Evidence Report/Technology Assessment: Number 81

Diagnosis and Treatment of Coronary Heart Disease in Women: Systematic Reviews of Evidence on Selected Topics

Summary


Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.

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Overview / Methodology / Findings / Future Research / Availability of Full Report


Overview

Coronary heart disease (CHD) is a common disease and cause of death in women, accounting for over 250,000 deaths in women per year. Over the last two decades, multiple important studies have helped define accurate clinical tests, risk factors, preventive interventions, and effective therapies for CHD. Unfortunately, many of these studies have either excluded women entirely or included only limited numbers of women and minorities. Thus, much of the evidence supporting contemporary recommendations for testing, prevention, and treatment of coronary disease in women is extrapolated from studies conducted predominantly in middle-aged men. The two best approaches to obtain additional evidence on diagnosis and treatment of CHD in women are to conduct large studies that include adequate numbers of women and minorities to answer the research question or to perform systematic reviews and meta-analyses summarizing effect estimates by subgroup.

The Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health Office of Research on Women's Health funded the University of California, San Francisco (UCSF)-Stanford Evidence-based Practice Center (EPC) to review the evidence regarding prevention, diagnosis, and management of coronary heart disease in women and minorities. In an initial phase of this work, the UCSF-Stanford EPC conducted a preliminary review of evidence on 42 topics related to CHD in women, titled Results of Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women.1 Based on these reviews, we identified four key questions for systematic review and meta-analysis. The results of these four reviews are presented in this report.

1 Grady D, Chaput L, Kristof M. Results of Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women. Evidence Report/Technology Assessment No. 80. (Prepared by the University of California, San Francisco-Stanford Evidence-based Practice Center under Contract No 290-97-0013.) AHRQ Publication No. 03-0035. Rockville, MD: Agency for Healthcare Research and Quality. May 2003.

Key Questions

1. What is the accuracy of noninvasive tests for diagnosis of CHD in women: exercise myocardial perfusion imaging (MPI) and exercise echocardiography?

  1. What are the summary estimates of sensitivity, specificity and likelihood ratios for exercise MPI and exercise echocardiography in women?
  2. What is the accuracy of exercise MPI and exercise echocardiography in women compared to men?

2. What is the effectiveness of treatment with lipid lowering drugs for reducing CHD risk in women with and without CHD?

  1. What is the effectiveness of drug treatment in reducing total mortality, CHD mortality, CHD events or CHD procedures in women with known CHD and those without known CHD?

3. What is the relative risk for CHD in women with type 2 diabetes?

  1. What is the relative risk for CHD in women with type 2 diabetes compared to women without diabetes?
  2. Does the relative risk for CHD differ between women and men with type 2 diabetes?

4. What is the prognostic value of troponin for CHD in women?

  1. What is the impact of troponin on risk for death among women with non-ST elevation acute coronary syndromes?
  2. Does the prognostic value of troponin for mortality differ between men and women?
  3. What is the impact of troponin on risk for death or myocardial infarction for women with non-ST elevation acute coronary syndromes?
  4. Does the prognostic value of troponin for mortality or myocardial infarction differ between men and women?

For each of the four questions, we also attempted to identify and summarize evidence stratified by race or ethnicity.

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Methodology

We performed standardized searches of electronic databases of publications relevant to the topic areas. We developed specific search terms for each of the four key topics and conducted a separate search for evidence regarding each. We also reviewed the bibliographies of retrieved articles and sought suggestions for additional articles from our expert peer reviewers. For each topic area, we established clear inclusion criteria that required that studies provide data regarding the research question specific to women.

For three of the key questions (noninvasive diagnostic tests, lipid lowering and diabetes), two UCSF-Stanford EPC investigators reviewed all identified titles and excluded those that did not meet inclusion criteria. The abstracts of remaining articles were reviewed by two UCSF-Stanford EPC physician investigators, who independently classified eligibility. The full text of the remaining eligible articles was reviewed independently by two UCSF-Stanford EPC physician investigators using standardized abstraction forms to classify eligibility, rate quality as fair or good based on predefined criteria, and abstract data for eligible studies. For the key question regarding troponin, titles and abstracts were reviewed by one UCSF-Stanford EPC investigator. Data were abstracted from each eligible article by two independent reviewers and entered on standardized electronic data forms.

