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Intranasal steroids vs antihistamines: Which is better for seasonal allergies and conjunctivitis?
INTRANASAL STEROIDS PROVIDE BETTER RELIEF for adult sufferers, according to nonstandardized, nonclinically validated scales. Steroids reduce subjective total nasal symptom scores (TNSS)—representing sneezing, itching, congestion, and rhinorrhea—by about 25% more than placebo, whereas oral antihistamines decrease TNSS by 5% to 10% (strength of recommendation [SOR]: B, systematic review of randomized controlled trials [RCTs], most without clinically validated or standardized outcome measures).
Intranasal steroids improve subjective eye symptom scores as well as (or better than) oral antihistamines in adults who also have allergic conjunctivitis (SOR: A, systematic review, RCTs).
Evidence summary
The most commonly measured outcomes in allergic rhinitis and conjunctivitis trials are symptom scales, which are neither standardized nor clinically validated. Almost all the studies discussed here calculated outcomes as a percentage change from baseline symptom scores but didn’t provide absolute values, so it isn’t clear whether statistical differences are clinically relevant.
Steroids provide more relief of nasal symptoms
A meta-analysis of 21 randomized placebo-controlled trials (total 2821 patients, average age mid-30s) that compared changes in TNSS with intranasal steroids and oral antihistamines among adults with seasonal allergic rhinitis found that steroids reduced TNSS more than antihistamines.1 Most of the patients had had moderate to severe symptoms for several years.
Investigators calculated percent changes from baseline in mean TNSS, which typically included sneezing, itching, congestion, and rhinorrhea, each usually scored on a scale of 0 to 3.1 Individual RCTs compared one of 3 intranasal steroids (fluticasone, triamcinolone, or budesonide) and one of 3 oral antihistamines (cetirizine, loratadine, or fexofenadine) with placebo; no studies compared medications within classes against each other.1
On individual symptom scores, intranasal steroids reduced sneezing, itching, congestion, and rhinorrhea more than placebo by more than 20%. Both intranasal steroids and oral antihistamines decreased itching and rhinorrhea a similar amount, but antihistamines reduced congestion by only 5% to 10% more than placebo.1
This meta-analysis included only studies reporting TNSS as an outcome, and individual studies used varying TNSS scales. Investigators attributed heterogeneity in the studies to intraclass differences between medications.1
Two drug company-sponsored RCTs (1616 patients combined, average age 30s, moderate to severe allergic rhinitis) published before the meta-analysis also demonstrated that the intranasal steroid fluticasone propionate modestly reduced TNSS compared with the oral antihistamine fexofenadine (1 point vs 1.3 on a scale of 0 to 12).2 TABLE 1 summarizes the results of studies comparing intranasal steroids and oral antihistamines to reduce nasal symptoms.
TABLE 1
Intranasal steroids vs oral antihistamines for nasal symptom relief
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review of RCTs1 | INS: 7 RCTs (total N=597) OAH: 14 RCTs (total N=2224) | Mean percentage change in TNSS from baseline: INS: –40.7% OAH: –23.5% Placebo: –15.0% | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | Not reported |
| Two RCTs, double blind, double dummy2 | Study 1* INS (N=312) OAH (N=311) Placebo (N=313) Study 2* INS (N=224) OAH (N=227) Placebo (N=229) Duration 2 wk | Least squares mean difference from baseline TNSS score of INS vs OAH: Study 1: TNSS: –1.0 (95% CI, –0.7 to –1.4) Study 2: TNSS: –1.3 (95% CI, –0.9 to –1.7) | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, inhaled nasal steroids; OAH, oral antihistamine; RCTs, randomized controlled trials; TNSS, total nasal symptom score. *The INS used was fluticasone furoate; the OAH used was fexofenadine. | ||||
Results for eye symptoms are mixed
A meta-analysis of 11 RCTs (1317 patients, average age 32) showed no significant difference in relief of eye symptoms between oral antihistamines (dexchlorpheniramine, terfenadine, and loratadine) and intranasal steroids (budesonide, beclomethasone, fluticasone, and triamcinolone) in patients with seasonal allergies, as measured by various symptom scores.3
Three other studies indicated that intranasal steroids (triamcinolone, fluticasone) relieved eye symptoms more effectively than oral antihistamines (loratadine, fexofenadine) based on mean reductions in TNSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Total Ocular Symptom Score (TOSS).4-6 Of these scoring systems, only the RQLQ has been clinically validated.7
One additional study (including 2 RCTs) showed conflicting results.2 TABLE 2 summarizes the results of studies comparing intranasal steroids and oral antihistamines to relieve eye symptoms.
