwise. b Interaction of therapy*risk factor significant at p 0.1 P28 Is There Sex Based Difference in Clinical and Angiographic Outcome in Patients Treated with Sirolimus Drug-Eluting Stent for Complex in-stent Restenosis? Merita Shehu, Letizia Giurlani, Guia Moschi, Angela Migliorini; Careggi Hosp, Florence, Italy Background. The are few data on the efficacy of sirolimus eluting stent (SES) for treatment of complex coronary in-stent restenosis (ISR). No data exist about the impact of female gender on outcome of SES for complex ISR. Methods. SES was implanted in all consecutive patients for the treatment of complex ISR (focal, diffuse proliferative or total occlusive). Clinical and angiographic follow-up was scheduled at 9 months from the procedure. Results. From June 2002 to January 2004 we treated 120 ISR in 100 consecutive pts. Baseline characteristics of pts were: age yrs, female 17%, diabetes mellitus 32%, previous myocardial infarction P26 P27 54%, previous CABG 12%, left ventricular disfunction (EF 0.40) 24%, associated noncardiac vasculopathy 28%, multivessel coronary disease 74%. Coronary target vessel was left anterior descending artery 49%, right coronary artery 24%, left circumflex 20%, left main 4%, venous graft 3%. Type of ISR was focal in 18% lesions and diffuse, or proliferative, or total occlusive in 82%. The major baseline differences between men and women were: smokers (52% vs 12%, p 0.003), previous myocardial infarction (59% vs 29%, p 0.026) and coronary multivessel disease (78% vs 53%, p 0.030). There were no difference in the clinical indication between groups (acute coronary syndrome in 39% vs 35%, p 0.902), or in ISR pattern (proliferative/occlusive 80% vs 85%, p 0.867).The procedural success rate was 100% and in-hospital stay was uneventful in both groups. The 9-month clinical follow-up rate was 100%, while the angiographic follow-up rate was 87% in male group and 88% in female group. MACE rate was 8.4% in the male group, and 5.8% in female group. There were 4 deaths (3 men, 1 woman), all non-related to target vessel failure. There were no infarctions. There were 4 TVR, all in men. The binary restenosis ( 50%) rate was 13% for patient in male group and 0% in women group. The restenosis rate for lesion was 11% in male group. Conclusions. Sirolimus DES for the treatment of complex ISR is feasible and safe. Long-term clinical and angiographic outcomes provide very encouraging results in both genders and suggest additional sirolimuseluting stent for ISR as a valid therapeutic option. P29 Trends in Mortality and Hospitalizations for Valvular Heart Disease among Women in the United States, Hylan D Shoob, Carma Ayala, Alexandra Hyduk, Janet B Croft, George A Mensah, Zhi-Jie Zheng; CDC, Atlanta, GA Valvular heart disease (VHD) encompasses all disorders affecting heart valves and is a major cause of heart failure in the US. Few epidemiologic studies have assessed VHD in women. This study provides a national perspective on the impact of VHD among US women by using data from the National Vital Statistics System and the National Hospital Discharge Survey to obtain age-adjusted and age-specific estimates (per 100,000 US population) of VHD as any contributing cause of death or hospitalization from Estimates were agestandardized to the 2000 US standard population using direct standardization. Women accounted for 58.1% of all deaths in 2000 with VHD as any of 20 causes; deaths with VHD increased from 8,452 in 1980 to 24,820 in 2000 among women; age-standardized death rates (per 100,000 women) doubled from 7.5 in 1980 to 14.2 in Among women dying with VHD as a contributing cause, 92.5% were aged 65 years. VHD was reported as the underlying cause only among 27.9% female decedents with any mention of VHD in Women also accounted for 62.5% of all hospitalizations in 2000 with VHD as any diagnosis. Hospitalizations with VHD as any diagnosis increased from over 179,000 in 1980 to almost 567,000 in 2000 among women; age-standardized prevalences (per 100,000 women) of hospitalization with VHD doubled from in 1980 to in Among women hospitalized with a diagnosis of VHD, 69.2% were aged 65 years and 14.4% were aged 45 years. VHD was rarely reported as the principal (first-listed) diagnosis among women (5.9% in ). Deaths and hospitalizations with VHD as a contributing cause increased among women from 1980 to Early detection is essential to prevent complications and the additive adverse outcomes of VHD. Prevention efforts should include broad-based public health initiatives to increase awareness of VHD and to foster diagnostic evaluation and testing, treatment, and surgery, if necessary, to prevent VHD-related disability, morbidity, mortality. P30 Beta-Blockers or Angiotensin Converting Enzyme Inhibitors (ACE-I): Which is Preferred in Atrial Fibrillation (AF) for the Maintanence of Sinus Rhythm Adalet Gurlek, Çaǧdas Özdöl, Irem Dinçer, Timuçin A Altın, Çetin Erol; Ankara Univ Med Sch, Ankara, Turkey Background and Aim: Beneficial effects of beta-blockers and ACE-I on atrial remodelling have been shown. The present study evaluated the impact of metoprolol or cilazapril addition to amiodarone in patients with persistent AF ( 7 days) who underwent successful electrical cardioversion. Methods and Results: One hundred and twenty-one patients (70 women, 51 men; years) with persistent AF were included. Three groups were compared: Group 1: Amiodarone (200 mg/day after loading, n 41), Group 2: Amiodarone metoprolol (50 mg twice a day, n 41) and Group 3: Amiodarone cilazapril (5 mg daily, n 39). The end-point was AF recurrence at one year. Thirty-one patients were lost to follow-up.groups were similar in terms of sex, age, left atrial size, left ventricular ejection fraction, underlying heart disease and AF duration. Twenty-six (84%) of 31 patients relapsed in group 1 compared to 20 (65%) of 31 patients in group 2 and 21 (75%) of 28 patients group 3. Only left atrial size predicted the maintanence of sinus rhythm. The groups were evaluated for AF recurrence rates with respect to gender. There was no statistically significant difference between men and women (Group 1: 83% (10 in 12) in men and 84% (16 in 19) in women; p 1.0, Group 2: 54%(7 in 13) in men and 65% (13 in 18) in women; p 0.5, Group 3: 75%(9 in 12) in men and 75%(12 in 16) in women; p 1.0). Conclusions: Although addition of metoprolol to amiodarone had a trend to lower rate of AF recurrence, neither metoprolol nor cilazapril provided statistically significant decrease in recurrence rates. None of the drug combinations are found to be related with sex in preventing AF recurrence. P31 Suboptimal Beta Blocker Dosing may Heighten the Risk of Cardiac Events in Women with Implantable Defibrillators Ashley N Biscardi, Jay H Curwin, Robert F Coyne, Uptal K Patel, John S Banas, Sherri Raquet, Karen Quinlan, Theresa Guarino, Stephen L Winters; Morristown Memorial Hosp, Morristown, NJ Introduction: Use of target doses of beta blockers (BB) in women, as well as men, who are post-myocardial infarction and/or suffering from heart failure improves survival independent of
