Gender, Anxiety, and Myocardial Ischemia During Exercise

Study Questions:

Do sex differences influence the association of mood disorders and myocardial ischemia during exercise?


Patients referred to a single medical center for single-photon emission computed tomography (SPECT) stress testing were included in this analysis. Only stable patients were included; no patients with conditions that increased morbidity significantly (such as chronic obstructive pulmonary disease), who were inpatients, or who had a recent cardiac event (such as coronary artery bypass grafting) were excluded. Data were collected between September 1998 and June 2002. A total of 2,342 patients including 760 women completed SPECT exercise stress testing in addition to a psychiatric interview (PRIME-MD). Mood disorders including anxiety were the primary exposures of interest. The primary outcome was ischemia observed on SPECT imaging. Patients with and without coronary artery disease (CAD) were included.


In this cohort of 2,342 patients, men were more likely to have cardiovascular disease risk factors (including current or prior smoking) and prior history of CAD. Men also were more likely to be taking cardiac medications including vasodilators, beta-blockers, calcium-channel blockers, angiotensin-converting enzyme inhibitors, aspirin, and lipid-lowering medications, with the exception of diuretics, which were more frequently prescribed in women. Women were more likely to have any psychiatric disorder, any anxiety disorder, any mood disorder, and any comorbid anxiety and mood disorders. Among patients without a history of CAD, women with anxiety were more likely to have ischemia during exercise compared to women without anxiety (odds ratio, 175; 95% confidence interval, 1.05-2.89). Among women with a history of CAD, no increased risk of ischemia was observed for women with anxiety compared to those without anxiety. Among men, no significant effects were observed for men for mood. However, men displayed a greater prevalence of ischemia compared to women.


The investigators concluded that women with anxiety and no CAD history had higher rates of ischemia than women without anxiety. Since symptoms of anxiety and CAD may overlap, the investigators suggest that anxiety symptoms may mask CAD symptoms and thus contribute to referral and diagnostic delays.


These data suggest that anxiety may be common among women, and among those without CAD, anxiety may co-exist with ischemia. Given this is from one medical center and selection biases related to testing may exist, further research is warranted.

Clinical Topics: Dyslipidemia, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Computed Tomography, Nuclear Imaging, Smoking

Keywords: Anxiety, Angiotensin-Converting Enzyme Inhibitors, Aspirin, Calcium Channel Blockers, Coronary Artery Disease, Depression, Diuretics, Exercise Test, Lipids, Mood Disorders, Myocardial Ischemia, Risk Factors, Sex Characteristics, Smoking, Tomography, Emission-Computed, Single-Photon, Vasodilator Agents

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