TABLE 2
How intranasal steroids compare with oral antihistamines for reducing eye symptoms
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review3 | INS vs OAH 11 RCTs reporting ocular symptoms, N=1317 | OR for deterioration or no change of varied scoring systems: –0.043 (CI, –0.157 to 0.072) | No significant difference between INS and OAH scores | Not reported |
| RCT, double blind, double dummy5 | INS (triamcinolone acetonide), N=153 OAH (loratadine), N=152 | Percent reduction from mean baseline TNS ocular score: INS: 59% OAH: 48% Total TNS ocular score: 3 | Changes in INS scores significantly greater than changes in OAH scores (P<.05) | INS: headache (22%), anxiety (<1%), epistaxis (<1%) OAH: headache (18%), increase in rhinitis symptoms (2%), conjunctivitis (<1%) |
| RCT, double blind, double dummy4 | INS (fluticasone propionate), N=150 OAH (loratadine), N=150 INS+OAH, N=150 Placebo, N=150 Duration 2 wk | Mean change in RQLQ ocular score from baseline: INS: –1.9 OAH: –1.3 Total RQLQ ocular score: 6 | Changes in INS scores significantly greater than changes in OAH scores (P<.05; 0.5 change in score is clinically significant) | INS and OAH: blood in mucus (1%-2%), xerostomia (1%-2%), epistaxis (<1%) |
| RCT, double blind, double dummy6 | INS (fluticasone propionate), N=158 OAH (loratadine), N=158 Placebo, N=155 Duration 4 wk | Mean change in TOSS score from baseline: INS: –88.7±5.3 OAH: 72.5±5.4 Total TOSS score: 100 | Changes in INS scores significantly greater than changes in OAH scores (P<.045) | INS: headache (17%) OAH: headache (18%) |
| Two RCTs, double blind, double dummy2 | Study 1: INS (fluticasone furoate), N=312 OAH (fexofenadine), N=311 Study 2: INS (fluticasone furoate), N=224 OAH (fexofenadine), N=227 Duration 2 wk | Least squares mean difference from baseline TOSS2 score: Study 1: TOSS2: –0.3 (95% CI, –0.6 to 0.0; P<.106) Study 2: TOSS2: –0.6 (95% CI, –0.9 to –0.2; P=.002) Total TOSS2 score: 9 | Changes in INS scores significantly greater than changes in OAH scores for Study 2 (P=.002) but not for Study 1 (P<.106) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, intranasal steroids; OAH, oral antihistamines; OR, odds ratio; RCT, randomized controlled trial; RQLQ, rhinoconjunctivitis quality of life questionnaire; TNS, total nasal score; TNSS, total nasal symptom score; TOSS, total ocular symptom score; TOSS2, (variation of) total ocular symptom score. | ||||
Antihistamines cost less than steroids and are available OTC
Oral antihistamines are less expensive than intranasal steroids and are available over the counter. The cost of antihistamines ranges from $5.70 to $21.99 for a month of treatment, whereas the cost of intranasal steroids for the same period varies from $60.99 to $149.99.8
In the studies reviewed here, the 2 interventions showed similar harms, including sore throat, epistaxis, and headache.2,4-6
Recommendations
The American Academy of Allergy, Asthma and Immunology’s 2010 guidelines conclude that intranasal steroids are first-line treatment for allergic rhinitis. If the patient prefers, use oral antihistamines.9
The Joint Task Force on Practice Parameters for Allergy and Immunology also recommends intranasal steroids as the most effective medication class for treating allergic rhinitis; no drug within the class is preferable to another. Daily administration is more effective than administration as needed, although the latter is an option. For treating ocular symptoms, intranasal corticosteroids and oral antihistamines work equally well.10
1. Benninger M, Farrar JR, Blaiss M, et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy Asthma Immunol. 2010;104:13-29.
2. Andrews CP, Martin BG, Jacobs RL, et al. Fluticasone furoate nasal spray is more effective than fexofenadine for nighttime symptoms of seasonal allergy. Allergy Asthma Proc. 2009;30:128-138.
3. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317:1624-1629.
4. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47:118-125.
5. Gawchik SM, Lim J. Comparison of intranasal triamcinolone acetonide with oral loratadine in the treatment of seasonal ragweed-induced allergic rhinitis. Am J Manag Care. 1997;3:1052-1058.
6. Bernstein DI, Levy AL, Hampel FC, et al. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy. 2004;34:952-957.
7. Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol. 1997;99:S742-S749.
8. www.drugstore.com. Accessed March 20, 2012.
9. Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.
10. Wallace DV, Dykewicz MS, Bernstein DI, et al. Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl 2):S1-S84.
INTRANASAL STEROIDS PROVIDE BETTER RELIEF for adult sufferers, according to nonstandardized, nonclinically validated scales. Steroids reduce subjective total nasal symptom scores (TNSS)—representing sneezing, itching, congestion, and rhinorrhea—by about 25% more than placebo, whereas oral antihistamines decrease TNSS by 5% to 10% (strength of recommendation [SOR]: B, systematic review of randomized controlled trials [RCTs], most without clinically validated or standardized outcome measures).
