Korean Cardiology-Related Societies Joint Scientific Congress 2014 Women's Heart Disease Data From Chest Pain in KoRean women S registry (KoROSE) Study Seong-Mi Park, M.D. Cardiovascular Center, Anam Hospital Korea University College of Medicine
F/60, Chest pain, Mild HTN
Prevalence of cardiovascular disease in adults 20 years of age by age and sex (National Health and Nutrition Examination Survey: 2005 2008) Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute. These data include coronary heart disease, heart failure, stroke, and hypertension.
Annual number of adults having diagnosed heart attack or fatal coronary heart disease (Atherosclerosis Risk in Communities Surveillance: 1987 2004 and Cardiovascular Health Study: 1989 2004)
Cardiovascular disease mortality trends for males and females, United States: 1979-2007 American Heart Association. Heart and Stroke Statistics 2011
2011 Korean Statistics 103.4 117.7
순환기계통질환의성별사망률추이, 2000-2010
Female to male ratio of prevalence of cardiovascular disease
Red Alert on Women s Hearts,2009,ESC
Gender Gap in Ischemic Heart Disease Differences in cardiovascular risk factors Difference in symptom presentation Female specific pathophysiology Low diagnostic accuracy of tests Less referral Less aggressive management Menopause Longer survival in female
Needs for Women s Heart Disease Studies in Korea
2012. 5.24 심장학회이사회에서여성심장질환연구회설립승인됨 목적 : 본회는여성심장질환과관련된학술연구의발전과질환의예방및회원상호간의친목도모를목적으로한다. 사업 1) 연수강좌, 집담회및강연회개최, 2) 여성심장질환관련도서발간 3) 국내외관련학술단체와의학술교류, 4) 여성심장질환의예방, 관리및홍보에관한사업 5) 회원상호간의친목과관련사업
Chest Pain in KoRean women S registry KoROSE study ( 가칭 ) Multicenter study To evaluate Korean women with chest pain suspected ischemic heart disease in outpatient clinic in diagnostic testing, management as well as understanding of the characteristics of patients with and without CAD
2011 년 4 월 1 일부터등록시작 2011. 12 추계심장학회에서심장학회내연구사업으로승인됨
고대안암심완주, 이화여대신길자서울대김명아, 서울대김용진연세대홍그루, 경희대손일석강남차조윤경, 고대안암박성미한림대김성은, 을지대박지영고대구로나진오, 고대안암김미나, 김수아, 서울대김학령 동국대이무용 한림대홍경순 가천대신미승인하대신성희 충남대박재형 고대안산김용현분당차양우인부천세종김경희한림대박미영 계명대조윤경 전남대윤현주 고신대조경임
2013 대한심장학회추계학술대회 1. Women Specific Predictors of Obstructive Coronary Artery Diesease in Symptomatic Women ( 서울대김학령 / 김명아 ) 2. Chest pain in women patients with normal coronary arteriograms ( 서울대김경희 / 김명아 ) 3. Clinical value of treadmill test in Korean women with chest pain ( 고려대김용현 / 가천대신미승 ) 4. Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction during Dobutamine Stress Echocardiography in Women with Chest Pain ( 고려대박성미 / 심완주 ) 5. Diagnostic Accuracy of Dobutamine Stress Echocardiography in Korean Women with Chest Pain ( 고려대박성미 / 김완주 ) 6. Higher frequency of coronary vasospasm and coronary atherosclerosis in depressed women with chest pain ( 고신대조경임 / 고려대심완주 ) 7. Relationship between depression and QTc interval in female patients with suspected coronary artery disease ( 고신대조경임 / 한림대홍경순 )
Reasons for catheterization Chest pain 98% Shortness of breath 20% Palpitation 15% Syncope 7% Headache 7% Other (e.g fatigue, dizziness, nausea, EKG change) CAD > 50% stenosis Cardiovascular Center, Sejong General Hospital
Diagnosis (non-cad) Angina pectoris with fixed lesion Vasospastic angina Microvascular angina Musculoskeletal problem GI disorder Pychologic disorder Myocardial infarction Arrythmia HCMP Coronary AV fistula Others Cardiovascular Center, Sejong General Hospital
Results Characteristic CAD (+) (n = 178) CAD (-) (n = 509) P value Age, years 65.7 ± 9.2 57.9 ± 11.4 < 0.001 BMI, kg/m 2 24.6 ± 2.8 24.8 ± 3.4 0.564 Diabetes, % 32.9 13.6 < 0.001 Hypertension, % 64.7 40.2 < 0.001 Dyslipidemia, % 22.8 22.9 0.423 Hemoglobin, g/dl 12.4 ± 1.2 12.8 ± 1.1 < 0.001 egfr, ml/min/m 2 81.7 ± 28.4 87.3 ± 23.5 0.022 Fasting glucose, mg/dl 123 ± 51 107 ± 50 0.001 HDL-cholesterol, mg/dl 48.1 ± 13.1 52.1 ± 13.7 0.003 Triglyceride, mg/dl 137 ± 111 119 ± 74 0.028 LA diameter, mm 38.7 ± 5.9 36.3 ± 5.5 < 0.001 E/e 13.0 ± 6.6 10.3 ± 3.8 < 0.001