17 E-56 Circulation Vol 111, No 4 February 2005 implantable defibrillator (ICD) therapy. However, whether concerns of side effects, especially excessive bradycardia, may preclude appropriate BB use in women with ICDs moreso than men is unknown. Thus, we assessed whether the pacing support feature of ICDs is associated with differences in BB usage in women and men. We also considered whether availability of atrial-based pacing increased the likelihood of appropriate BB use. Methods: BB therapy was evaluated in 312 ICD recipients [women -45; men - 267; single-chamber (S) - 228, dual-chamber (D) - 84] at follow-up over a 3 months period. S-ICDs were more commonly used: women -31 (69%), men -197 (74%) [p ns]. BBs were prescribed at the discretion of the patients primary cardiologists. Results: Indications for ICD therapy included: sustained ventricular arrhythmias-231; prophylactic-81. Primary structural diagnoses were: coronary artery disease (CAD)-255; cardiomyopathy -34; other-23. Overall BB use was not significantly different between women [36 (80%)] and men [234 ( 88%)]. The overall doses of comparable BB agents used did not differ. At follow-up only 9 (20%) women (D-ICD 6; S-ICD 3) were paced, 8 (89%) of whom were on BBs. Similarly 71 (27%) men (D-ICD 42; S-ICD 29) were paced at follow-up 62 (87%) of whom were on BBs. Of the remaining patients who were not paced, fewer women [28/36 ( 78 %)] than men [172/196 (88%)] were treated with BBs although the trend was not significant. Metoprolol (112) and carvedilol (97) were the most widely prescribed BBs; however, optimal daily mean doses were not approached in either women or men, irrespective of the type of ICD and whether or not pacing was documented at follow-up. Conclusions: 1. Beta blocker use is equivalent in female and male ICD recipients. 2. Bradycardia requiring pacing from ICDs does not appear to be a limiting factor to BB use in women or men. 3. Physician complacency with the protective benefits of shock therapy in women, as well as men, with ICD s may preclude adherence to treatment with target beta blocker doses and may heighten overall risk for adverse outcomes. P32 Outcomes in Women Following Coronary Artery Bypass Surgery: Results from the Rosetta-CABG Study Thao Huynh, Montreal General Hosp, Montreal, Canada; Karen Wou, Mark Eisenberg; Jewish General Hosp, Montreal, Canada Background: Coronary artery bypass surgery (CABG) is increasingly offered to sicker patients. It is unclear whether CABG is equally beneficial in both genders, since women are generally older with more co-morbid diseases. Methods and results: The ROSETTA-Registry was a prospective multicenter study examining the use of functional testing after CABG. There were 395 patients with 78 females (19.8%). Women were older (65.3 vs 62.2 years, p 0.02) and with more hypertensive patients (78.2% vs 59.3%, p 0.002) than in men. There was also a trend towards more diabetic mellitus among the women (35.9% vs 26.2%, p 0.09). More women required CABG for acute coronary syndromes (64.1% vs 49.2%, p 0.02). At 12-month, the composite clinical event pre-defined as death, non-fatal infarction, unstable angina occurred in 14.1% of the women vs 5.4% (p 0.01) in men. Percutaneous coronary intervention (PCI) was necessary in 9.0% of the women vs 2.2% for men (p 0.008). Conclusion: Women had significantly more clinical events and required more PCI following CABG. Physicians should be particularly vigilant in managing women following CABG, since these patients are at increased risk for adverse outcomes. CLINICAL OUTCOMES AT 12-MONTHS AFTER CABG Male (%) (n 317) Female (%) (n 78) P-Values Clinical Events Death Myocardial Infarction Unstable Angina NS Composite endpoint Inflammatory Atherosclerosis in Women Richard J Frink; Heart Rsch Foundation of Sacramento, Sacramento, CA Objective: To compare the pathologic substrate in men and women who died of acute coronary disease. The hearts of 19 women, mean age 70, and 64 men, mean age 56, were studied by injecting a colored barium gelatin mass into the coronary arteries, followed by dissection, decalcification, cutting at 2 3 mm and mounting all sections. On average, 86 coronary sections per heart were examined microscopically (total sections 7,143) using subserial sectioning. All microscopic sections were graded on basis of luminal stenosis (percent of cross sectional area), inflammatory infiltrates in the adventitia, calcification, atheroma formation and acute lesions. There was no significant difference in the frequency or severity of luminal stenosis between men and women. However, women showed significantly more inflammation, calcification, and atheroma formation. There was no significant difference in the frequency of coronary thrombosis, occlusive or non-occlusive, or ulcerated plaques without thrombosis between men and women. Conclusions: Active, destructive, inflammatory atherosclerosis resulting in more calcification and atheroma formation, is more widespread in women. Women harbor and survive the injurious agent causing atherosclerosis for a longer period of time than men, suggesting women are more resistant to the injurious agent. Active, inflammatory atherosclerosis in women is not associated with more frequent coronary thrombosis or ulcerated plaques without thrombosis. P33 RESULTS Males Females P Values # microscopic sections 5,479 1,664 Luminal stenosis % number of sections 50% 2, NS 50 80% 1, NS 80% 1, NS Inflammation 2, p Calcification p Atheroma formation 1, p Acute lesions NS Results of Bilateral Internal Thoracic Artery Grafting in Women Sandhya K Balaram, Ionnis K Toumpoulis, Joseph J DeRose, Jr., Daniel G Swistel; St. Luke s-roosevelt Hosp Cntr, New York, NY Introductions Studies have reported increased morbidity and mortality in women requiring coronary artery bypass surgery (CABG). Compared to men, women present at a later age with more diffuse disease and smaller target vessels. They typically receive fewer arterial bypass grafts and fewer grafts overall. The purpose of this study is to examine the outcome of using bilateral internal thoracic artery (BITA) grafts in women. Methods From January March 2002, 350 women underwent isolated coronary artery revascularization using bilateral internal