Accuracy of Exercise Myocardial Perfusion Imaging and Echocardiography for Diagnosis of CHD in Women

We searched PubMed®, the Cochrane Database, and DARE for articles in English and other languages published from 1990 through January 2002. We used the following search terms to identify cross-sectional studies in which the accuracy of the exercise MPI or exercise echocardiography was compared to angiographic findings:

(Note: An asterisk indicates truncation of the search term.)

Searches for noninvasive diagnostic tests identified 3,136 titles. After eliminating ineligible studies by review of titles and abstracts, we reviewed the full text of 326 articles and found 14 eligible cross-sectional studies with data on women that were included in the systematic review. Ten studies examined the accuracy of MPI and four examined the accuracy of exercise echocardiography.

Efficacy of Lipid Lowering to Reduce Risk of CHD in Women

We searched PubMed®, the Cochrane Database, and DARE for articles in English and other languages published from 1966 through January 2002. We used the following search terms to identify clinical trials:

Searches for clinical trials of lipid lowering treatment identified 1,335 titles. After eliminating ineligible studies by review of titles and abstracts, we reviewed the full text of 120 articles and found 11 eligible randomized trials that provided data on women and were included in the systematic review.

Diabetes as a Risk Factor for CHD in Women

We searched PubMed®, the Cochrane Database, and DARE for articles in English and other languages published from 1966 through January 2002. We used the following search terms to identify cohort and cross-sectional studies:

Searches for diabetes as a risk factor for CHD in women identified 4,578 titles. After eliminating ineligible studies by review of titles and abstracts, we reviewed the full text of 233 articles. We found 17 studies that fulfilled all inclusion criteria; 12 were prospective cohort studies and five were cross-sectional analyses.

Prognostic Value of Troponin for CHD in Women

We searched MEDLINE® for articles in English and other languages published from 1966 through January 2002. We used the following search terms to identify clinical trials or cohort studies:

We also performed a search of EMBASE from 1990-1998, but did not find any additional articles fulfilling the study criteria.

Searches identified 1,049 articles. We excluded 878 articles based on title or abstracts and reviewed the full text of 171 articles. Of these, eight eligible studies provided data on women and were included in the systematic review; six were clinical trials and two were cohort studies.

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Findings

Overall

Accuracy of Exercise Myocardial Perfusion Imaging and Echocardiography for Diagnosis of CHD in Women

Efficacy of Lipid Lowering to Reduce Risk of CHD in Women

Diabetes as a Risk Factor for CHD in Women

Prognostic Value of Troponin for CHD in Women

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Future Research

The major problem in performing these systematic reviews was lack of availability of data on women and minority populations. Many studies that include women did not provide estimates stratified by sex. Attempts to obtain unpublished data from women were time-consuming and only modestly successful.

Recommendations for future research follow.

Overall

Accuracy of Exercise Myocardial Perfusion Imaging and Echocardiography for Diagnosis of CHD in Women

Efficacy of Lipid Lowering to Reduce Risk of CHD in Women

Diabetes as a Risk Factor for CHD in Women

Prognostic Value of Troponin for CHD in Women

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Availability of Full Report

The full evidence report from which this summary was taken was prepared for the Agency for Healthcare Research and Quality (AHRQ) by the University of California, San Francisco-Stanford Evidence-based Practice Center, under Contract No. 290-97-0013. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 1-800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 81, Diagnosis and Treatment of Coronary Heart Disease in Women: Systematic Reviews of Evidence on Selected Topics (AHRQ Publication No. 03-E037).

The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a set of PDF files or as a zipped file.

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AHRQ Publication No. 03-E036
Current as of May 2003


Internet Citation:

Diagnosis and Treatment of Coronary Heart Disease in Women: Systematic Reviews of Evidence on Selected Topics. Summary, Evidence Report/Technology Assessment: Number 81. AHRQ Publication No. 03-E036, May 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/chdwtopsum.htm


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