The main results of the study were the following: 1. Long-term survival in patients with IHD was markedly poorer in those with MI as first clinical manifestation of the disease as compared to AP; 2. Occurrence of MI during the follow-up was more frequent in patients who had already a MI than in the others. 3. Coronary atherosclerosis was prevalent in MI independently by sex. 4. Female sex was preferentially associated with AP course, had a significantly lower incidence of MI during the follow-up and a better long-term outcome.
To our knowledge, this is the first report that correlates the long-term prognosis of IHD to the modality of its first clinical manifestation and underlines that patients with persistent episodes of angina but free of MI infrequently report MI during the follow-up, differently from patients with initial MI. Moreover, our study underlines the role of sex in the clinical phenotype of IHD and its progression.
Comparison with previous studies
Our study expands the investigation to a relatively large cohort of well characterized patients with IHD with a mean follow-up period of 10 years, and in particular provides additional evidence regarding the follow-up events in the two IHD phenotypes which did never overlap until the index hospitalization and database inclusion. It is important to consider, that the overlap between the two phenotypes is quite common in the populations enrolled in many studies which makes quite difficult to compare the results [
14‐
16].
In the present study the proportion of MI and AP patients was quite similar, which is in contrast with the reported lower prevalence of MI as first presentation of IHD as compared to angina without infarction [
6]. A recent report from American Heart Association reports a prevalence around 2.8% for MI and 3.8 for AP [
17]. The discrepancy with our population could be due to different selection criteria. Patients in our study were consecutive and < = 70 years old, most admitted
for special investigation and treatment as coronary angiography and or PCI, without history of congestive heart failure (group AP). Another reason could be the different prevalence of AP and MI in different countries. In the Hemingway meta-analysis, angina prevalence varied approximately 20-fold between countries, ranging from 0.73 to 14.4% in women and 0.76 to 15.1% in men [
18]. In Italy the reported prevalence of the two phenotypes is very similar and this could explain our results [
19,
20].
The overall prognosis was significantly more benign in AP and in particular the incidence of new MI during follow-up (0.9/100 patient years vs 1.6/100 patient years,
p < 0.001), which was lower than the one reported by Daly et al. (3.2/100 patient years, CI 2.3–4.4) [
21] and in other trials (ranging from 1.1 to 1.5%) [
21‐
24]. The re-infarction rate was also in the lower range of the one reported in the literature (range 1.8–6.9% year in different studies, 95% CI 0.97–1.77,
P = 0.08.) [
25]. The difference might reflect the duration of follow-up, age, inclusion and exclusion criteria, coronary atherosclerosis involvement, type of treatment. This study included in both groups, with a prevalence in AP (25% vs 7%), patients with normal coronary vessels who have a well known good prognosis. However, the Kaplan-Meier estimates of MI occurrence performed excluding patients with normal coronary vessels obtained similar results (Additional file
2: Figure S3a). Our study was a single-center study and all patients received similar treatment at discharge as secondary prevention and revascularization procedure when required.
In the literature, MI databases report on the significance of angina before and/or after MI [
3,
5,
16,
26], and stress the association of angina with higher likelihood of readmission to the hospital, and higher risk of events [
26] but can hardly be compared with our results due to different criteria of patients’ selection, modalities and duration of follow-up.
The severity and location of the coronary lesions are among the main factors that have been compared in the two ischemic syndromes in the literature and that have been taken into account to explain the differences in clinical outcomes [
27,
28]. A number of studies reported that patients with AP have more severe and extensive coronary lesions than patients with acute unheralded MI [
29]. According with more recent papers [
16] we found a higher coronary atherosclerotic involvement (expressed as average number of main coronary diseased vessels at target coronary angiography) in MI compared to AP patients, and the extent of coronary atherosclerosis was predictive of new infarct during the follow-up.
IHD and sex
A major result of the study was that the different association of sex with the two manifestations of IHD does not wane over time. In contrast with previous studies [
6,
18,
30,
31], we compared the two IHD phenotypes of similar age and followed them for a longer time period to investigate the persisting long term effect of sex on MI occurrence independently by age. In the AP group, the incidence of new MI was still significantly lower in females, while no significant difference between sexes was found in the MI group (Fig.
3). On the contrary, sex did not have any significant effect on cardiac and non-cardiac death at approximately 20 years (Additional file
4: Figure S4 and Additional file
5: Figure S5). To the best of our knowledge, this long-term different effect of sex on the two phenotypes of IHD and on (re)infarction rate has never been reported in a large population
.
The mechanisms through which sex participates in the pathogenesis of IHD remains speculative [
32]. It is assumed that exposure to endogenous estrogens during the fertile period of life delays the development of atherosclerosis in women. In the Women’s Ischemia Syndrome Evaluation (WISE) study it was shown that young women with endogenous estrogen deficiency have a more than sevenfold increase in coronary event risk [
33]. Our results showed that the protective effect in females was evident in the AP group and persisted after menopausal age, preventing acute cardiac instability and MI. On the other hand the female sex was not protective against cardiac and total mortality in both IHD phenotypes (MI or AP). This was in accord with previous report on the adverse IHD prognosis in women [
33]. Adverse coronary reactivity and microvascular dysfunction have been suggested as contributory factors to a female-specific myocardial ischemia pathophysiology [
32]. Moreover differences in medical strategy in the follow-up comparing to men cannot be excluded. Finally, new MI in females could have been underestimated particularly if considered that sex did not have any significant effect on cardiac and non-cardiac death. It’s known that women compared to men are more frequently underdiagnosed for acute MI and they are less frequently studied with coronary angiography.
Study limitations
Our study has several potential limitations. It was a single-center study, which, on the other way, meant similar treatment at discharge.
The type and number of events occurring in the two groups from disease onset to the time of enrollment in the study were carefully taken into account. However, it should be considered that the patients enrolled in the study were only those newly affected by IHD who survived from the onset of the disease up to the time of enrollment. In other words, the incidence of death in our study as well as the final disparity in outcome between the two groups were underestimated in proportion to the time elapsed between onset and enrollment (average 4 years in our study).
During the follow-up we had no information either on the site of the new infarct in all patients or on the potential progression of coronary disease in the follow-up in those not undergoing a new coronary angiography. As such, we cannot definitively draw conclusions on the coronary atherosclerotic burden leading to new MI.
We did not use time-dependent covariates in the Cox model and we cannot exclude the effect of changes in life style, such as smoking cessation on mortality curves.
Moreover, we did not have detailed information on the interim changes in medical treatment as compared to time of enrollment. At discharge from the hospital, medical treatment and lifestyle recommendations did not differ substantially in the two groups and were generally comparable in women and men. During the follow-up medical therapy was left to the clinical judgment of the referring physician-cardiologist. Some chronic medical therapy are associated to a reduced risk of events, such as aspirin or statins or beta-blockers and angiotensin-converting enzyme inhibitors. Although we did not have detailed information regarding medical treatment during follow-up, we feel confident that patients adhered to the best therapy according to physician recommendations.