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Objective: The purpose of this study was to describe type A behavior pattern and trait anger in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and compare them with patients with coronary heart disease and healthy controls. Type A behavior pattern and anger have been linked to coronary heart disease in previous studies. This is the first study to assess type A behavior pattern and trait anger in MINOCA patients., Methods: One hundred MINOCA patients, consecutively recruited during 2007-2011 at 5 coronary care units in Stockholm, were matched for sex and age to 100 coronary heart disease patients and 100 healthy controls. All participants completed the Bortner Rating Scale to quantify type A behavior pattern and the Spielberger Trait Anger Scale to quantify anger 3 months after the acute event., Results: MINOCA patients' Bortner Rating Scale score was 70.9 ± 10.8 (mean ± SD) and Spielberger Trait Anger Scale score was 14 (12-17) (median; interquartile range). Coronary heart disease patients' Bortner Rating Scale score was 70.5 ± 10.2 and Spielberger Trait Anger Scale score was 14 (12-17). Healthy controls' Bortner Rating Scale score was 71.9 ± 9.1 and Spielberger Trait Anger Scale score was 13 (11-16)., Conclusion: We found no significant differences in Bortner Rating Scale score and Spielberger Trait Anger Scale score among MINOCA, coronary heart disease patients, and healthy controls, regardless of whether total scores, subscales, or cutoffs were used to classify type A behavior pattern and trait anger. However, we cannot exclude the existence of an occasional episode of anger or mental stress in relation to the coronary event. This is the first study to assess type A behavior pattern and trait anger in patients with MINOCA, and future studies need to confirm the current findings before any firm conclusions can be made., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Cardiovascular disease (CVD) including coronary heart disease (CHD) and stroke is the most common cause of female death. Premenopausal CHD is very rare but when women enter the menopause the incidence of CHD increases markedly. CHD presents 10 years later in women than in men. The reason is still unclear but the protective effects of estrogens have been suggested., Aims: To formulate a position statement on the management of menopause women in the context of coronary heart disease., Materials and Methods: Literature review and consensus of expert opinion., Results and Conclusions: Based on long term randomized placebo-controlled studies hormone therapy (HT) is not recommended for the primary or secondary prevention of CHD in postmenopausal women. In most countries the only indication for HT is the treatment of menopausal symptoms. Women with known CHD or with many coronary risk factors seeking HT because of troublesome climacteric symptoms should be evaluated for their individual baseline risk of developing breast cancer, venous thromboembolism and CHD recurrence. The same applies to non hormone therapy-based treatments where long term clinical studies are lacking. Risks should be weighed against expected benefit from symptom relief and improved quality of life. The lowest effective estrogen dose should be used during the shortest possible time. Transdermal administration is preferred if risk factors for VTE exist. Different progestogens might differ in their cardiovascular effects. Observational studies suggest that micronized progesterone or dydrogesterone may have a better risk profile than other progestogens with regard to thrombotic risk., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Previous studies have established a link/relationship between haemostatic factors and increased risk of cardiovascular disease. In addition, physical conditioning is associated with lower coronary heart disease risk. The purpose of this study was to assess the association between physical exercise and haemostatic factors among middle-aged women surviving an acute coronary event. The Stockholm Female Coronary Risk Study included 292 women aged < 65 years, resident in the greater Stockholm area, who were hospitalized for an acute coronary syndrome. Extensive clinical screening including exercise testing, and blood tests were performed 3-6 months after the coronary event. Self-reported physical activity was assessed by a WHO questionnaire. Patients on warfarin treatment were excluded from our analyses. Haemostatic factors were generally higher among physically inactive patients when compared to physically active women in our univariate models. Exercise capacity had a statistically significant relationship with factor VII antigen (p = 0.039) and vWFag (p = 0.038) even in our multiadjusted analyses. Physical inactivity and poor physical fitness are associated with a potentially prothrombotic blood profile in middle aged women with coronary heart disease.

Background: Depression is an unfavorable state that is difficult to recognize in patients with coronary heart disease (CHD). Little is known about the characteristics of depressed female CHD patients., Objective: The purpose of this study was to investigate the occurrence of depressive symptoms in women entering a cardiac rehabilitation program, and furthermore, to examine whether women who have CHD and depressive symptoms display any unfavorable physical or psychological characteristics that could be helpful in identifying female CHD patients at increased risk of depression., Methods: In a Swedish cross-sectional survey of Swedish women entering a randomized, female cardiac rehabilitation trial, patients with a Beck Depression Inventory (BDI) score indicating depression were compared with patients without depressive symptoms., Results: Of the 121 women with CHD who participated in the study, 23.1% had BDI scores consistent with moderate to severe depression (BDI > or =19). Scores of > or =19 were strongly correlated to established angina pectoris (P = 0.007) and higher rates of anxiety on the Beck Anxiety Inventory (P < 0.001). Depressed women also were more likely to have a family history of heart disease (P = 0.036) and were less likely to care for their health in the future (P = 0.005)., Conclusions: This study suggests a strong relationship between depression and angina pectoris in women with CHD. The study also confirms previous findings that depressive symptoms are common in women with CHD. Findings of more pronounced cardiac symptoms in depressed women with CHD suggest that depressive symptoms may present differently or alter cardiac symptoms in female CHD patients. Consequently, the occurrence of increased cardiac symptoms indicates the need to screen for depression, whether depressive symptoms are apparent or not. The higher scores for anxiety in depressed women with CHD and their poorer health care practices, in combination with their more pessimistic beliefs about lifestyle changes, highlight the need to identify depression to enhance adherence to treatment regimens in the cardiac rehabilitation process.

