Previous investigations have demonstrated the presence of gender differences in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations have had certain limitations, including being retrospective, an interview-related bias, a various duration of myocardial ischemia, and a lack of multivariate analysis, all of which would have affected the results. Accordingly, we prospectively examined the presence or absence of chest pain and non–chest pain symptoms during a 60-second balloon inflation in the setting of percutaneous coronary intervention, which provides a unique model of transient myocardial ischemia, in 110 men and 80 women with coronary artery disease. Chest pain and/or non–chest pain symptoms (occipital pain, jaw pain, neck/throat pain, shoulder pain, upper arm pain, back pain, and nausea) were observed during the balloon inflation in 72 men and 52 women. In the 124 patients with any symptoms during the balloon inflation, non–chest pain symptoms were more common in women than in men (31% vs 14%, p = 0.02); however, the incidence of chest pain did not differ between the men and women. After adjustment for covariables, including age, body mass index, hypertension, diabetes mellitus, current smoking, previous myocardial infarction, target vessels, β-blocker use, and calcium antagonist use, female gender remained significantly associated with non–chest pain symptoms (odds ratio 3.3, 95% confidence interval 1.2 to 9.9, p = 0.02). In conclusion, non–chest pain symptoms during the 60-second balloon occlusion of the coronary artery were more common in women than in men, supporting the presence of the gender difference in myocardial ischemic symptoms.
Previous studies have shown that some gender differences exist in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations had certain limitations, including being retrospective, the presence of an interview-related bias, varying durations of myocardial ischemia, and a lack of multivariate analysis, all of which would affect the results. Accordingly, we prospectively examined whether any gender differences were present in the symptoms of myocardial ischemia during a 60-second balloon inflation in the setting of percutaneous coronary intervention (PCI), which provides a unique model of transient myocardial ischemia.
Methods
Eligible patients with coronary artery disease who were planning to undergo elective PCI for significant stenosis in a major “native” coronary artery at Koseiren Tsurumi Hospital from January 1, 2011 to May 30, 2012 were prospectively enrolled in the present study. The exclusion criteria included acute coronary syndrome, severe congestive heart failure (New York Heart Association functional class IV), PCI for a totally or subtotally occluded coronary artery (Thrombolysis In Myocardial Infarction grade 0 to 2 flow) or left main trunk disease, the presence of myocardial ischemic symptom at baseline (immediately before PCI), and severe cognitive disorder.
Elective PCI, including balloon coronary angioplasty and coronary stenting, was performed using a radial, brachial, or femoral approach. We collected data on symptoms during the first balloon inflation for the target lesion, which was performed for 60 seconds. Immediate after the balloon deflation, we interviewed the patients about the presence or absence of the following symptoms during the balloon inflation: chest pain, toothache, jaw pain, neck/throat pain, shoulder pain, upper or lower arm pain, epigastralgia, occipital pain, back pain, dyspnea, nausea, and vomiting. We also evaluated the intensity of the symptoms using the modified Borg scale (0 to 10 scale). The institutional review board of Oita University Hospital approved by the study protocol, and all patients provided informed consent before study entry.
Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or treatment with antihypertensive medication. Dyslipidemia was defined as serum low-density lipoprotein cholesterol ≥140 mg/dl, high-density lipoprotein cholesterol <40 mg/dl, triglycerides ≥150 mg/dl, or treatment with lipid-lowering drugs. Diabetes mellitus was defined as fasting plasma glucose ≥126 mg/dl, plasma glucose ≥200 mg/dl at 2 hours after a 75-g glucose load, or treatment with hypoglycemic agents.
Continuous data are expressed as the mean ± SD. Comparisons of the continuous variables between the 2 groups were performed using the unpaired t test or the Mann-Whitney U test. Comparisons of the categorical variables between the 2 groups were analyzed using the Fisher test or Chi-square test. Univariate and multivariate logistic regression analyses were performed to determine whether female gender were associated with non–chest pain symptoms. A value of p <0.05 was considered statistically significant. Statistical analyses were performed using a statistical software package (IBM SPSS Statistics, version 20, IBM, Armonk, New York).