Intranasal steroids improve subjective eye symptom scores as well as (or better than) oral antihistamines in adults who also have allergic conjunctivitis (SOR: A, systematic review, RCTs).
Evidence summary
The most commonly measured outcomes in allergic rhinitis and conjunctivitis trials are symptom scales, which are neither standardized nor clinically validated. Almost all the studies discussed here calculated outcomes as a percentage change from baseline symptom scores but didn’t provide absolute values, so it isn’t clear whether statistical differences are clinically relevant.
Steroids provide more relief of nasal symptoms
A meta-analysis of 21 randomized placebo-controlled trials (total 2821 patients, average age mid-30s) that compared changes in TNSS with intranasal steroids and oral antihistamines among adults with seasonal allergic rhinitis found that steroids reduced TNSS more than antihistamines.1 Most of the patients had had moderate to severe symptoms for several years.
Investigators calculated percent changes from baseline in mean TNSS, which typically included sneezing, itching, congestion, and rhinorrhea, each usually scored on a scale of 0 to 3.1 Individual RCTs compared one of 3 intranasal steroids (fluticasone, triamcinolone, or budesonide) and one of 3 oral antihistamines (cetirizine, loratadine, or fexofenadine) with placebo; no studies compared medications within classes against each other.1
On individual symptom scores, intranasal steroids reduced sneezing, itching, congestion, and rhinorrhea more than placebo by more than 20%. Both intranasal steroids and oral antihistamines decreased itching and rhinorrhea a similar amount, but antihistamines reduced congestion by only 5% to 10% more than placebo.1
This meta-analysis included only studies reporting TNSS as an outcome, and individual studies used varying TNSS scales. Investigators attributed heterogeneity in the studies to intraclass differences between medications.1
Two drug company-sponsored RCTs (1616 patients combined, average age 30s, moderate to severe allergic rhinitis) published before the meta-analysis also demonstrated that the intranasal steroid fluticasone propionate modestly reduced TNSS compared with the oral antihistamine fexofenadine (1 point vs 1.3 on a scale of 0 to 12).2 TABLE 1 summarizes the results of studies comparing intranasal steroids and oral antihistamines to reduce nasal symptoms.
TABLE 1
Intranasal steroids vs oral antihistamines for nasal symptom relief
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review of RCTs1 | INS: 7 RCTs (total N=597) OAH: 14 RCTs (total N=2224) | Mean percentage change in TNSS from baseline: INS: –40.7% OAH: –23.5% Placebo: –15.0% | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | Not reported |
| Two RCTs, double blind, double dummy2 | Study 1* INS (N=312) OAH (N=311) Placebo (N=313) Study 2* INS (N=224) OAH (N=227) Placebo (N=229) Duration 2 wk | Least squares mean difference from baseline TNSS score of INS vs OAH: Study 1: TNSS: –1.0 (95% CI, –0.7 to –1.4) Study 2: TNSS: –1.3 (95% CI, –0.9 to –1.7) | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, inhaled nasal steroids; OAH, oral antihistamine; RCTs, randomized controlled trials; TNSS, total nasal symptom score. *The INS used was fluticasone furoate; the OAH used was fexofenadine. | ||||
Results for eye symptoms are mixed
A meta-analysis of 11 RCTs (1317 patients, average age 32) showed no significant difference in relief of eye symptoms between oral antihistamines (dexchlorpheniramine, terfenadine, and loratadine) and intranasal steroids (budesonide, beclomethasone, fluticasone, and triamcinolone) in patients with seasonal allergies, as measured by various symptom scores.3
Three other studies indicated that intranasal steroids (triamcinolone, fluticasone) relieved eye symptoms more effectively than oral antihistamines (loratadine, fexofenadine) based on mean reductions in TNSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Total Ocular Symptom Score (TOSS).4-6 Of these scoring systems, only the RQLQ has been clinically validated.7
One additional study (including 2 RCTs) showed conflicting results.2 TABLE 2 summarizes the results of studies comparing intranasal steroids and oral antihistamines to relieve eye symptoms.