Objective: To examine the impact of psychosocial stress, experienced in the family and work life, on the progression of coronary atherosclerosis in women cardiac patients., Design: Longitudinal follow-up study. The mean luminal diameter change over 3 years was averaged over 10 predefined coronary segments, representing the entire coronary tree. Stress in family life was measured by using the Stockholm Marital Stress Scale and that of work life by the demand-control questionnaire., Subjects: Amongst patients enrolled in the Stockholm Female Coronary Angiography Study, 80 women were evaluated for stress exposure and coronary atherosclerosis progression using serial quantitative coronary angiography., Results: Multi-variable-controlled mixed models anova analyses revealed that women with high stress from either family or work had significant disease progression over 3 years, whereas those with low stress had only slight progression. In women who were free of stress from either family or work life, i.e. they were satisfied with both of these life domains, the coronary artery changes had regressed. Their mean coronary luminal diameter increased by 0.22 mm (95% CI: 0.10; 0.35 mm) when compared with women who experienced stress from both sources, whose luminal diameter decreased by 0.20 mm (95% CI: -0.14; -0.25). These associations were independent of baseline luminal diameter and standard cardiovascular risk factors, including age smoking, hypertension and HDL at baseline., Conclusions: Stress from family or work life may accelerate coronary disease processes in women, whereas relative protection may be obtained from a satisfactory job and a happy marriage.

Background: Clinical trials have demonstrated that, compared with placebo, intensive statin therapy reduces ischemia in patients with acute coronary syndromes and in patients with stable coronary artery disease. However, no studies to date have assessed intensive versus moderate statin therapy in older patients with stable coronary syndromes., Methods and Results: A total of 893 ambulatory coronary artery disease patients (30% women) 65 to 85 years of age with > or = 1 episode of myocardial ischemia that lasted > or = 3 minutes during 48-hour ambulatory ECG at screening were randomized to atorvastatin 80 mg/d or pravastatin 40 mg/d and followed up for 12 months. The primary efficacy parameter (absolute change from baseline in total duration of ischemia at month 12) was significantly reduced in both groups at month 3 and month 12 (both P<0.001 for each treatment group) with no significant difference between the treatment groups. Atorvastatin-treated patients experienced greater low-density lipoprotein cholesterol reductions than did pravastatin-treated patients, a trend toward fewer major acute cardiovascular events (hazard ratio, 0.71; 95% confidence interval, 0.46, 1.09; P=0.114), and a significantly greater reduction in all-cause death (hazard ratio, 0.33; 95% confidence interval, 0.13, 0.83; P=0.014)., Conclusions: Compared with moderate pravastatin therapy, intensive atorvastatin therapy was associated with reductions in cholesterol, major acute cardiovascular events, and death in addition to the reductions in ischemia observed with both therapies. The contrast between the therapies' differing efficacy for major acute cardiovascular events and death and their nonsignificant difference in efficacy for reduction of ischemia suggests that low-density lipoprotein cholesterol-lowering thresholds for ischemia and major acute cardiovascular events may differ. The Study Assessing Goals in the Elderly (SAGE) demonstrates that older men and women with coronary artery disease benefit from intensive statin therapy.

Objectives: Low heart rate variability (HRV) is associated with poor prognosis after acute coronary events in men. In women, the prognostic impact is not well documented. The objective of this study was to assess the long-term predictive power of HRV on mortality amongst middle-aged women with coronary heart disease (CHD). DESIGN, SETTINGS AND SUBJECTS: Consecutive women below 65 years hospitalized for an acute coronary syndrome during a 3-year period in Stockholm were examined for cardiovascular prognostic factors including HRV, and followed for a median of 9 years. An ambulatory 24-h electrocardiograph was recorded during normal activities, 3-6 months after hospitalization. SDNN index (mean of the standard deviations of all normal to normal intervals for all 5-min segments of the entire recording) and the following frequency domain parameters were assessed: total power, high-frequency (HF) power, low-frequency (LF) power, very-low frequency (VLF) power and LF/HF ratio. Using Cox proportional hazards regression, the hazard ratios (HR) for each 25% decrease of the HRV parameters were assessed., Results: After controlling for the independent, significant predictors of mortality amongst the clinical variables, the following HRV parameters were found to be significant predictors of all-cause mortality: SDNN index [HR 1.56, 95% confidence intervals (CI) 1.19-2.05], total power (HR 1.21, 95% CI 1.08-1.35), VLF power (HR 1.22, 95% CI 1.09-1.36), LF power (HR 1.18 95%, CI 1.07-1.30) and HF power (HR 1.18, 95% CI 1.05-1.33). The results were essentially the same when cardiovascular mortality was used as end-points. The HRV parameters were stronger predictors of mortality in the first 5 years following the index event., Conclusion: Low HRV is a predictor of long-term mortality amongst middle-aged women with CHD when measured 3-6 months after hospitalization for an acute coronary syndrome, even after controlling for established clinical prognostic markers.