mammary grafts at our institution. These procedures were performed by a single surgeon in an unselected population of women with multi-vessel coronary artery disease. Survival data was obtained from the National Death Index. Kaplan-Meier analysis was performed to assess long-term survival. Results The mean age of the patients was years. Comparison of preoperative characteristics showed the majority (80.6% or 282/350) of women had three-vessel disease with 74% (258/350) presenting with unstable angina. Many patients were operated on an urgent (54% or 190/350) or emergent (11% or 38/350) basis. The average ejection fraction was 30 50% with 38/350 (11%) less than 30%. Co-morbidities included COPD in 12% (42/350), PVD in 20% (71/350), CHF in 20% (71/350) and diabetes mellitus in 48.3% (169/350). At surgery, the average number of bypasses was The 30-day mortality was 2.6% (9/350). Complications included a stroke rate of 2.3% (8/350), sternal wound infection in 2.3%(8 of 350), bleeding requiring reoperation in 1.7%(6/350), and renal failure in 0.9% (3/350). The most common complication of respiratory failure occurred in 3.7% (13 /350). Our mean follow-up was years. The 5-year survival was % with a 10-year survival of %. Conclusion Despite a known increased risk of coronary revascularization among women, we demonstrate with this study that use of BITA grafts results in comparable peri-operative outcomes and good long-term survival. Symptom Clusters in Women with Acute Myocardial Infarction Anne G Rosenfeld, Nancy A Perrin, Blair G Darney; Oregon Health & Science Univeristy, Portland, OR Introduction: Women s symptoms of acute myocardial infarction (AMI) most often occur in groups or clusters rather than as single, isolated symptoms. Further, women s AMI symptoms differ from those of men and are often labeled as atypical. Understanding how symptoms cluster as groups may aid in the recognition of AMI by both women and their health providers. Purpose: This exploratory pilot study had 2 research questions: 1. Are there groups of women who experience similar sets of symptoms?; 2. Is cluster membership related to treatmentseeking delay time and neuroticism? Methods: A secondary data analysis was performed on data from the parent study of treatment-seeking delay in women with AMI and predictors of delay patterns, including neuroticism. Information about the presence of symptoms was obtained through interviews of 51 women hospitalized for AMI, using the 15-item Myocardial Infarction Symptom Survey. Cluster analysis, a multivariate exploratory statistical technique, was used to determine groups or clusters of women with similar patterns of symptoms. The clusters were then compared on treatment-seeking delay time and neuroticism. An initial cluster analysis was done to group the symptoms into 6 categories: chest pain (all sites), chest discomfort, shortness of breath, nausea & vomiting, indigestion & epigastric discomfort (GI symptoms), and fatigue. Results: Agglomeration coefficients and interpretability were used to select a 5 cluster solution. These clusters were labeled as: 1. chest discomfort and fatigue (n 11); 2. shortness of breath, chest pain, and fatigue (n 9), 3. all symptoms (n 21); 4. absence or low level of GI symptoms (n 6); 5. chest pain, nausea & vomiting, fatigue, and GI symptoms (n 4). ANOVA revealed that the 5 clusters were not significantly different on delay time and neuroticism. However, women in cluster 4 had the shortest median delay time (.63 hours, compared to a range of in the other clusters) and the highest mean neuroticism scores. Conclusions: AMI is manifested by differing clusters of symptoms. Cluster analysis can be used to find groups of women who experience different clusters of AMI symptoms. Understanding the various patterns of symptoms adds helpful clarification of women s clinical presentation. Women s Interpretation of Prodromal Cardiac Symptoms Lynne A Jensen, Debra K Moser; Univ of Kentucky, Lexington, KY Introduction: Cardiovascular disease (CVD) is the leading cause of death among women in the United States. Emerging evidence suggests that women have a number of prodromal symptoms for weeks to months before developing an acute cardiac event, and that these symptoms often are not typical of cardiac disease. Specifically, fatigue, sleep difficulties and shortness of breath, but not chest pain are common prodromal symptoms. Objective: The P34 P35 P36
18 Poster Presentations E-57 purpose of this study was to describe women s perceptions of their prodromal cardiac symptoms. Methods: A qualitative descriptive study was conducted in nine Caucasian women (age range 42 72) with known ischemic cardiac disease. One-on-one interviews were audiotaped and transcribed verbatim. The transcripts were analyzed to identify recurrent themes. Results: Participants described experiencing: fatigue, shortness of breath, tight arm pain and just not feeling good. Participants had these prodromal symptoms for a few months to years before being diagnosed with cardiac disease. For most participants, the diagnosis was made after they suffered an acute myocardial infarction (AMI). Three major themes related to these women s experience of prodromal symptoms were identified: 1) lack of their own knowledge about symptoms of heart disease or AMI; 2) failure to describe their own symptoms as being related to the heart; and 3) failure of health care providers to discuss symptoms of heart disease or attribute the women s symptoms to heart disease. All respondents failed to describe their symptoms as being related to their heart even though they knew something was wrong. Most respondents stated their health care provider never discussed their risk for heart disease and when they described their symptoms, were told they were not related to their heart. Over half of the women had family members insist on further evaluation of their symptoms. Conclusion: Women often do not experience typical cardiac symptoms. Both patient and health care provider factors contributed to women s delay in seeking treatment for their prodromal symptoms of heart disease. Education of both women and health care providers is necessary to decrease delay in seeking care and increase timely treatment of symptoms. Characterization of Acute Myocardial Infarction in Young Women Pao-Hsien Chu, Chip-Jin Ng, Dah-Chin Yan, Jih-Chang Chen; Chung Gang Memorial Hosp and Univ, Taipei, Taiwan Republic of China Purpose: This study assessed the characteristics between young women and men ( 41 years) after acute myocardial infarction (AMI). Method: A retrospective study was conducted of 178 patients (mean age, 36 4 years), 11(7%) women and 