Results
Figure 1 shows a flow chart of the study cohort. A total of 190 patients (110 men and 80 women) with coronary artery disease were enrolled in the present study. Of these 190 patients, 124 (72 men and 52 women) experienced any symptoms during the 60-second balloon inflation, and we analyzed the data from these 124 patients. The 124 patients had ST-segment elevation or depression in ≥2 contiguous leads during the balloon inflation. The patient characteristics of the 124 patients are listed in Table 1 . The women were older (74.3 ± 9.0 years vs 69.8 ± 8.9 years, p = 0.01) and had a lower prevalence of current smokers (8% vs 36%, p <0.001) than the men.
| Variable | Men (n = 72) | Women (n = 52) | p Value |
|---|---|---|---|
| Age (yrs) | 69.8 ± 8.9 | 74.3 ± 9.0 | 0.01 |
| Body mass index (kg/m 2 ) | 24.1 ± 3.6 | 23.2 ± 3.0 | 0.16 |
| Hypertension | 60 (83) | 36 (69) | 0.08 |
| Dyslipidemia | 46 (64) | 28 (54) | 0.27 |
| Diabetes mellitus | 31 (43) | 19 (37) | 0.58 |
| Current smoker | 26 (36) | 4 (8) | <0.001 |
| Previous myocardial infarction | 20 (28) | 13 (25) | 0.84 |
| Previous PCI | 37 (51) | 27 (52) | 1.00 |
| Left ventricular ejection fraction (%) | 60.8 ± 16.3 | 63.4 ± 14.8 | 0.37 |
| Multivessel coronary disease | 38 (53) | 20 (39) | 0.15 |
| Target coronary artery | 0.55 | ||
| Right | 20 (28) | 19 (37) | |
| Left anterior descending | 37 (51) | 22 (42) | |
| Left circumflex | 15 (21) | 11 (21) | |
| Medications | |||
| Antiplatelet agents | 72 (100) | 52 (100) | 1.00 |
| Calcium antagonists | 41 (57) | 23 (44) | 0.20 |
| β blockers | 19 (26) | 6 (12) | 0.07 |
| Angiotensin-converting inhibitors/angiotensin receptor blockers | 29 (40) | 25 (48) | 0.46 |
| Statins | 33 (46) | 27 (52) | 0.59 |
| Nitrates | 41 (57) | 33 (64) | 0.58 |
Of the 124 patients with any symptoms during the 60-second balloon inflation ( Table 2 ), the incidence of chest pain did not differ significantly between the men and women (100% vs 96%); however, non–chest pain symptoms were more common in the women than in the men (31% vs 14%, p = 0.02). The incidence of right shoulder/upper arm pain and neck/throat pain tended to be more common in women than in men. The modified Borg scale did not differ significantly between the men and women (2.0 ± 1.8 vs 2.2 ± 1.7, p = 0.40).
| Variable | Men (n = 72) | Women (n = 52) | p Value |
|---|---|---|---|
| Chest pain | 72 (100) | 50 (96) | 0.96 |
| Non–chest pain symptoms | 10 (14) | 16 (31) | 0.02 |
| Right shoulder/upper arm pain | 0 (0) | 3 (6) | 0.07 |
| Left shoulder/upper arm pain | 8 (11) | 4 (8) | 0.76 |
| Jaw pain | 1 (1) | 0 (0) | 1.00 |
| Neck/throat pain | 4 (6) | 8 (15) | 0.12 |
| Back pain | 1 (1) | 3 (6) | 0.31 |
| Occipital pain | 1 (1) | 1 (2) | 1.00 |
| Nausea/vomiting | 0 (0) | 2 (4) | 0.17 |
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