Objective: To study a possible use of sex hormone-binding globulin (SHBG) and corticosteroid-binding globulin (CBG) as markers for changes in hemostatic factors during oral postmenopausal hormone replacement therapy (HRT)., Methods: Twenty-eight postmenopausal women were treated with oral conjugated equine estrogens+oral medroxyprogesterone acetate (CEE + MPA, n = 15) or with placebo (n = 13). Serum SHBG, CBG, testosterone, cortisol and plasma coagulation factors, coagulation inhibitors and markers of coagulation activation were measured before and after 6 and 12 months of treatment., Results: Pretreatment plasminogen activator inhibitor 1 (PAI-1) levels correlated negatively to SHBG and antithrombin III (AT III) negatively to total and free cortisol. In the CEE + MPA group, CBG, SHBG and Factor VII increased, and PAI-1, AT III and free testosterone decreased during treatment. No significant changes were found in plasma von Willebrand factor antigen, thrombin-antithrombin complex, fibrin D-dimer and fibrinogen. A significant, negative correlation was found between changes in SHBG and PAI-1. No changes were found in the placebo group., Conclusion: The only correlation found between changes in "steroid sensitive" proteins and hemostatic factors was between increased SHBG and a possibly beneficial effect of estrogens, i.e. decreased PAI-1 values. SHBG or CBG could not be used as predictors of increased cardiovascular risk during postmenopausal oral HRT.

The haemostatic activity of von Willebrand Factor (VWF) is dependent on VWF multimer stability. Fragments, arising from the proteolytic cleavage of the multimers by VWF-cleaving protease, are ineffective in initiating platelet aggregation. We designed a simple method to determine the protease activity, which was expressed as the reduction in the level of ristocetin-induced platelet aggregation between the inactive enzyme and the enzyme when activated by the addition of calcium. Samples from senior women (n = 14) with chronic coronary heart disease (CHD), age-matched control subjects (n = 15) and young healthy individuals (n = 13), as well as patients with either thrombotic thrombocytopenic purpura (TTP) (n = 2) or von Willebrand disease type 2A (VWD-2A) (n = 2), were examined. The lower protease activity observed in the CHD group, compared with the control subjects, indicated that the increased levels of VWF found in CHD relate to impaired enzyme function. The assessment of TTP patients reconfirmed the reduced protease activity previously observed in this disorder. In VWD-2A, normal enzyme function was observed, suggesting that there is an increased sensitivity of the mutated VWF protein to the protease, rather than an increase in the activity or quantity of the enzyme involved in pathogenesis. In summary, the present simplified method efficiently determines VWF protease activity and is suitable for use in laboratories where platelet aggregation analyses can be performed.

Background: The role of chronic stress in coronary artery disease (CAD) is not well known. Conflicting results have been obtained with regard to the stress hormone cortisol and 'vital exhaustion', a psychological construct defining the effects of long-term stress. We investigated the relationship between chronic stress, assessed by serum cortisol and vital exhaustion, and coronary artery stenosis and the importance of chronic stress in relation to standard risk factors of CAD., Methods and Results: Women, or=50%) had elevated cortisol levels compared to the others (p=0.009). A 25% increase of cortisol increased the probability of significant coronary stenosis by 41% (p=0.005). Compared to standard risk variables of CAD, only high-density lipoprotein cholesterol (HDL-C) was a more important predictor. Each 25% decrease of HDL-C increased the probability of significant coronary stenosis by 65% (p=0.0021). Vital exhaustion was not related to coronary stenosis (p=0.47). However, it appeared to have an additive effect as women with both a cortisol level and vital exhaustion score above the sample median, had a near three-fold risk of having CAD, OR=2.85 (95% CI 1.31-6.18), compared to those who did not have this combination. The results remained after adjusting for age, glucose, and use of calcium channel- and beta-blockers., Conclusion: Cortisol, but not vital exhaustion, was independently related to coronary stenosis in women with acute coronary syndrome. The influence of cortisol was important compared to standard risk factors of CAD.

