Key result
Female sex is linked to ~5 points worse angina status than men, regardless of CAD or INOCA.
Why the study?
To examine whether perceived stress and depressive symptoms mediate sex differences in angina severity among patients with CCD, and whether this relationship differs between CAD and INOCA.
Observational (n=1,626)
Yes
Mean Difference: -5.12 (95% CI -7.21–-3.02)
p-value: p=0.001
High stress and depressive symptoms are independently associated with worse angina in chronic coronary disease, but they do not fully explain the worse angina-related health status observed in women compared to men.
Women with angina warrant psychosocial assessment; hypothesis-generating for sex-specific trials independent of CAD/INOCA.
Background: Sex differences in angina frequency and health status have been previously described in patients with chronic coronary disease (CCD), with women more severely affected despite lesser coronary artery disease (CAD) severity. Psychosocial factors, such as perceived stress and depression, are associated with increased angina and are more common in women and in those with ischemia and no obstructive coronary artery disease (INOCA). We examined whether perceived stress and depressive symptoms mediate sex differences in angina severity among patients with CCD, and whether this relationship differs between those with CAD vs. INOCA. Methods: The association between sex, stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-8) and angina-specific health status (Seattle Angina Questionnaire, SAQ) at enrollment and changes over 1 year in North American ISCHEMIA participants and in the CIAO-ISCHEMIA study (INOCA) were compared using linear regression. Results: Among 1,626 participants (N=1,439 CAD and N=187 INOCA) with available SAQ, PSS-4 and PHQ-8 data, women had worse SAQ-7 summary scores than men in both CAD and INOCA cohorts (Table). Higher stress and depressive symptoms were associated with worse angina in both CAD and INOCA cohorts. Given consistency of results, cohorts were pooled for multivariable analysis. Female sex, PSS-4 score and PHQ-8 score were each independently associated with lower SAQ scores, (female vs. male difference -5.12 points, 95% CI -7.21, -3.02, p=0.001; PSS-4 -0.78 per point, 95% CI -1.06, -0.50, p=0.001; PHQ-8 -1.38 per point, 95% CI -1.58, -1.18, p=0.001) but CAD vs. INOCA was not and the effects were similar by sex. Conclusions: Women, with both CAD and INOCA, had worse angina and angina-related health status than men. High stress and depressive symptoms were each independently associated without a significant interaction by sex, and regardless of presence of obstructive CAD. Therefore, stress and depression levels are not a central explanation for worse health status in women than men with CAD or INOCA.
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Hausvater et al. (2024) conducted an observational in Chronic coronary disease (CAD and INOCA) (n=1,626). Female sex, perceived stress, and depressive symptoms vs. Male sex, lower stress, and lower depressive symptoms was evaluated on Angina-specific health status (Seattle Angina Questionnaire summary scores) (MD -5.12, 95% CI -7.21 to -3.02, p=0.001). Female sex was independently associated with worse angina-specific health status compared to men (difference -5.12 points; 95% CI -7.21 to -3.02; p=0.001), regardless of CAD or INOCA presence.
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