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To evaluate innovative diagnostic methods that will improve the diagnostic reliability of cardiovascular testing in evaluation
of ischemic heart disease in women. Innovative approaches proposed include physiologic or functional measurements such as
impaired metabolism, perfusion, or endothelial function as well as assessment of epicardial coronary arteries by angiography.
Other objectives include developing safe, accurate, and cost effective diagnostic approaches for evaluating women with suspected
ischemic heart disease, and determining the frequency of myocardial ischemia in the absence of significant epicardial coronary
stenosis, as well as the frequency of non-ischemic or non-cardiac chest pain. A key aspect of the WISE study is to determine
whether evidence of myocardial ischemia occurs in the absence of obstructive coronary disease.
Study Type: Interventional Study Design: Diagnostic
Further Study Details:
Study start: August 1996;
Study completion: April 2005
BACKGROUND: Cardiovascular disease exacts a heavy burden on the health of women. Ischemic heart disease claims the lives
of nearly 250,000 women in the United States each year. Recognition of ischemic heart disease in women is a major challenge
to the primary care physician. Diagnosis of ischemic heart disease requires recognition of clinical symptoms such as chest
pain, or events such as a myocardial infarction, which are evaluated by a physician who will confirm the diagnosis with objective
tests. Unfortunately, both symptom recognition and diagnostic tests confuse rather than confirm a diagnosis of myocardial
ischemia in women. Chest pain syndromes suspicious for myocardial ischemia are common in women. Noninvasive diagnostic methods
which often confirm the diagnosis and assess disease severity in men are less reliable in women. This lack of objective data
to support the diagnosis of chronic or acute myocardial ischemia may influence the physician's decision to further evaluate
women at risk. With precision in diagnosis, efforts to optimize therapies are hampered.
The detection of epicardial coronary atherosclerosis is a major objective in clinical cardiology. The utility of this approach
is well established. However, although the presence of atherosclerosis is sufficient to cause myocardial ischemia, whether
significant ischemia or risk of ischemia exists in the absence of angiographic epicardial stenosis, is not known and may be
important for women.
Recent progress in understanding the pathophysiology of myocardial ischemia provides a more complex causal pathway than the
heretofore notion of fixed atherosclerotic obstructions in passive conduits. Diseased arteries which may appear angiographically
normal as well as arteries with fixed obstructions can respond to vasomotor influences with a detrimental amount of vasoconstriction.
The endothelium generates vasoactive and anticoagulant factors that are important mediators of thrombosis. Cycling hormones
may further influence these complex interactions. Methods which do not rely solely on fixed obstruction of epicardial arteries
are not only possible but may be useful to recognize early atherosclerosis or, for example, endothelial dysfunction which
places the patient at risk for untoward coronary events.
The concept for the study was developed by the Cardiology Advisory Committee in collaboration with staff and was approved
by the May 1993 National Heart, Lung, and Blood Advisory Council. The Request for Proposals was released in April 1994.
DESIGN NARRATIVE: The Women's Ischemia Syndrome Evaluation (WISE) was a four center study designed to evaluate ischemic heart
disease and its pathophysiology in women. WISE testing focused on three areas: 1) optimizing symptom evaluation and diagnostic
testing for ischemic heart disease; 2) exploring mechanisms for symptoms and evidence of myocardial ischemia in the absence
of epicardial coronary artery disease; 3) evaluating the influence of reproductive hormones on symptoms and diagnostic test
response. The WISE core data base included demographic and clinical data, symptom and psychosocial variables, coronary angiography
and ventriculography data, blood lipoprotein/homocysteine/lipid peroxidation/genetic/hormone/ phytoestrogen analysis, brachial
artery reactivity testing, and resting/ambulatory electrocardiographic (ECG) monitoring. Site specific complementary methods
included physiologic and functional cardiovascular assessments of myocardial perfusion and metabolism, ventriculography, endothelial
vascular function and coronary angiography. Women were followed for at least one year to assess clinical events and symptom
status. In the Phase I (1996-7), a pilot phase, 256 women were studied. Phase II has completed enrolling 1008 women in the
study. The WISE study defined contemporary and comprehensive state-of-the-art diagnostic testing to evaluate women with suspected
ischemic heart disease, and explore sex specific ischemic heart disease pathophysiology.
The study has been renewed through April, 2005 to extend patient follow-up for a minimum of five years. Dr. Kelsey (U01HL64829)
of the Data Coordinating Center at the University of Pittsburgh will continue the follow-up, develop sex-specific incremental
outcome models to evaluate the prognostic value of female reproductive variables, assess cost effectiveness of the WISE testing
techniques, and continue data analyses. Dr. Reis (U01HL64914) will study the immunologic basis of coronary disease in women,
focusing on the role of inflammation and cytokine production. He will measure several cytokines and cytokine-related proteins
and genotypes in approximately 900 stored samples from WISE participants. Dr. Pepine (U01HL64924) will study the renin angiotensin
system in coronary microvascular dysfunction, focusing on whether polymorphisms of the renin-angiotensin/kallikrein-kinin
systems and beta-adrenergic receptors polymorphisms are associated with abnormal coronary microvascular function determined
by coronary flow reserve measurements.
Eligibility
Ages Eligible for Study:
15 Years and above,
Genders Eligible for Study:
Female
Criteria
Women over the age of 18 who have suspected ischemic heart disease.
Location
Information
Study chairs or principal investigators
Sheryl Kelsey, University of Pittsburgh
Carl Pepine, University of Florida
Steven Reis, University of Pittsburgh
Steven Reis, University of Pittsburgh
Study ID Numbers:
98
Record last reviewed:
September 2004
Record first received:
October 27, 1999
ClinicalTrials.gov Identifier:
NCT00000554 Health Authority: United States: Federal Government
ClinicalTrials.gov processed this record on 2004-10-14