Objective: This study evaluated the ability of mental stress testing to discriminate between women with and without CHD, and among women with different disease manifestations, taking into account history of hypertension and beta-blocker use., Methods: Analyses were based on data from a community-based case-control study of women aged 65 years or younger. The study group consisted of 292 women who were hospitalized for an acute event of CHD, either AMI or unstable AP in Stockholm between 1991 and 1994. Controls were matched to cases by age and catchment area. Cardiovascular reactivity and emotional response to an anagram task solved under time pressure were measured 3 to 6 months after hospitalization., Results: Patients reacted with smaller increases in heart rate (4 bpm) than their controls (7 bpm). Results for the rate-pressure product were similar. Cardiovascular reactions did not distinguish patients with AP from those with AMI. History of hypertension (present in 50% of patients and 11% of controls) was related to enhanced diastolic blood pressure reactivity. Patients on beta-blockers (66%) had lower heart-rate levels throughout testing, but did not differ in their cardiovascular stress reactions when compared with the remaining participants., Conclusions: Women with heart disease have somewhat lower heart-rate responses to stress than healthy age-matched controls. History of hypertension is related to enhanced diastolic blood pressure reactivity to mental stress in both patients and controls.

Low levels of von Willebrand factor (VWF) in von Willebrand's disease type 2A (VWD 2A) result from increased cleavage of the bond 842Tyr-843Met in the VWF protein by VWF cleaving protease. On the other hand, decreased levels of this protease result in unusually large VWF in thrombotic thrombcytopenic purpura with thrombotic complications. In the present study, we designed an enzyme-liked immunosorbent assay of VWF cleaving protease activity to be used to assess whether the high levels of VWF in coronary heart disease (CHD) relate to a deficiency of this protease. Plasma samples with added Pefabloc and CaCl(2) were incubated with purified VWF coated on a microtiter plate. The remaining undigested multimers were quantified by an antibody directed against the intact 842Tyr-843Met bond of the VWF protein. Phosphate-buffered saline (PBS), instead of plasma, was used to obtain the initial level of coated undigested VWF. The reduction in absorbance at 492 nm between PBS and the unknown sample was taken as a measure of the protease activity. The assay was applied to plasma samples from 21 senior women with chronic CHD (cases) and 34 age-matched controls, as well as to samples from three patients with VWD 2A. The protease activity was similar in the two women groups (P>.05), although the VWF antigen levels were higher in the cases (P<.01). The VWD 2A patients had similar plasma levels of the protease to that in normal pooled plasma (NPP). In the senior controls, the protease activity correlated with the subject age (r's=-.61, P<.01, n=34). In conclusion, the developed method is specific for evaluating the protease function on VWF cleavage. The moderate increase of VWF antigen in chronic CHD may not depend on the protease activity. The age influence on the protease levels supports earlier findings of higher VWF levels in healthy older subjects. A high sensitivity of the mutated protein of VWF for the protease effect rather than increases in activity or quantity of the enzyme is probably involved in the pathogenesis of VWD 2A.

Epidemiological studies of coagulation factor VII as a risk factor for coronary heart disease (CHD), mainly conducted in men, have shown discrepant results. We examined the associations of coagulation factor VII antigen (VIIag) and activated factor VII (VIIa) with manifest CHD in a community-based case-control study of women aged < or =65 years. Mean plasma concentrations of VIIag and VIIa in patients and controls were 443 +/- 10(8) and 418 +/- 89 ng/L (p <0.01) and 5.26 +/- 2.21 and 4.90 +/- 1.65 ng/L (NS), respectively. The odds ratio (OR) for CHD for the highest versus the lowest quartile of VIIag was 1.75 (95% CI, 1.05 to 2.92). The adjusted OR was 0.76 (95% CI, 0.28-1.98) after controlling for other cardiovascular risk factors. The corresponding ORs for VIIa were non-significant. In conclusion, the plasma concentration of VIIa was not significantly increased in a large group of women with precocious CHD, and VIIag levels, although elevated, were not independently associated with manifest disease.

Context: Psychosocial stress has been associated with incidence of coronary heart disease (CHD) in men, but the prognostic impact of such stress rarely has been studied in women., Objective: To investigate the prognostic impact of psychosocial work stress and marital stress among women with CHD., Design and Setting: Population-based, prospective follow-up study conducted in the city of Stockholm, Sweden., Participants: A total of 292 consecutive female patients aged 30 to 65 years (n = 279 working or cohabiting with a male partner) who were hospitalized for acute myocardial infarction or unstable angina pectoris between February 1991 and February 1994. Patients were followed up from the date of clinical examination until August 1997 (median, 4.8 years)., Main Outcome Measures: Recurrent coronary events, including cardiac death, acute myocardial infarction, and revascularization procedures, by marital stress (assessed using the Stockholm Marital Stress Scale, a structured interview) and by work stress (assessed using the ratio of work demand to work control)., Results: Among women who were married or cohabiting with a male partner (n = 187), marital stress was associated with a 2.9-fold (95% confidence interval [CI], 1.3-6. 5) increased risk of recurrent events after adjustment for age, estrogen status, education level, smoking, diagnosis at index event, diabetes mellitus, systolic blood pressure, smoking, triglyceride level, high-density lipoprotein cholesterol level, and left ventricular dysfunction. Among working women (n = 200), work stress did not significantly predict recurrent coronary events (hazard ratio, 1.6; 95% CI, 0.8-3.3)., Conclusions: Our results indicate that marital stress but not work stress predicts poor prognosis in women aged 30 to 65 years with CHD. These findings differ from previous findings in men and suggest that specific preventive measures be tailored to the needs of women with CHD.