167 (93%) men, admitted between 1992 and 2002 in a medical center, Chang Gung Memorial Hospital. During their hospital stay and afterward, assessment was made of: risk factors, treatment used, pattern of coronary artery obstruction, complications in cardiac function, and factors related to subsequent major events. Results: The most presentation of AMI in young women was chest pain (87%) and ST-elevated infarction. Females had a higher Killip classification (p 0.006), despite a shorter history of smoking and drinking (p ), and lower hemoglobin levels (p 0.001) than males did. Sudden death tended to be more frequent in females and worse initial cardiac function (p 0.016) than in males. Female patients were treated less aggressively than male patients, including primary percutaneous coronary intervention, thrombolytic treatment (31% in men vs. 0% in women), bypass graft and medications. Both initial and follow up angiograms demonstrated a lower severity of injury in women than in men. Conclusion: Women with premature coronary disease may differ from men in risk factors such as smoking and drinking, as well as differ in severity of disease, type and aggressiveness of treatments, and prognosis, depending on gender. P37 is the benefits and risk factors of cardiac surgical and medical interventions for senior women in the community with cardiac problems, particularly with heart failures. This is partly because major cardiac clinical trials exclude patients 65 years and older, have a much smaller proportion of women, or neglect to analyze outcomes by age and gender. Given the elevated risks of mortality and morbidity in women with heart failures and undergoing invasive interventions, a method to quantify the risks and to predict health outcomes is needed. Frailty has been used in many studies as a tool to identify individuals at risk, to predict health outcomes and to target interventions. About 6,200 seniors (28% man, 72% women) who were receiving home care services from community-based agencies were assessed using the Minimum Data Set for Home Care (MDS-HC) at 3 time points in this longitudinal study (which yielded 14,000 individual assessments). A frailty scale and several functional outcome measures based on the MDS, together with comorbidity, obesity, social support, and demographic factors, were used as independent variables to predict mortality and institutionalization in senior women and men with ACS. The applicability of this frailty scale in predicting outcomes for women and men in the elderly cardiac population will be discussed. P40 One-year Outcomes Following Myocardial Infarction in Young to Middle-aged Women Treated in a Rural Midwest Community Health Center Ana M Schaper, Sharon I Barnhart, Michelle A Mathiason, Vicki L McHugh, Kwame O Akosah; Gundersen Lutheran Health System, La Crosse, WI A retrospective chart review was conducted on 147 women, age 65 years (mean age 55 8) presenting with an MI in a two-year time period. In this cohort, 113 subjects (77%) had no history of CAD. Rates of risk factors were high: history of smoking, 70% (103/147); hypertension, 63% (92/147); family history, 52% (76/147); and 70% (103/147) were overweight or obese. The triglyceride level (177 mg/dl 102) was the only mean lipid value not at an acceptable level. Eighty-eight women did not have a history of CAD or a CAD equivalent. Of this group, 80 individuals had sufficient data for risk stratification per NCEP III based on risk factors prior to their MI. Only 10% (8/80) of women would have qualified for medical management and 18% (14/80) for therapeutic lifestyle changes, but 49% (39/80) were identified with metabolic syndrome. Kaplan-Meier curves indicated there was a significant difference in event-free survival between women with a history of CAD or diabetes mellitus and those without (p 0.003). In this cohort, 12 women died during the initial hospitalization. Of the 135 women followed at 1-year, 54 were readmitted for a cardiac reason (chest pain, MI, revascularization procedure). At one-year, medication use was available for 87 women. Women discharged on an ACEI or ARB, and lipid therapy remained on these meds at 1-year. Of the women discharged on a beta blocker, 90% (75/83) were taking a beta blocker at 1-year. At 1-year, total and LDL cholesterol levels were lower while HDL levels increased, but there was no change in triglyceride. These findings suggest that young to middle-aged women should be routinely assessed for metabolic syndrome, and aggressively managed to address all risk factors. P38 In-Stent Restenosis: Predictors of Subsequent Restenosis after Sirolimus Eluting Stent Implantation. An Angiographic Study Paola Colombo, Irene Bossi, Giuseppe Bruschi, Giacomo Piccalò, Pedro Silva, Silvio Klugmann; Niguarda Ca Granda Hosp, Milan, Italy Background: The rate of recurrent restenosis after repeated percutaneous procedures for in-stent restenosis (ISR) is high, ranging from 20 to 80 % according to the angiographic pattern of restenotic lesions. Sirolimus eluting stent (SES) can be of potential utility for treatment of ISR Methods: Between July 2002 and Jenuary 2004, 67 ISR (19 recurrent restenosis) were treated with SES implantation in 61 consecutive patients (46 males, mean age 63 11; 20 diabetic). ISR was in a native vessel in 59 cases (33 LAD, 11 LCX, 12 RCA, 3 other segment) and in a saphenous vein graft (SVG) in 8 cases. Mean ISR length measured by QCA was mm. Restenotic lesions pattern was defined as focal ( 10mm), diffuse ( 10 mm within the stent margins), proliferative ( 10 mm beyond the stent margins) or total occlusion and were present in 13%, 57%,18%, and 12% respectively. ISR reference diameter was mm. A total of 79 SES were implanted (18% multiple stents) with a mean stented segment length of mm. In 68% of cases the total previously stented segment was covered with the SES. Post SES implantation MLD was mm. During the in-hospital stay two patients died, one because of cardiogenic shock not related to the procedure and the other for non cardiac causes. Results: At six-month ( days) follow up MACE included 1 MI due to subacute stent thrombosis at day 91, treated percutaneously with primary PCI, 7 TLR procedures (10.3%) and 7 repeated procedures for non TLR lesions. At angiographic follow up, available in 50 pts (55 lesions), late loss averaged in-stent. Recurrent restenosis was observed in 9 patients, with a focal pattern in six cases and total occlusion in two out of four SVGs. Four patients with recurrent restenosis after SES implantataion were diabetic. Univariate correlates of recurrent restenosis after SES implantation for ISR were the stented segment length (p 