TABLE 2
How intranasal steroids compare with oral antihistamines for reducing eye symptoms
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review3 | INS vs OAH 11 RCTs reporting ocular symptoms, N=1317 | OR for deterioration or no change of varied scoring systems: –0.043 (CI, –0.157 to 0.072) | No significant difference between INS and OAH scores | Not reported |
| RCT, double blind, double dummy5 | INS (triamcinolone acetonide), N=153 OAH (loratadine), N=152 | Percent reduction from mean baseline TNS ocular score: INS: 59% OAH: 48% Total TNS ocular score: 3 | Changes in INS scores significantly greater than changes in OAH scores (P<.05) | INS: headache (22%), anxiety (<1%), epistaxis (<1%) OAH: headache (18%), increase in rhinitis symptoms (2%), conjunctivitis (<1%) |
| RCT, double blind, double dummy4 | INS (fluticasone propionate), N=150 OAH (loratadine), N=150 INS+OAH, N=150 Placebo, N=150 Duration 2 wk | Mean change in RQLQ ocular score from baseline: INS: –1.9 OAH: –1.3 Total RQLQ ocular score: 6 | Changes in INS scores significantly greater than changes in OAH scores (P<.05; 0.5 change in score is clinically significant) | INS and OAH: blood in mucus (1%-2%), xerostomia (1%-2%), epistaxis (<1%) |
| RCT, double blind, double dummy6 | INS (fluticasone propionate), N=158 OAH (loratadine), N=158 Placebo, N=155 Duration 4 wk | Mean change in TOSS score from baseline: INS: –88.7±5.3 OAH: 72.5±5.4 Total TOSS score: 100 | Changes in INS scores significantly greater than changes in OAH scores (P<.045) | INS: headache (17%) OAH: headache (18%) |
| Two RCTs, double blind, double dummy2 | Study 1: INS (fluticasone furoate), N=312 OAH (fexofenadine), N=311 Study 2: INS (fluticasone furoate), N=224 OAH (fexofenadine), N=227 Duration 2 wk | Least squares mean difference from baseline TOSS2 score: Study 1: TOSS2: –0.3 (95% CI, –0.6 to 0.0; P<.106) Study 2: TOSS2: –0.6 (95% CI, –0.9 to –0.2; P=.002) Total TOSS2 score: 9 | Changes in INS scores significantly greater than changes in OAH scores for Study 2 (P=.002) but not for Study 1 (P<.106) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, intranasal steroids; OAH, oral antihistamines; OR, odds ratio; RCT, randomized controlled trial; RQLQ, rhinoconjunctivitis quality of life questionnaire; TNS, total nasal score; TNSS, total nasal symptom score; TOSS, total ocular symptom score; TOSS2, (variation of) total ocular symptom score. | ||||
Antihistamines cost less than steroids and are available OTC
Oral antihistamines are less expensive than intranasal steroids and are available over the counter. The cost of antihistamines ranges from $5.70 to $21.99 for a month of treatment, whereas the cost of intranasal steroids for the same period varies from $60.99 to $149.99.8
In the studies reviewed here, the 2 interventions showed similar harms, including sore throat, epistaxis, and headache.2,4-6
Recommendations
The American Academy of Allergy, Asthma and Immunology’s 2010 guidelines conclude that intranasal steroids are first-line treatment for allergic rhinitis. If the patient prefers, use oral antihistamines.9
The Joint Task Force on Practice Parameters for Allergy and Immunology also recommends intranasal steroids as the most effective medication class for treating allergic rhinitis; no drug within the class is preferable to another. Daily administration is more effective than administration as needed, although the latter is an option. For treating ocular symptoms, intranasal corticosteroids and oral antihistamines work equally well.10
INTRANASAL STEROIDS PROVIDE BETTER RELIEF for adult sufferers, according to nonstandardized, nonclinically validated scales. Steroids reduce subjective total nasal symptom scores (TNSS)—representing sneezing, itching, congestion, and rhinorrhea—by about 25% more than placebo, whereas oral antihistamines decrease TNSS by 5% to 10% (strength of recommendation [SOR]: B, systematic review of randomized controlled trials [RCTs], most without clinically validated or standardized outcome measures).
Intranasal steroids improve subjective eye symptom scores as well as (or better than) oral antihistamines in adults who also have allergic conjunctivitis (SOR: A, systematic review, RCTs).
Evidence summary
The most commonly measured outcomes in allergic rhinitis and conjunctivitis trials are symptom scales, which are neither standardized nor clinically validated. Almost all the studies discussed here calculated outcomes as a percentage change from baseline symptom scores but didn’t provide absolute values, so it isn’t clear whether statistical differences are clinically relevant.
Steroids provide more relief of nasal symptoms
A meta-analysis of 21 randomized placebo-controlled trials (total 2821 patients, average age mid-30s) that compared changes in TNSS with intranasal steroids and oral antihistamines among adults with seasonal allergic rhinitis found that steroids reduced TNSS more than antihistamines.1 Most of the patients had had moderate to severe symptoms for several years.
Investigators calculated percent changes from baseline in mean TNSS, which typically included sneezing, itching, congestion, and rhinorrhea, each usually scored on a scale of 0 to 3.1 Individual RCTs compared one of 3 intranasal steroids (fluticasone, triamcinolone, or budesonide) and one of 3 oral antihistamines (cetirizine, loratadine, or fexofenadine) with placebo; no studies compared medications within classes against each other.1
On individual symptom scores, intranasal steroids reduced sneezing, itching, congestion, and rhinorrhea more than placebo by more than 20%. Both intranasal steroids and oral antihistamines decreased itching and rhinorrhea a similar amount, but antihistamines reduced congestion by only 5% to 10% more than placebo.1
This meta-analysis included only studies reporting TNSS as an outcome, and individual studies used varying TNSS scales. Investigators attributed heterogeneity in the studies to intraclass differences between medications.1
Two drug company-sponsored RCTs (1616 patients combined, average age 30s, moderate to severe allergic rhinitis) published before the meta-analysis also demonstrated that the intranasal steroid fluticasone propionate modestly reduced TNSS compared with the oral antihistamine fexofenadine (1 point vs 1.3 on a scale of 0 to 12).2 TABLE 1 summarizes the results of studies comparing intranasal steroids and oral antihistamines to reduce nasal symptoms.