Recent studies of men have shown that job stress is important in understanding the occupational gradient in coronary heart disease (CHD), but these relationships have rarely been studied in women. With increasing numbers of women in the workforce it is important to have a more complete understanding of how CHD risk may be mediated by job stress as well as other biological and behavioural risk factors. The objective of this study was to examine the occupational gradient in CHD risk in relation to job stress and other traditional risk factors in currently employed women. We used data from the Stockholm Female Coronary Risk Study, a population based case-control study, comprising 292 women with CHD aged 65 years or younger and 292 age-matched healthy women (controls). An inversely graded association was observed between occupational class and CHD risk. Compared with the highest (executive/professional), women in the lowest occupational class (semi/unskilled) had a four-fold (95% CI 1.75-8.83) increased age-adjusted risk for CHD. Simultaneous adjustment for traditional risk factors and job stress attenuated this risk to 2.45 (95% CI 1.01-6.14). Neither job control nor the Karasek demand-control model of job stress substantially explained the increased CHD risk of women in the lowest occupational classes. It is likely that lower occupational class working women face multiple and sometimes interacting sources of work and non-work stress that are mediated by behavioural and biological factors that increase their CHD risk.

Aims: Several studies have reported that women with coronary heart disease have a poorer prognosis than men. Psychosocial factors, including social isolation and depressive symptoms have been suggested as a possible cause. However, little is known about these factors and their independent predictive value in women. Therefore, we investigated the prognostic impact of depression, lack of social integration and their interaction in the Stockholm Female Coronary Risk Study., Methods and Results: Two hundred and ninety-two women patients aged 30 to 65 years and admitted for an acute coronary event between 1991 and 1994, were followed for 5 years from baseline assessments, which were performed between 3 and 6 months after admission. Lack of social integration and depressive symptoms, assessed at baseline by standardized questionnaires, were associated with recurrent events, including cardiovascular mortality, acute myocardial infarction and revascularization procedures (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). Adjusting for age, diagnosis at index event, symptoms of heart failure, diabetes mellitus, high density lipoprotein (HDL) cholesterol, history of hypertension, systolic blood pressure, smoking, sedentary lifestyle, body mass index, and severity of angina pectoris symptoms, the hazard ratio associated with low (lowest quartile) as compared to high social integration (upper quartile) was 2.3 (95% CI 1.2-4.5) and the hazard ratio associated with two or more (upper three quartiles) as compared to one or no depressive symptoms was 1.9 (95% CI 1.02-3.6)., Conclusions: The presence of two or more depressive symptoms and lack of social integration independently predicted recurrent cardiac events in women with coronary heart disease. Women who were free of both these risk factors, had the best prognosis.

Objective: To investigate 1-year effects of hormone replacement therapy (HRT) on ambulatory blood pressure (ABP) and lipoprotein levels in postmenopausal women with coronary artery disease (CAD)., Methods: Sixty patients at a mean age (+/- SD) of 59 +/- 7 years were randomized into three groups: conjugated equine oestrogens (CEE) 0.625 mg daily (n = 20), 50 microg 17beta-oestradiol transdermally (TTSE) per 24 h (n = 20) or placebo (n = 20) for 18 days, then combined with medroxyprogesterone acetate 5 mg for 10 days. Each cycle of 28 days was repeated for one year., Results: Night-time systolic ABP had decreased by 9.6% (P= 0.0075) in 15 of 18 women in the CEE group and by 22% in 12 of 13 women (P = 0.0034) in the placebo group after 1 year. In the CEE group, a 4.6% rise in daytime systolic ABP (P< 0.05) and a 4.2% rise in night-time systolic ABP (P< 0.05) appeared from baseline to 6 months in 13 of 18 women. In the CEE group (14 women analysed), high-density lipoprotein levels showed a 15.8% increase (P= 0.0018) in 13 women, low-density lipoprotein levels a 15.2% decrease (P= 0.0129) in 12 women and total cholesterol levels a 7.5% decrease (P = 0.057) in 11 women after 1 year. Triglyceride levels showed no changes. In the TTSE group and in the placebo group, with 12 and 13 women analysed respectively, no significant changes appeared., Conclusions: One year of HRT in patients with CAD does not influence ABP. Oral HRT induces beneficial effects on lipoprotein levels.