0.001), multiple stents implantation (p 0.05) and SVG location (p 0.005). Conclusion: Sirolimus eluting stent implantation to treat in-stent restenosis appears safe and seems to significantly reduce the rate of hyperplasia and recurrent restenosis in this high risk subset of diffuse restenotic lesions. Frailty as an Indicator for Risk Stratification and Outcomes of Senior Women and Men with Acute Coronary Syndromes Erin Y Tjam, Stuart J Smith, St. Mary s General Hosp, Kitchener, Canada; John P Hirdes, Univ of Waterloo, Waterloo, Canada; Bruce Arai, Wilfrid Laurier Univ, Waterloo, Canada; Jeff Poss; Univ of Waterloo, Waterloo, Canada Individuals with acute coronary syndromes (ACS) who require active interventions are becoming increasingly diverse with respect to their age, gender and comorbidity status. What is unclear P39 P41 Thoracoabdominal Aortic Aneurysm Repair in Women: How Do They Do? Tam T Huynh, Charles C Miller, III, Hazim J Safi, Anthony L Estrera, Eyal E Porat, Ali Azizzadeh, Jennifer S Goodrick; Univ of Texas Med Sch at Houston, Houston, TX Introduction: Female patients with coronary artery disease have long been known to have a worse prognosis than males. Women have also been observed to suffer aortic rupture at smaller aneurysm diameters than men. We evaluated cardiovascular risk factors and outcome in women as compared to men following thoracoabdominal aortic repair. Methods: Between 1991 and 2003, we repaired 1004 thoracic / thoracoabdominal aortas, 373 (37.2%) in females, 631 (62.8%) in males. We compared known cardiovascular risk factors (hypertension, smoking status, vascular disease history, etc.) between women and men, and computed genderadjusted estimates of 30-day mortality and neurologic deficit risk. Results: Women had less chronic aortic dissection (15 vs. 32%, p 0.001) and less prior aortic (6 vs. 18%, p 0.001) and coronary (10 vs. 18%, p 0.001) surgery than men. Women reported more current smoking (38 vs. 28%, p 0.001) and had more COPD (36 vs. 30%, p 0.05). No significant differences in mortality or paraplegia between genders were apparent in univariate analysis. In multivariable analysis, no main effects of gender were noted for postoperative neurologic deficit or for mortality, however, a significant interaction effect of gender with crossclamp time was present for mortality (p 0.05). With this effect, women appeared to be at greater risk for mortality than men beyond 45 minutes of aortic crossclamp time. Conclusion: The major new finding in this study is that women may be less tolerant to extended aortic crossclamp times than men. Further research should investigate the mechanisms of this effect. In the meantime, efforts should be made to minimize crossclamp time in women.
19 E-58 Circulation Vol 111, No 4 February 2005 P42 Is Marriage as Good for Women as Men? The Impact of Marital Status on Social Support at the Time of an Acute Coronary Syndrome Linda S Garavalia, W.S. Carlos Poston, II, Univ of Missouri-Kansas City, Kansas City, MO; Carole Decker, Mid America Heart Institute, Kansas City, MO; Phil Jones, Mid American Heart Institute, Kansas City, MO; Kristen K O Byrne, Univ of Kansas, Lawrence, KS; John Spertus; Mid America Heart Institute, Kansas City, MO Background: Social support is associated with mortality after Acute Coronary Syndrome (ACS). Although being married is considered to be a strong indicator of higher social support, the relationship between marriage and social support may differ between men and women due to differences in their roles within a relationship. To address this, we examined the influence of marital status on social support by gender in a consecutive cohort of ACS patients. Methods: We prospectively enrolled 1199 ACS patients from 3/01 11/02, of whom, marital status and social support scores were available for Social support at the time of hospitalization was quantified with the ENRICHD Social Support Inventory (ESSI); higher scores indicate better social support. Gender differences in ESSI scores were examined with ANCOVAs adjusted for age. Results: At the time of ACS, social support differed for female and male patients ( females & males; p ). Married ACS patients reported significantly greater social support than unmarried patients, regardless of gender (figure). However, a marked interaction between gender and marital status was observed. Unmarried females had greater social support scores than unmarried males, whereas married females had lower ESSI scores than married males (p-value for marital status X gender interaction ). Conclusions: Although married patients have better social support, significant differences exist between genders within strata of marital status. Identifying determinants of married females lower improvement in social support may be important in examining potential differences in long-term outcomes. depressive symptoms following a myocardial infarction (MI) than men, and these symptoms may more detrimentally affect women s prognosis. The objective of this study was to longitudinally examine the course of depressive symptoms among women and men for one year following a cardiac event, and the effect of multi-component cardiac rehabilitation (CR) on this trajectory. 913 unstable angina (UA) and MI patients (590 men, 323 women) were recruited from 12 coronary units, with follow-up at 6 and 12 months. Measures included sociodemographics, CR participation, medication usage, and Beck Depression Inventory (BDI). Longitudinal analysis was conducted using SAS PROC MIXED. Women experience significantly greater depressive symptoms than men across the year of recovery (ps.001). At baseline there were 277 (31.3%) participants with elevated depressive symptoms (BDI 10), 131 (25.2%) at 6 months, and 107 (21.7%) at 1 year. Overall, approximately 5% were taking an anti-depressant, and 20% attended CR. CR did not have an effect on depressive symptoms over time, and while fewer women than men attended CR, those women who attended were significantly more depressed than women non-attenders (interaction, p.01). Participants with greater depressive symptoms participated in significantly fewer CR exercise sessions (p.02). The longitudinal analysis revealed that all respondents experienced reduced depressive symptoms over time (p.04), but younger, UA participants with lower family income fared worst (ps.001). Women experience a greater burden of depression in the year following UA or MI. Over 1/5 of respondents still experienced elevated depressive symptoms one year later, and respondents were under-treated. Depressed female patients may seek the social support that can be found in CR, although CR was not effective in reducing