TABLE 1
Intranasal steroids vs oral antihistamines for nasal symptom relief
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review of RCTs1 | INS: 7 RCTs (total N=597) OAH: 14 RCTs (total N=2224) | Mean percentage change in TNSS from baseline: INS: –40.7% OAH: –23.5% Placebo: –15.0% | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | Not reported |
| Two RCTs, double blind, double dummy2 | Study 1* INS (N=312) OAH (N=311) Placebo (N=313) Study 2* INS (N=224) OAH (N=227) Placebo (N=229) Duration 2 wk | Least squares mean difference from baseline TNSS score of INS vs OAH: Study 1: TNSS: –1.0 (95% CI, –0.7 to –1.4) Study 2: TNSS: –1.3 (95% CI, –0.9 to –1.7) | Changes in INS scores significantly greater than changes in OAH scores (P<.001) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, inhaled nasal steroids; OAH, oral antihistamine; RCTs, randomized controlled trials; TNSS, total nasal symptom score. *The INS used was fluticasone furoate; the OAH used was fexofenadine. | ||||
Results for eye symptoms are mixed
A meta-analysis of 11 RCTs (1317 patients, average age 32) showed no significant difference in relief of eye symptoms between oral antihistamines (dexchlorpheniramine, terfenadine, and loratadine) and intranasal steroids (budesonide, beclomethasone, fluticasone, and triamcinolone) in patients with seasonal allergies, as measured by various symptom scores.3
Three other studies indicated that intranasal steroids (triamcinolone, fluticasone) relieved eye symptoms more effectively than oral antihistamines (loratadine, fexofenadine) based on mean reductions in TNSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Total Ocular Symptom Score (TOSS).4-6 Of these scoring systems, only the RQLQ has been clinically validated.7
One additional study (including 2 RCTs) showed conflicting results.2 TABLE 2 summarizes the results of studies comparing intranasal steroids and oral antihistamines to relieve eye symptoms.
TABLE 2
How intranasal steroids compare with oral antihistamines for reducing eye symptoms
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review3 | INS vs OAH 11 RCTs reporting ocular symptoms, N=1317 | OR for deterioration or no change of varied scoring systems: –0.043 (CI, –0.157 to 0.072) | No significant difference between INS and OAH scores | Not reported |
| RCT, double blind, double dummy5 | INS (triamcinolone acetonide), N=153 OAH (loratadine), N=152 | Percent reduction from mean baseline TNS ocular score: INS: 59% OAH: 48% Total TNS ocular score: 3 | Changes in INS scores significantly greater than changes in OAH scores (P<.05) | INS: headache (22%), anxiety (<1%), epistaxis (<1%) OAH: headache (18%), increase in rhinitis symptoms (2%), conjunctivitis (<1%) |
| RCT, double blind, double dummy4 | INS (fluticasone propionate), N=150 OAH (loratadine), N=150 INS+OAH, N=150 Placebo, N=150 Duration 2 wk | Mean change in RQLQ ocular score from baseline: INS: –1.9 OAH: –1.3 Total RQLQ ocular score: 6 | Changes in INS scores significantly greater than changes in OAH scores (P<.05; 0.5 change in score is clinically significant) | INS and OAH: blood in mucus (1%-2%), xerostomia (1%-2%), epistaxis (<1%) |
| RCT, double blind, double dummy6 | INS (fluticasone propionate), N=158 OAH (loratadine), N=158 Placebo, N=155 Duration 4 wk | Mean change in TOSS score from baseline: INS: –88.7±5.3 OAH: 72.5±5.4 Total TOSS score: 100 | Changes in INS scores significantly greater than changes in OAH scores (P<.045) | INS: headache (17%) OAH: headache (18%) |
| Two RCTs, double blind, double dummy2 | Study 1: INS (fluticasone furoate), N=312 OAH (fexofenadine), N=311 Study 2: INS (fluticasone furoate), N=224 OAH (fexofenadine), N=227 Duration 2 wk | Least squares mean difference from baseline TOSS2 score: Study 1: TOSS2: –0.3 (95% CI, –0.6 to 0.0; P<.106) Study 2: TOSS2: –0.6 (95% CI, –0.9 to –0.2; P=.002) Total TOSS2 score: 9 | Changes in INS scores significantly greater than changes in OAH scores for Study 2 (P=.002) but not for Study 1 (P<.106) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, intranasal steroids; OAH, oral antihistamines; OR, odds ratio; RCT, randomized controlled trial; RQLQ, rhinoconjunctivitis quality of life questionnaire; TNS, total nasal score; TNSS, total nasal symptom score; TOSS, total ocular symptom score; TOSS2, (variation of) total ocular symptom score. | ||||