Objectives: To investigate the effect of short stature on prognosis following an acute event of coronary heart disease (CHD) in women., Setting: All women who were hospitalized for an acute event of CHD in any of the 10 cardiology clinics in greater Stockholm were investigated for the first time in the Stockholm Female Coronary Risk Study between 1991 and 1994, and were followed until August 1997 for recurrent coronary events., Design: A follow-up study of women with either acute myocardial infarction (AMI) or unstable angina pectoris. Median follow-up period was 4.8 years., Subjects: A total of 292 Swedish women. aged 65 years or younger., Main Outcome Measures: Recurrent AMI, death from CHD or revascularization procedure (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting)., Results: Independent of the confounding effects of other risk factors of clinical importance for CHD (age, socioeconomic status, menopausal status, index event, congestive heart failure, angina severity, diabetes, hypertension, smoking, triglycerides and HDL cholesterol), the shortest 25% of women (< 160 cm) had a 2.1-fold (95% CI = 1.0-4.4) increased rate of developing adverse cardiac events (cardiovascular death, recurrent AMI or revascularization procedure) compared with the tallest 25% (> 165 cm). In addition, an increased rate was observed for each 10 cm difference in height (hazard ratio = 1.7, 95% CI = 1.4-2.7). Similar results were observed when analysing each outcome separately., Conclusions: These data indicate that short stature is a strong predictor of poor prognosis after an acute coronary event in women, independent of socioeconomic status and other risk factors for CHD.

Objectives: This study examined the association between educational attainment and coronary heart disease (CHD) and the factors that may explain this association., Methods: This population-based case-control study included 292 women with CHD who were 65 years or younger and 292 age-matched controls., Results: Compared with the adjusted odds ratio for CHD associated with college education, the age-adjusted odds ratio associated with mandatory education (< or = 9 years) was 1.87 (95% confidence interval [CI] = 1.23, 2.84) and the odds ratio for high school education was 1.35 (95% CI = 0.81, 2.25) (P for trend < .01). The odds ratio for mandatory education was reduced by 82%, to 1.16 (95% CI = 0.69, 2.09), after adjustment for psychosocial stress, unhealthy lifestyle patterns, hemostatic factors, hypertension, and lipids., Conclusions: Much of the increased risk of CHD in women with low education appears to be linked to psychosocial stress and lifestyle factors. Hemostatic factors, lipids, and hypertension also contribute to a lesser extent. These factors may be considered in strategies geared to reducing socioeconomic inequalities in cardiovascular health.

Plasma fibrinogen is an independent risk factor for coronary heart disease (CHD) in men; however, its role in women is less clear. We examined the ability of plasma fibrinogen to predict CHD in a community-based, case-control study of women aged 65 years or younger living in the greater Stockholm area. Cases were all patients hospitalized for an acute coronary event between February 1991 and February 1994. Controls were randomly selected from the city census and were matched to cases by age and catchment area. Plasma fibrinogen was measured 3 to 6 months after hospitalization by using a fibrinogen assay based on fibrinogen polymerization time measurement. Of the 292 consecutive cases, 110 (37%) were hospitalized for an acute myocardial infarction and 182 (63%) for angina pectoris. The mean age+/-SD in both patients and controls was 56+/-7 years. Mean levels of plasma fibrinogen in patients and controls were 3.66+/-0.81 and 3.25+/-0.64 g/L (P<0.0001), respectively. The age-adjusted odds ratio (OR) for CHD in the highest versus the lowest quartile of plasma fibrinogen was 6.0 (95% confidence interval [CI], 3.5 to 10.4). After adjustment for age, cigarette smoking, body mass index, systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, triglycerides, and educational level, the OR was 3.0 (95% CI, 1.6 to 5.5). Further adjustment for C-reactive protein yielded the same result. In both premenopausal and postmenopausal women, the multivariate-adjusted ORs were 7.0 (95% CI, 1.8 to 28.3) and 2.1 (95% CI, 1.0 to 4.4), respectively. These results provide evidence that plasma fibrinogen is associated with an excess risk of CHD in women.

Aims: Social relations have been repeatedly linked to coronary heart disease in men, even after careful control for standard risk factors. Women have rarely been studied and results have not been conclusive. We investigated the role of social support in the severity and extent of coronary artery disease in women., Methods and Results: One hundred and thirty-one women, aged 30 to 65 years, who were hospitalized for an acute coronary event and were included in the Stockholm Female Coronary Risk Study, were examined with computer assisted quantitative coronary angiography. Angiographic measures included presence of stenosis greater than 50% in at least one coronary artery (severity) and the number of stenoses greater than 20% within the coronary tree (extent). Social factors included two measures of social support, which were previously shown to predict coronary disease in prospective studies of men. After adjustment for age, lack of social support was associated with both measures of coronary artery disease. With further adjustment for smoking, education, menopausal status, hypertension, high density lipoprotein and body mass index, the risk ratio for stenosis greater than 50% in women with poor as compared to those with strong social support was 2.5 (95% confidence interval 1.2 to 5.3; P=0.003). Also, women with poor social support had more stenoses obstructing at least 20% of the coronary lumen with multivariate adjustment, but the difference from women with strong support was only of borderline significance (P=0.09)., Conclusion: The findings suggest that lack of social support contributes to the severity of coronary artery disease in women, independent of standard risk factors.

