Outcome differences for men, women with nonobstructive CAD not explained by sex

By Will Boggs MD

NEW YORK (Reuters Health) - Differences in impaired health status, psychological distress, and personality between women and men with nonobstructive coronary artery disease (NOCAD) cannot be attributed to sex/gender alone, according to results from the TWIST study.

"It was striking that the sex and gender differences - more anxiety, fatigue, negative affectivity, and poor health status in women compared to men - were explained by other sex and gender differences,” Dr. Paula M. C. Mommersteeg from Tilburg University in the Netherlands told Reuters Health by email.

Patients with established CAD are known to have significantly impaired health status and a higher burden of depressive symptoms, but little is known about these features or about sex and gender differences in patients with NOCAD.

Dr. Mommersteeg and colleagues in the Tweesteden Mild Stenosis (TWIST) observational study examined sex differences in health status, psychological distress, and personality subtypes in their survey of 523 individuals with NOCAD and 1,347 matched reference participants.

Compared with the reference group, both men and women in the NOCAD group showed a lower general health status, elevated fatigue, more anxiety, more depressive symptoms, more negative affect and less positive affect, and a higher propensity for Type D personality (experiencing negative emotions but inhibiting them in social situations).

Within the NOCAD group, women reported significantly lower physical and mental health status, more fatigue, more physical limitation, more anxiety, more negative affect, and less positive affect than men. They did not differ significantly on other measures, the researchers report in Circulation Cardiovascular and Quality Outcomes, online February 21.

Adjustment for age, partner, college education, employment and alcohol use - all of which were associated with impaired physical health status, fatigue, physical limitation, anxiety, positive affect, and negative affect - rendered the sex differences in psychosocial factors in patients with NOCAD nonsignificant.

“This gives us information that the higher reported psychosocial factors in women do not only reflect biological sex differences, but for a large part reflect sociocultural gender differences,” Dr. Mommersteeg said. “This makes the picture of ‘women report higher psychosocial distress’ more complex but also, as a scientist, very interesting at the same time.”

“Most health care and coronary interventions are being aimed at patients with obstructive coronary artery disease, a patient group in which men are much more prevalent,” she said. “Women more often present with cardiac symptoms in the absence of coronary artery disease. We observed that these patients with nonobstructive coronary artery disease have a higher burden of psychosocial stress and poor health status, which was more apparent in women. Since psychosocial factors are relevant in this patient group as well, special attention is needed for both female and male patients reporting more psychosocial stress and poor health status.”

“At any point asking the patient what she or he needs in addition to their heart problems may be a good starting point,” Dr. Mommersteeg said.

Dr. Colleen M. Norris from the University of Alberta in Edmonton, Canada, who has also written about the contribution of gender to apparent sex differences in CAD patients, told Reuters Health by email, "In my opinion, the findings should influence management in two ways. The first is for all clinicians to realize that not only do these patients report significant physical limitations as a result of a NOCAD diagnosis but they are likely to keep coming back because we are looking for a magic bullet to fix what is still not truly understood.”

“The second is that we have validated health status questionnaires (SAQ) that can be used especially in these cases to try and treat the dimensions of physical or mental health status that the patients are reporting as impaired,” she said. “Looking at the specific items of the SAQ or HADS (Hospital Anxiety and Depression Scale; which patients can complete before the seeing the clinician) will help direct the treatment.”

“Specifically in NOCAD patients (which have had and continue to have a higher representation of women) we need to take a patient-centered, symptom-based approach,” Dr. Norris said. “There are no randomized controlled trials to guide us here. As the authors state, ‘there is currently no guidelines-recommended therapy for patients with NOCAD, other than symptom relief and cardiovascular risk factor management.’ I would suggest given the lack of research, there is not likely to be any in the near future.”

She concluded, “We need to focus on alleviating the patient-reported health status/symptoms. As evidenced by the SAQ scores for the NOCAD group in this paper, the 'symptom relief' is not presently happening.”

SOURCE: bit.ly/2mzAMMM

Circ Cardiovasc Qual Outcomes 2017.

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