Negative VS Positive TMT : TMT parameters Negative (n=297) n Mean±SD /Number(%) Positive (n=160) n Mean±SD /Number(%) Heart rate, baseline 283 75.6±15.1 159 74.5±12.4 0.403 Target heart rate 277 154.7±14.7 147 159.8±12.7 0.000 Maximum heart rate 285 148.8±20.4 159 150.0±9.4 0.523 Maximum heart rate/target heart rate (%) 277 94.7±15.0 160 92.7±10.3 0.092 Systolic blood pressure, peak 282 163.4±26.3 159 169.6±25.4 0.015 Diastolic blood pressure, peak 281 81.3±16.8 159 81.0±0.832 0.832 Exercise capacity (METs) 277 9.5±2.3 159 9.2±2.5 0.216 Duration of treadmill test (seconds) 297 490.1±229.5 160 446.1±153.3 0.015 Cause of treadmill test termination (n,%) 200 113 *Signs of ischemia 44 (22) 58 (51.3) Target Heart rate 100 (50) 27 (23.9) Body or leg fatigue 50 (25) 27 (23.9) 0.000 Other 6 (6) 1 (0.9) Arrhythmia during Treadmill (n,%) 272 158 No 245 (90.1) 138(87.3) Supraventricular 7 (2.6) 6 (3.8) Ventricular 15 (5.5) 14 (8.9) 0.273 AV block 2 (0.7) 0 (0.0) Atrial fibrillation 3 (1.1) 0 (0.0) * Chest pain/discomfort or significant ST segment shift p
Coronary Artery Disease status based on TMT and CAG Negative Treadmill test Positive n Coronary angiography Non-significant 241 (56%) 104 (24.2%) 345 Significant 32 (7.4) 53 (12.3) 85 n 273 157 sensitivity 62.4% Specificity 69.9% Positive predictability 33.8% Negative predictability 88.3%
Comparison of diagnostic accuracy of TMT & DSE for the diagnosis of CAD (n=122) all CAD severe CAD multivessel CAD TMT Sensitivity (%) 63.3 62.5 69.25 Specificity (%) 64.1 60.4 94.3 DSE Sensitivity (%) 40 56.3 53.8 Specificity (%) 87.7 94.3 94.4 The diagnostic accuracy for the presence of CAD was similar between two methods (p=0.44) and for severe CAD, was slightly better with DSE than with TMT (p=0.08).
Dynamic Left Ventricular Outflow Tract Obstruction Hypertrophic cardiomyopathy After valve operation Anterior myocardial infarction In states of hypercontractility Dobutamine stress echocardiography (DSE)
Relation between peak LVOT PG at stress and RWT & DT r=0.428, p<0.001 r=0.328, p=0.001
LVOTO and DTS Patients with LVOTO had lower DTS (3.9±4.1 vs. 6.1±4.1, p=0.02).
Prevalence (%) 80 70 60 * * 50 40 30 no depression depression 20 10 0 significant CAD vasospasm
Regression analysis of depression parameters and QTc interval
Microvascular Angina known as cardiac syndrome X Aginal chest pain Abnormal stress test Normal coronary arteries on angiography At least one cardiovascular risk factor More common in women than in men Approximately 50% of these patients have physiologic evidence of microvascular coronary dysfunction
Limitation of Diagnosis of Microvascular Angina No recognition No vaso- or coronary reactivity test Subjective diagnosis Slow flow Specific hospital bias Co-existing mild coronary stenosis (<50%) or myocardial bridging
~2014.3 KoROSE data 943 women with chest pain who suspected IHD 444 patients diagnosed as angina 499 patients diagnosed as non-angina 216 patients with obstructive CAD 122 patients with microvascular angina 106 patients with vasospastic angina 2014 SMP
~2014.3 KoROSE data years 70 65 60 55 Age P<0.001 50 CAD MVA VSA Non-angina Non-angina CAD: obstructive coronary artery disease MVA: microvascular angina VSA: vasospastic angina 2014 SMP
CV risk factors DM P=0.001 % % 40 80 30 60 20 40 10 20 0 0 CAD MVA VSA HTN P<0.001 CAD MVA VSA Smoking, Dyslipidemia: NS 2014 SMP
LV diastolic function 105 90 75 60 g/m 2 LV mass index P<0.001 40 38 36 34 mm LA size P<0.001 45 CAD MVA VSA 32 CAD MVA VSA 2014 SMP
LV diastolic function 8 cm/s Mitral e' P<0.001 14 E/e' P<0.001 6 4 2 12 10 0 CAD MVA VSA 8 CAD MVA VSA 2014 SMP
Age-matched non-angina vs. MVA years 63 Age 60 57 54 Non-angina MVA P=0.708 Prevalence of DM, HTN, smoking and dyslipidemia between two groups: NS Non-angina, n=122 MVA: microvascular angina, n=122 2014 SMP
Age-matched non-angina vs. MVA 94 g/m 2 LV mass index 92 90 88 86 Non-angina MVA P=0.042 7.2 cm/s Mitral e' 6.8 6.4 6 5.6 Non-angina MVA P=0.017 Non-angina, n=122 MVA: microvascular angina, n=122 2014 SMP
Ischemic Chest Pain Obstructive CAD Vasospasm Myocardial substrate? Microvascular dysfunction
Summary In women, Aging is the most strong factor for IHD. Considerable patients may have microvascular angina. Impairment of LV diastolic function may have some relation to microvascular angina. Additional studies with specific diagnostic testing are required.
KoROSE 경청해주셔서감사합니다