Antihistamines cost less than steroids and are available OTC
Oral antihistamines are less expensive than intranasal steroids and are available over the counter. The cost of antihistamines ranges from $5.70 to $21.99 for a month of treatment, whereas the cost of intranasal steroids for the same period varies from $60.99 to $149.99.8
In the studies reviewed here, the 2 interventions showed similar harms, including sore throat, epistaxis, and headache.2,4-6
Recommendations
The American Academy of Allergy, Asthma and Immunology’s 2010 guidelines conclude that intranasal steroids are first-line treatment for allergic rhinitis. If the patient prefers, use oral antihistamines.9
The Joint Task Force on Practice Parameters for Allergy and Immunology also recommends intranasal steroids as the most effective medication class for treating allergic rhinitis; no drug within the class is preferable to another. Daily administration is more effective than administration as needed, although the latter is an option. For treating ocular symptoms, intranasal corticosteroids and oral antihistamines work equally well.10
1. Benninger M, Farrar JR, Blaiss M, et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy Asthma Immunol. 2010;104:13-29.
2. Andrews CP, Martin BG, Jacobs RL, et al. Fluticasone furoate nasal spray is more effective than fexofenadine for nighttime symptoms of seasonal allergy. Allergy Asthma Proc. 2009;30:128-138.
3. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317:1624-1629.
4. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47:118-125.
5. Gawchik SM, Lim J. Comparison of intranasal triamcinolone acetonide with oral loratadine in the treatment of seasonal ragweed-induced allergic rhinitis. Am J Manag Care. 1997;3:1052-1058.
6. Bernstein DI, Levy AL, Hampel FC, et al. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy. 2004;34:952-957.
7. Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol. 1997;99:S742-S749.
8. www.drugstore.com. Accessed March 20, 2012.
9. Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.
10. Wallace DV, Dykewicz MS, Bernstein DI, et al. Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl 2):S1-S84.
1. Benninger M, Farrar JR, Blaiss M, et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy Asthma Immunol. 2010;104:13-29.
2. Andrews CP, Martin BG, Jacobs RL, et al. Fluticasone furoate nasal spray is more effective than fexofenadine for nighttime symptoms of seasonal allergy. Allergy Asthma Proc. 2009;30:128-138.
3. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317:1624-1629.
4. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47:118-125.
5. Gawchik SM, Lim J. Comparison of intranasal triamcinolone acetonide with oral loratadine in the treatment of seasonal ragweed-induced allergic rhinitis. Am J Manag Care. 1997;3:1052-1058.
6. Bernstein DI, Levy AL, Hampel FC, et al. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy. 2004;34:952-957.
7. Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol. 1997;99:S742-S749.
8. www.drugstore.com. Accessed March 20, 2012.
9. Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.
10. Wallace DV, Dykewicz MS, Bernstein DI, et al. Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl 2):S1-S84.
Evidence-based answers from the Family Physicians Inquiries Network
What is the best noninvasive diagnostic test for women with suspected CAD?
MULTIDETECTOR COMPUTED TOMOGRAPHY (MDCT) may be the most sensitive and specific noninvasive diagnostic test for women with suspected coronary artery disease (CAD) (strength of recommendation [SOR]: A, multiple prospective cohort studies). However, stress echocardiography and nuclear medicine perfusion testing are still the best well-tested and readily available alternatives in light of the newness of MDCT and concerns regarding its use (SOR: A, meta-analysis and cohort studies).
Standard exercise treadmill testing (ETT) doesn’t adequately exclude or confirm CAD in women (SOR: A, multiple prospective cohort studies).