depressive symptoms. This could be due to depressed participants lower exercise adherence, leaving room to capitalize on the psychological benefits of exercise, and the psychosocial services offered in CR. P45 Improvements in Psychosocial Outcomes for Women Enrolled in Phase II and Community-Based Cardiac Rehabilitation: The Women s Initiative to Save Heart (WISH) Study Nieca Goldberg, Lenox Hill Hosp, New York, NY; Jonathan N Tobin, Clinical Directors Network, New York, NY; Barrie Huberman, Lenox Hill Hosp, New York, NY; Mirabai Holland, 92nd Street YM-YWCA, New York, NY; Alison Dunn; Lenox Hill Hosp, New York, NY Determinants of Depression in Women and Men at Entry into a Cardiovascular Risk Reduction Program Deborah Da Costa, Ilka Lowensteyn, Kaberi Dasgupta, Steven A Grover; McGill Univ Health Cntr, Montreal, Canada Depression has been shown to predict morbidity and mortality among individuals with coronary heart disease (CHD) and recently has been associated with increased risk of developing CHD in both women and men. Studies examining the prevalence and determinants of depression among patients entering a cardiovascular risk reduction (CRR) program have either been restricted to men or analyzed both genders together. Moreover, the extent to which routinely assessed CHD risk factors are predictive of depressed mood in women remains unclear. Forty-three women (mean age 57.8; SD 9.1) and 88 men (mean age 59.5; SD 11.6) entering a multidisciplinary outpatient CRR program completed the Beck Depression Inventory (BDI) and the Perceived Stress Scale (PSS). Demographics and CHD risk factors were also measured at program entry. Thirty-five percent of women (15 of 43) reported depressive symptoms (30.2% mild, 2.3% moderate, 2.3% severe). A similar rate (37.5%, 33 of 88) of depressive symptoms was reported by men (23.9% mild, 8% moderate, 5.7% severe). Overall perceived stress scores were moderately high in women (mean 16.0; SD 6.4) and men (mean 14.5; SD 7.3). Univariate analyses showed that depressed women were younger (p.034), had a higher body mass index (p.009), reported higher perceived stress (p.001) and tended to have lower HDL levels (p.09) compared to nondepressed women. Compared to nondepressed men, depressed men scored significantly higher on perceived stress (p.001) and were more likely to be smokers (p.053). In a multivariate regression model, controlling for presence of CVD, only younger age (p.002) and increased perceived stress (p.001) remained significant independent predictors of elevated depressed mood for women. Among men, only elevated stress (p.001) remained a significant independent predictor of depressed mood. Our results demonstrate a high prevalence of depressive symptoms among women and men entering a CRR program. With the exception of younger age for women, readily assessed CHD risk factors in the clinic are poor determinants of depressed mood in both genders, reinforcing the need for routine screening of depressed mood in order to identify and tailor behavioral modification programs to alleviate depressive symptoms. Depression Longitudinally Post-Cardiac Event Sherry L Grace, York Univ and Toronto General Rsch Institute, Toronto, Canada; Susan E Abbey, Univ Health Network and Univ of Toronto, Toronto, Canada; Ruxandra Pinto, Univ Health Network, Toronto, Canada; Zachary M Shnek, Credit Valley Hosp and Univ of Toronto, Toronto, Canada; Jane Irvine, York Univ and Univ Health Network, Toronto, Canada; Donna E Stewart; Univ Health Network and Univ of Toronto, Toronto, Canada Research has linked depression to cardiac mortality, and shown a high burden of persistent depressive symptoms among cardiac patients. Moreover, women generally experience greater P43 P44 Introduction: Women with coronary heart disease (CHD) have lower rates of initiation and adherence to cardiac rehabilitation programs compared to men. Although women have higher levels of risk factors and lower functional capacity. Following rehabilitation men and women have similar improvements in physiologic outcomes: Exercise tolerance (EXT), blood pressure (BP), Heart rate (HR), quality of life (QOL), depression, anxiety and other psychosocial indices. The Women s Initiative to Save Heart evaluated women s compliance to Phase II and community-based cardiac rehabilitation for two years. Methods: Thirty women with CHD (mean age years, 73% white, 17% Black, 10% other) were randomized into a traditional Phase II coed cardiac rehabilitation (CR) program (n 14) or a women s only program (n 16) using a low impact aerobics class as the exercise component. All women had experienced an index cardiac event, including coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention or chronic angina. In addition to cardiovascular outcomes, psychosocial outcomes including: depression (Beck Depression Inventory BDI-II), Anxiety (Spielberger State and Trait Anxiety) and QOL (SF-12 MCS, PCS) were measured at enrollment and 3, 6, 12 and 24 months after randomization. Results: Overall, for all women enrolled and followed from baseline to six months, statistically significant improvements were observed for QOL/physical symptoms (p 0.06), QOL/mental symptoms (p 0.05), depression (p 0.01), and state anxiety (p 0.05). Twelve month follow-up suggests declines to baseline levels over six months. Conclusions: Structured CR shows reductions in levels of depression, anxiety and QOL/physical and mental symptoms. Interventions that continue after Phase II cardiac rehabilitation are needed to preserve the improvements in anxiety and quality of life that female participants experience in structured exercise programs. P46 Sex Differences in Predictors of Depression Post Coronary Artery Bypass Graft Surgery Rachel H Mitchell, Emma Robertson, Paula Harvey, Gary Rodin, Robert Nolan, Univ Health Network, Toronto, Canada; Sarah Romans, Cntr for Rsch in Women s Health, Toronto, Canada; Beth Abramson, St. Michael s Hosp, Toronto, Canada; Stephanie Brister, Donna Stewart; Univ Health Network, Toronto, Canada Background: Despite recent advances, there are gaps in our knowledge about the risks and benefits of coronary artery bypass graft (CABG) surgery in women. Limited research indicates that women, as compared to men, experience a worsening of depressive symptoms after CABG surgery. The constructs of the cognitive adaptation theory, self-esteem, optimism and mastery, are believed to be protective of mental health after a life-threatening cardiac event, such as CABG surgery. Objective: This study investigates sex differences in predictors of depression post CABG surgery, with a focus on sex differences in cognitive adaptation. Methods: We prospectively