Background: A variety of vascular effects have been ascribed to 17 beta-oestradiol. These effects may partially explain the reduced incidence of cardiovascular disease found in post-menopausal women on oestrogen replacement therapy., Objectives: To evaluate the effects of 2 mg sublingual 17 beta-oestradiol on exercise capacity, exercise-induced myocardial ischaemia and circulating levels of endothelin-1 in post-menopausal women with stable coronary artery disease., Methods: Twelve post-menopausal women, mean age 61 (range 52-72) years, with angiographically verified significant coronary artery disease, were randomly assigned to 2 mg of sublingual 17 beta-oestradiol, 2.5 mg of buccal nitroglycerine and to placebo in a double-blind cross-over study design with at least 2 days between each of the study arms. Antianginal medications, with the exception of beta-blockers, were discontinued before investigation. All study patients underwent a maximal bicycle exercise test 30 min after drug intake. Blood was withdrawn immediately before and up to 8 h after medication for analyses of circulating levels of oestradiol and endothelin-1., Results: The mean serum levels of oestradiol increased from a control level of 72 +/- 28 pmol.l-1 to 3557 +/- 1731 pmol.l-1 after 30 min and to 5028 +/- 3971 pmol.l-1 after 60 min with a gradual decline thereafter. Sublingual 17 beta-oestradiol did not induce any improvement in exercise duration when compared with nitroglycerin and placebo (500 +/- 112 s, 505 +/- 107 s, 498 +/- 157 s), and did not influence time to onset of ST-segment depression (358 +/- 89 s, 436 +/- 93 s, 384 +/- 116 s). The plasma levels of endothelin-1 did not change after administration of 17 beta-oestradiol, nitroglycerin or placebo., Conclusions: No effects of exercise capacity, exercise-induced acute ischaemia, or plasma levels of endothelin-1 were found after a single dose of 2 mg 17 beta-oestradiol in post-menopausal women with documented coronary artery disease.

Objective: The aim of the present study was to evaluate the effects of HRT on symptoms of angina pectoris, quality of life and factors of importance for compliance in women with ischemic heart disease., Methods: Sixty postmenopausal women with coronary artery disease were randomized into three groups: one group received transdermal 17 beta-estradiol at a dose of 50 micrograms per 24 h alone for 18 days followed by 10 days of combined treatment with medroxyprogesterone acetate (MPA) 5 mg orally; the second group received placebo and the third group received conjugated estrogens orally for 18 days followed by a combined treatment with MPA for 10 days. Clinical evaluations were performed at baseline, after 3, 6 and 12 months. The investigations included gynecological history. occurrence of climacteric symptoms, quality of life evaluation, cardiac history and symptoms of angina pectoris., Results: Forty-six women (77%) completed the study during 1 year. The following cardiac events occurred in the women who completed the study: one patient was hospitalized because of congestive heart failure (patch), two patients because of angina pectoris, one patient because of coronary bypass operation (CEE) and three patients underwent balloon dilatation (placebo), all three on CEE. Among the 14 women who discontinued, two patients had TIA (patch), one experienced palpitations (CEE) and one woman died from myocardial infarction (placebo). Overall improvement in mood and cognitive functions were reported in all three treatment groups., Conclusions: HRT does not seem to have negative effects on symptoms of angina pectoris and seems to increase quality of life in older women with coronary heart disease. It also seems safe from the cardiovascular point of view.

Background: Hypertriglyceridemia is now accepted as a risk factor for coronary heart disease, although the mechanism behind the increased risk is not well understood. The present study was undertaken to investigate the effects of triglyceridemia on endothelial function, because impaired endothelial function is considered a marker of atherogenesis., Methods and Results: Flow- and nitroglycerin-induced dilatation of the brachial artery was investigated noninvasively by high-resolution ultrasound technique in seven young, healthy men without risk factors for coronary heart disease. Transient triglyceridemia was induced by infusion of a triglyceride emulsion, Intralipid, which raised free fatty acid concentrations twofold and triglyceride levels fourfold. Flow-induced vasodilatation decreased from 7.1+/-3.0% to 1.6+/-2.6% (P<.0002), whereas nitroglycerin-induced vasodilatation decreased from 20.5+/-5.8% to 11.5+/-3.2% (P<.002) before and after 1 hour of infusion of Intralipid, respectively., Conclusions: Transient triglyceridemia decreases vascular reactivity, presumably by both endothelium-dependent and endothelium-independent mechanisms.