Evidence summary
A prospective cohort study of 96 symptomatic women, average age 55.8 years, who were referred for coronary angiography, examined the accuracy of ETT compared with the gold standard of conventional coronary angiography.1 Sensitivity, specificity, and diagnostic accuracy were comparatively low for ETT (TABLE). The authors concluded that ETT has limited diagnostic value in women with suspected CAD. Myocardial perfusion imaging (MPI) is more predictive of CAD, as a prospective cohort study of 68 symptomatic women demonstrated.2
TABLE
Suspect CAD in your female patient? Here’s how various tests compare with coronary angiography
| Test | Number of subjects | Sensitivity (95% CI) | Specificity (95% CI) | LR+(95% CI) | LR-(95% CI) | Diagnostic accuracy* |
|---|---|---|---|---|---|---|
| ETT1 | 96 | 31% (17%-49%) | 52% (40%-64%) | 0.65 (0.36-1.18) | 1.32 (0.95-1.84) | 46% |
| ETT2 | 68 | 33% (21%-48%) | 74% (53%-87%) | 1.28 (0.57-2.81) | 0.90 (0.66-1.24) | 47% |
| MPI2 | 68 | 80% (66%-89%) | 78% (58%-90%) | 3.68 (1.67-8.10) | 0.26 (0.14-0.48) | 79% |
| DSE3 | 901 | 72% (67%-76%) | 88% (85%-91%) | 5.97 (4.64-7.68) | 0.32 (0.28-0.37) | 80% |
| 64-slice MDCT4 | 123 | 99% (93%-100%) | 75% (62%-84%) | 3.91 (2.54-6.01) | 0.01 (0.00-0.17) | 88% |
| 40-slice MDCT5 | 21 | 73% (51%-96%) | 83% (53%-100%) | 4.39 (0.72-27.02) | 0.32 (0.13-0.80) | 76% |
| 16-slice MDCT6 | 70 | 89% (67%-97%) | 88% (77%-95%) | 7.61 (3.53-16.38) | 0.12 (0.03-0.44) | 89% |
| CAD, coronary artery disease; CI, confidence interval; DSE, dobutamine stress echocardiography; ETT, exercise treadmill testing; LR+, positive likelihood ratio; LR-, negative likelihood ratio; MDCT, multidetector computed tomography; MPI, myocardial perfusion imaging. *Diagnostic accuracy=true positive + true negative out of total number of subjects. | ||||||
A meta-analysis of 14 studies that compared dobutamine stress echocardiography with conventional coronary angiography in 901 women found an overall sensitivity of 72% and specificity of 88% for echocardiography.3
MDCT has high accuracy, but also some limitations
Three prospective cohort studies compared 64-, 40-, and 16-slice MDCT with conventional coronary angiography in 123, 21, and 70 symptomatic women, respectively, and each study demonstrated high sensitivity and specificity for MDCT in diagnosing CAD.4-6 Diagnostic accuracy was similar among slice techniques. The studies had multiple limitations, including location (potential population bias), patient symptoms, and setting (potential referral bias).
All the studies of MDCT included symptomatic patients from cardiologists or tertiary care centers in Europe and Israel, potentially lessening the technique’s generalizability to many clinical settings. Moreover, the availability of MDCT is limited, especially compared with stress echocardiogram and MPI.
MDCT requires a heart rate <60 to 70 beats per minute, which necessitates giving beta-blockers to patients with higher heart rates; not all patients can tolerate the medication or lower heart rate. MDCT also requires giving intravenous contrast media to visualize the coronary arteries and exposes the patient to a high level of radiation.
Notably, all studies of ETT, MPI, stress echocardiography, and MDCT enrolled symptomatic patients, limiting their evaluation as screening tools.
Recommendations
The American Heart Association recommends testing symptomatic women with a Framing-ham risk score of 10% or greater. A 2005 consensus statement allows providers to rely on local practices and available tests, with the caveat that ETT is the preferred initial test.7
The American College of Radiology expert consensus panel recommends the use of stress nuclear imaging and chest radiography to evaluate patients with chronic chest pain and suspected CAD; the recommendation does not specify testing method based on sex.8
1. Lewis JF, McGorray S, Lin L, et al. Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J. 2005;149:527-533.
2. Bokhari S, Shahzad A, Bergmann SR. Superiority of exercise myocardial perfusion imaging compared with the exercise ECG in the diagnosis of coronary artery disease. Coron Artery Dis. 2008;19:399-404.
3. Geleijnse ML, Krenning BJ, Soliman OI, et al. Dobutamine stress echocardiography for the detection of coronary artery disease in women. Am J Cardiol. 2007;99:714-717.
4. Meijboom WB, Weustink AC, Pugliese F, et al. Comparison of diagnostic accuracy of 64-slice computed tomography coronary angiography in women versus men with angina pectoris. Am J Cardiol. 2007;100:1532-1537.
5. Halon DA, Gaspar T, Adawi S, et al. Uses and limitations of 40 slice multi-detector row spiral computed tomography for diagnosing coronary lesions in unselected patients referred for routine invasive coronary angiography. Cardiology. 2007;108:200-209.
6. Shivalkar B, Goovaerts I, Salgado RA, et al. Multislice cardiac computed tomography in symptomatic middle-aged women. Ann Med. 2007;39:290-297.
7. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.
8. Gerson DS, Rybicki FJ, Yucel EK, et al. and the Expert Panel on Cardiac Imaging. Chronic chest pain—suspected cardiac origin (online publication). Reston, Va: American College of Radiology; 2006. Available at: www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/
ChronicChestPainNoEvidenceofMyocardialIschemiaInfarctionUpdateinProgressDoc7.aspx. Accessed April 13, 2009.