followed 130 consecutive patients (69 men, 60 women) undergoing elective, isolated, first CABG surgery between July 2003 and April Patients were interviewed 28 days before surgery and between 6 to12 weeks after surgery. Patients completed the Beck Depression Inventory (BDI), the ENRICHD Social Support Inventory (ESSI), and the Cognitive Adaptation Theory Index (CATI). Relevant medical data were retrieved from charts and a Total Risk Score (TRS) was calculated for each patient. Results: Women at baseline, were less likely than men to be married (P 0.003), and earn a family income of $19,000 (P 0.003). Women were also at a greater risk of operative mortality than men (P 0.001). Women were more depressed than men (P 0.003), but there were no significant differences on the ESSI or CATI. Hierarchical regression analysis with the first step including age, sex, income, race, anti-depressant use, baseline BDI and TRS score, and the second step including the CATI and ESSI competing for entry, revealed the CATI as an independent and significant predictor of depression post CABG (P 0.02). Sex, however, was not a significant predictor. Conclusions: Women do not differ from men on pre CABG markers of cognitive adaptation such as mastery and control. However, the CATI is an independent predictor of depression post CABG and may serve as a useful screening tool for both men and women at risk for depression after CABG
20 Poster Presentations E-59 surgery. Future study should be directed towards understanding sex differences in predictors of depression during the convalescent period of CABG surgery. Depression; The Gender Specific Consequence of Recovery in Women Following an Acute Myocardial Infarction Colleen M Norris, Univ of Alberta, Edmonton, Canada; Louise Pilote; Montreal General Hosp, Montreal, Canada Background: Several Studies report that women with coronary artery disease (CAD) have a poorer prognosis that men and suggest that depressive symptoms, may be contributing factors. Results of our recent study using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database, comparing the health related quality of life (HRQOL) outcomes of patients following treatment for CAD, demonstrated that women reported worse HRQOL at one-year follow-up compared to men. The objective of this study was to examine the gender differences in depressive symptoms, as they relate to HRQOL outcomes in a prospective cohort of individuals after acute myocardial infarction (AMI). Methods: Patients with documented AMI, admitted to 5 tertiary care and 5 community hospitals in Quebec were recruited at within 2 3 days of admission. Trained nurses collected demographic and clinical information from medical records and patients completed a mailed questionnaire that included the SF36 physical (PCS), and mental component summary (MCS) scores, and Beck Depression Inventory at baseline and the one-year anniversary of their admission for AMI. Results: Of the 587 study subjects recruited, 486 (82%) completed the one-year follow-up questionnaire. Results showed that females had significantly worse PCS and MCS QOL at baseline and one-year follow-up compared to the males. While there was no significant difference in the mean Beck depression scores at baseline, the mean one-year Beck scores were significantly higher ( p 0.01) for females (10.02 sd 8.23) compared to males (7.78 sd 8.01) indicating more reported depressive symtomatology at one year. Multivariate analyses adjusting for clinical differences, baseline QOL, and baseline and one-year Beck scores, showed significant gender-related differences in the PCS scores. However no gender-related differences in the 1-year MCS remained following adjustment. This would suggest that gender differences in the 1-year reported mental composite summary QOL result in part from gender-related differences in 1-year levels of depression. More reported depression in women at 1-year may be a consequence of gender-specific recovery from an AMI and requires further investigation. P48 Delay in Seeking Care: Comparison of Symptoms and Self-Treatment Activities between Q-Wave and Non-Q Wave Myocardial Infarction Patients Jill R Quinn; Univ of Rochester, Rochester, NY Recent evidence has indicated that patients experiencing an acute non-q wave myocardial infarction (NQWMI) have an equal or greater risk of morbidity and mortality compared to patients experiencing an acute Q-wave myocardial infarction (QWMI). In examining reasons for delay in seeking care for symptoms of acute myocardial infarction, it was found that type of AMI experienced (QWMI versus NQWMI) was a significant predictor of time to seek care (p.027). Symptoms and self-treatment activities were examined in 78 QWMI subjects and 22 NQWMI subjects. Subjects in the NQWMI group included those subjects diagnosed with Non-ST segment elevated MI (NSTEMI), who until the recent development of troponin markers for AMI were diagnosed with unstable angina and not included in studies examining delay. Subjects who experienced a NQWMI delayed in seeking emergency care significantly longer (mean 24 hours vs 9.7 hours) than those subjects who experienced a QWMI (p.006). More NQWMI subjects than QWMI subjects reported having similar symptoms before this episode (59% vs 32%), had a history of angina (41% vs 8%), and a history of hyperlipidemia (77% vs 53%). Only two symptoms were reported to be different between the QWMI and NQWMI groups. Significantly more NQWMI subjects reported their discomfort feeling like a band across their chest (57% vs 24%); whereas, significantly more QWMI subjects reported vomiting (26% vs 0 %). More NQWMI subjects than QWMI subjects reported trying some activity to relieve their symptoms before seeking emergency care, such as turning in bed (62% vs 30%) and taking sublingual nitroglycerin (38% vs 11%). No significant differences were found for either gender or age between the QWMI and NQWMI groups. Conclusion: NQWMI subjects are more likely to have a history of angina and CAD, and attempt to self-treat before seeking care for symptoms of AMI, resulting in delay in seeking care. Patients with history of angina and CAD are more likely to self-treat because they have been told by providers to take SL NTG for symptoms and will wait to see if symptoms are relieved before seeking care. Providers need to re-assess if education that includes strategies to try to alleviate symptoms before seeking care by patients with history of CAD and angina is best for patient outcomes. P49 The Relationship between Employment Status and Women s Physical and Psychological Health Sari D Hopson, Sheree Marshall-Williams; Cntrs for Disease Control and