Anginal symptoms, coronary artery disease, and adverse outcomes in Black and White women: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study

Abstract

Background: Black women are less likely to be evaluated and treated for anginal symptoms, despite a higher premature cardiac mortality rate compared to white women. Our objective was to compare angina symptoms in black versus white women regarding (1) angina symptoms characterization; (2) relationship with obstructive coronary artery disease (CAD); and (3) relationship with subsequent mortality.

Methods: A cohort of 466 women (69 black and 397 white) undergoing coronary angiography for suspected ischemia and without prior history of CAD completed symptom checklists. Four symptom clusters (CHEST, UPPER, STOMACH, and TYPICAL TRIGGERS) were derived by factor analysis. All angiograms were analyzed by core lab. Mortality data over 10 years were obtained from National Death Index.

Results: (1) Black women had lower mean CHEST cluster scores (0.60±0.30 vs. 0.73±30, p=0.002), but higher STOMACH scores (0.41±0.25 vs. 0.30±0.25, p=0.011) than white women. (2) Prevalence and severity of CAD did not differ in black and white women and was not predicted by symptom cluster scores. (3) All-cause mortality rates were 24.9% in blacks versus 14.5% in whites, p=0.007; and cardiovascular mortality 22.5% vs.8.8%, p=0.001. Symptom clusters were not predictive of adverse events in white women. However, black women with a low TYPICAL score had significantly higher mortality compared to those with a high TYPICAL score (43% vs. 10%, p=0.006).

Conclusions: Among women undergoing coronary angiography, black women report fewer chest-related and more stomach-related symptoms, regardless of presence or severity of CAD, and these racial symptom presentation differences are linked with the more adverse prognosis observed in the black women. Atypical symptom presentation may be a barrier to appropriate and timely diagnosis and treatment and contribute to poorer outcomes for black women.

FIG. 1.

Mean adjusted CHEST and STOMACH scores stratified by race (black vs. white) and presence vs. absence of obstructive CAD. The “error bars” represent standard deviations. Means were adjusted by significant correlates of CHEST and STOMACH scores. Means for CHEST scores were adjusted by age, functional capacity, self-reported stress, number of live births, ever hormone therapy use and location (south vs. north). Means for STOMACH scores were adjusted by self-reported stress and BMI. CAD, coronory artery disease; BMI, body mass index.

FIG. 2.

Kaplan-Meier curves of % survival from major events among 4 subgroups stratified by race (black vs. white) and low vs. high TYPICAL symptom presentation scores (median split of 0. 71). Major events are defined as all-cause mortality, CV mortality, MI, HF and stroke.