Background: Lipoprotein(a) [Lp(a)] appears to be a risk factor for coronary heart disease (CHD) in men. The role of Lp(a) in women, however, is less clear., Methods and Results: We examined the ability of Lp(a) to predict CHD in a population-based case-control study of women 65 years of age or younger who lived in the greater Stockholm area. Subjects were all patients hospitalized for an acute CHD event between February 1991 and February 1994. Control subjects were randomly selected from the city census and were matched to patients by age and catchment area. Lp(a) was measured 3 months after hospitalization by use of an immunoturbidometric method (Incstar) calibrated to the Northwest Lipid Research Laboratories (coefficient of variation was < 9%). Of the 292 consecutive patients, 110 (37%) were hospitalized for an acute myocardial infarction, and 182 were hospitalized (63%) for angina pectoris. The mean age for both patients and control subjects was 56 +/- 7 years. Of participants, 74 patients (25%) and 84 control subjects (29%) were premenopausal. The distributions of Lp(a) were highly skewed in both patients and control subjects, with a range from 0.001 to 1.14 g/L. Age-adjusted odds ratio for CHD in the highest versus the lowest quartile of Lp(a) was 2.3 (95% confidence interval [CI], 1.4 to 3.7). After adjustment for age, smoking, education, body mass index, systolic blood pressure, total cholesterol, triglycerides, and HDL, the odds ratio was 2.9 (95% CI, 1.6 to 5.0). The odds ratios were similar when myocardial infarction and angina patients were compared with their respective control subjects. The odds ratios were 5.1 (95% CI, 1.4 to 18.4) and 2.4 (95% CI, 1.3 to 4.5) in premenopausal and postmenopausal women, respectively., Conclusions: These results suggest that Lp(a) is a determinant of CHD in both premenopausal and postmenopausal women.

Coronary heart disease (CHD) is the most important cause of death and disability among older women. A 50-year-old woman has a 46% risk of having CHD and a 31% risk of dying from it. Female CHD patients have a distinct clinical presentation, which includes more severe thromboembolic disease without coronary arteriosclerosis. Syndrome X also appears to be more prevalent in women. Oestrogen deficiency may be a trigger for this syndrome. The magnitude of the effect of various risk factors may also differ between women and men. In addition, there are risk factors unique to women. Lipid profiles differ between men and women. After menopause, the lipid profile changes unfavourably, with increasing levels of LDL cholesterol and decreasing levels of HDL cholesterol. Cigarette smoking, hypertension, diabetes mellitus, and obesity are all recognised risk factors for CHD in women. It is important to recognise that risk factors for CHD differ between men and women. Advising women to quit cigarette smoking, avoid obesity, increase physical activity, and prevent and treat hypertension and hyperlipidaemia will result in a reduction in CHD risk. Additional studies are needed to further contribute to our understanding of the complex risk factors underlying the development of CHD in women.

Aim. To evaluate the importance of exercise testing (ET) parameters and leisure time physical activity in predicting long-term prognosis in middle-aged women hospitalized for acute coronary syndrome (ACS). Methods and results. Women aged <66 years recently hospitalized for ACS in the Greater Stockholm area in Sweden were recruited. All underwent baseline clinical examinations including ET and then were followed up for 9 years. Nonparticipation in ET had a hazard ratio of 4.26 (95% confidence interval 2.02–8.95) for total mortality and 3.03 (1.03–8.91) for cardiovascular mortality. All ET parameters were significantly different between survivors than nonsurvivors, except for chest pain and ST-segment depression during ET. Sedentary lifestyle and ET parameters were related to total mortality and cardiovascular mortality in a multivariate analysis adjusting for potential confounders. Predictors of total mortality were sedentary lifestyle 2.94 (1.31–6.62), exercise time 1.75 (1.07–2.87) and inadequate haemodynamic responses: low increase in pulse rate 2.04 (1.16–3.60) and systolic blood pressure (SBP) 1.88 (1.19–2.95) from rest to peak exercise. Parameters that predicted cardiovascular mortality were sedentary lifestyle 3.15 (1.13–8.74) and poor increase in SBP 2.76 (1.30–5.86) from rest to peak exercise. The relation of sedentary lifestyle to survival was substantially weakened when exercise parameters were added to the multivariate analysis model. Conclusion. In female patients <66 years surviving ACS, important independent predictors of long-term all-cause mortality were sedentary lifestyle, low physical fitness and inadequate pulse rate and SBP increase during exercise. Predictors of cardiovascular mortality were sedentary lifestyle and inadequate blood pressure response during exercise. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the importance of different clinical parameters predicting long-term cardiac prognosis in younger women with an acute coronary event.Design: The Stockholm Female Coronary Risk Study is a follow-up study in women Setting: Patients were included between 1991 and 1994 from all 10 coronary care or intensive care units in the greater Stockholm area.Subjects: A total of 335 consecutive female patients hospitalized for an acute coronary event.Main Outcome Measures: Cardiac death and nonfatal myocardial infarction (AMI).Results: During the follow-up period of 5 years there were 26 (8%) all cause deaths and 39 (12%) recurrent cardiac events. In the group that participated in the complete study, the following age adjusted parameters were found as strong predictors of adverse outcome: AMI as index event [Hazard Ratio (HR) 9.13, 95% CI 3.09-26.99], diabetes mellitus (HR 4.13, 95% CI 1.68-10.17), left ventricular dysfunction (HR 3.94, 95% CI 1.52-10.17), serum HDL cholesterol <1.0 mmol L-1 (HR 4.01, 95% CI 1.62-6.12), and serum triglycerides >2.0 mmol L-1 (HR 2.46, 95% CI 1.06-5.54). AMI as index event and diabetes mellitus were the most significant predictors in a multivariate statistical model. Diabetes mellitus was the strongest predictor when the analysis was repeated in the total patient cohort, integrating patients that did not participate in the extended investigations.Conclusion: Women aged