Prevention, Atlanta, GA There have been conflicting reports in the literature about the relationship of employment status to women s health. The objective of this study was to examine the relationship of employment status to physical and mental health. The health conditions examined were self-reported high blood pressure (HBP) and Cardiovascular Disease (CVD), which includes Myocardial Infarction, Angina, and Stroke. The mental health condition examined was self-perceived general mental health, which includes stress, depression, and problems with emotions. Data from 34,879 African American and White American female respondents, ages from the 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed. Women were categorized into three groups based on their employment status: Group 1 (employed); Group 2 (unemployed-involuntarily) and Group 3 (homemaker). Data were weighted to state population estimates and analyzed using SUDAAN 8.0 a statistical program designed to manipulate data P47 from complex surveys. Univariate and multivariate (logistic regression) procedures were used in the analysis. Unemployed women reported the worst physical health (self-reported HBP 28%; CVD 6%) and poor mental health (mean # of poor mental health days in last 30 days 9). Employed women reported the best physical health, (self-reported HBP 19%; CVD 2%) and mental health (4 poor mental health days). Homemakers, generally had health conditions comparable to the employed women, with the exception of CVD. When comparing homemakers to employed women the odds of reporting a CVD diagnosis was 1.7 times higher among homemakers. Work status independently contributed to CVD and mental health, but not to HBP. The findings differed significantly by race, with homemakers and unemployment status having a more negative impact on African American women s physical health. Findings corroborate previous epidemiological and sociological research among women, suggesting that employment is compensatory and is associated with positive health conditions. P50 Women s Cardiovascular Health Initiative Cognitive Behavioural Therapy Workshop for Depression Lina Jobanputra, Mireille Landry, Jennifer A Price; Women s College Ambulatory Care Cntr, Toronto, Canada The Cognitive Behavioural Therapy (CBT) workshop was created in response to the ongoing need for psychological support around the issue of depression and anxiety, as reported by the women participating in exercise programs at the Women s Cardiovascular Health Initiative. From May 2002 to April 2004, 99 out of 188 women assessed for entry into a six-month cardiac rehabilitation (CR) (46) or three-month primary prevention program (53) self-reported symptoms of anxiety (54) or depression (45). Despite the high percentage (52.6%) of women experiencing these symptoms, relatively few women were currently receiving standard treatment for depression (SSRI & cognitive therapy). The presence of anxiety and depression after a coronary artery event is a predictor of cardiac morbidity and mortality, and is cited as a common reason why women spend less time in physical activities and are less likely to participate or complete CR programs. Properly managing depression and anxiety in these patients is important in achieving maximum benefit from secondary prevention strategies. Over this two year time period, 3 eight-week CBT workshops, with14 women enrolled in total, were completed. The group format allowed each participant to practice CBT principles in a supportive setting. Participants filled out a Beck Depression Inventory weekly so that their mood could be carefully monitored throughout the program. Sessions were highly structured with an expectation that the participants complete weekly readings and homework assignments. Participants expressed their satisfaction with workshop and described significant improvements to the way they coped with stressful life situations. Each participant described improvements to their mood. This intervention was successful in reducing patients symptoms of depression. The CBT model would suggest that this change in mood was due to the changes in thoughts and behaviours that took place during the eight-week workshop. Continuing to offer CBT workshops will help patients deal with symptoms of depression, anxiety and chronic stress, making them better able to participate fully in CR. Withdrawn P52 Gender Differences in the Effects of Physical and Emotional Symptoms on Health-Related Quality of Life in Patients with Heart Failure Seongkum Heo, Debra K Moser, Terry A Lennie, Misook L Chung; Univ of Kentucky, Lexington, KY Background: Physical and emotional symptoms are common in heart failure (HF). These symptoms are theorized to affect health-related quality of life (HRQOL), but their impact is likely mediated or moderated by a number of variables not yet explored. Moreover, gender may affect these relationships. Methods and Results: The purpose of this study was to determine whether there are gender differences in the effects of physical (i.e. dyspnea and fatigue) and emotional symptoms (i.e. anxiety, depression) on HRQOL. Also, based on a theoretical model of HRQOL, the mediator effect of functional status and the moderator effects of perceived control and health perception on the relationship between symptoms and HRQOL in women and men were tested. Data from 51 men (age 74 10, NYHA 2.5.6) and 47 women (age 72 11, NYHA 2.7.6) with HF were analyzed using regression analyses techniques. There were no gender differences in physical or emotional symptoms, or HRQOL, but there were substantial gender differences in models of HRQOL. Both physical and emotional symptoms were related to HRQOL in men and women. However, in women physical symptoms were more highly correlated with HRQOL than anxiety or depression (standardized beta (SB) -.63,.46,.49, respectively), while in men physical and emotional symptoms affected HRQOL to a similar degree (SB -.44,.49,.52, respectively). Functional status mediated only the effects of anxiety and depression on HRQOL only in women. Health perception moderated only the effect of anxiety on HRQOL only in men. Perceived control did not moderate any effect of physical or emotional symptoms on HRQOL. Conclusion: Although there were no gender differences in symptom status or HRQOL, there were gender differences in the dynamic relationships among variables related to HRQOL. The effect of symptom status on HRQOL in direct relationships was changed when the impact of moderating or mediating variables was considered. Therefore, it is necessary to consider both direct and indirect relationships among relevant variables when attempting to model HRQOL. P51