MULTIDETECTOR COMPUTED TOMOGRAPHY (MDCT) may be the most sensitive and specific noninvasive diagnostic test for women with suspected coronary artery disease (CAD) (strength of recommendation [SOR]: A, multiple prospective cohort studies). However, stress echocardiography and nuclear medicine perfusion testing are still the best well-tested and readily available alternatives in light of the newness of MDCT and concerns regarding its use (SOR: A, meta-analysis and cohort studies).
Standard exercise treadmill testing (ETT) doesn’t adequately exclude or confirm CAD in women (SOR: A, multiple prospective cohort studies).
Evidence summary
A prospective cohort study of 96 symptomatic women, average age 55.8 years, who were referred for coronary angiography, examined the accuracy of ETT compared with the gold standard of conventional coronary angiography.1 Sensitivity, specificity, and diagnostic accuracy were comparatively low for ETT (TABLE). The authors concluded that ETT has limited diagnostic value in women with suspected CAD. Myocardial perfusion imaging (MPI) is more predictive of CAD, as a prospective cohort study of 68 symptomatic women demonstrated.2
TABLE
Suspect CAD in your female patient? Here’s how various tests compare with coronary angiography
| Test | Number of subjects | Sensitivity (95% CI) | Specificity (95% CI) | LR+(95% CI) | LR-(95% CI) | Diagnostic accuracy* |
|---|---|---|---|---|---|---|
| ETT1 | 96 | 31% (17%-49%) | 52% (40%-64%) | 0.65 (0.36-1.18) | 1.32 (0.95-1.84) | 46% |
| ETT2 | 68 | 33% (21%-48%) | 74% (53%-87%) | 1.28 (0.57-2.81) | 0.90 (0.66-1.24) | 47% |
| MPI2 | 68 | 80% (66%-89%) | 78% (58%-90%) | 3.68 (1.67-8.10) | 0.26 (0.14-0.48) | 79% |
| DSE3 | 901 | 72% (67%-76%) | 88% (85%-91%) | 5.97 (4.64-7.68) | 0.32 (0.28-0.37) | 80% |
| 64-slice MDCT4 | 123 | 99% (93%-100%) | 75% (62%-84%) | 3.91 (2.54-6.01) | 0.01 (0.00-0.17) | 88% |
| 40-slice MDCT5 | 21 | 73% (51%-96%) | 83% (53%-100%) | 4.39 (0.72-27.02) | 0.32 (0.13-0.80) | 76% |
| 16-slice MDCT6 | 70 | 89% (67%-97%) | 88% (77%-95%) | 7.61 (3.53-16.38) | 0.12 (0.03-0.44) | 89% |
| CAD, coronary artery disease; CI, confidence interval; DSE, dobutamine stress echocardiography; ETT, exercise treadmill testing; LR+, positive likelihood ratio; LR-, negative likelihood ratio; MDCT, multidetector computed tomography; MPI, myocardial perfusion imaging. *Diagnostic accuracy=true positive + true negative out of total number of subjects. | ||||||
A meta-analysis of 14 studies that compared dobutamine stress echocardiography with conventional coronary angiography in 901 women found an overall sensitivity of 72% and specificity of 88% for echocardiography.3
MDCT has high accuracy, but also some limitations
Three prospective cohort studies compared 64-, 40-, and 16-slice MDCT with conventional coronary angiography in 123, 21, and 70 symptomatic women, respectively, and each study demonstrated high sensitivity and specificity for MDCT in diagnosing CAD.4-6 Diagnostic accuracy was similar among slice techniques. The studies had multiple limitations, including location (potential population bias), patient symptoms, and setting (potential referral bias).
All the studies of MDCT included symptomatic patients from cardiologists or tertiary care centers in Europe and Israel, potentially lessening the technique’s generalizability to many clinical settings. Moreover, the availability of MDCT is limited, especially compared with stress echocardiogram and MPI.
MDCT requires a heart rate <60 to 70 beats per minute, which necessitates giving beta-blockers to patients with higher heart rates; not all patients can tolerate the medication or lower heart rate. MDCT also requires giving intravenous contrast media to visualize the coronary arteries and exposes the patient to a high level of radiation.
Notably, all studies of ETT, MPI, stress echocardiography, and MDCT enrolled symptomatic patients, limiting their evaluation as screening tools.
Recommendations
The American Heart Association recommends testing symptomatic women with a Framing-ham risk score of 10% or greater. A 2005 consensus statement allows providers to rely on local practices and available tests, with the caveat that ETT is the preferred initial test.7
The American College of Radiology expert consensus panel recommends the use of stress nuclear imaging and chest radiography to evaluate patients with chronic chest pain and suspected CAD; the recommendation does not specify testing method based on sex.8
MULTIDETECTOR COMPUTED TOMOGRAPHY (MDCT) may be the most sensitive and specific noninvasive diagnostic test for women with suspected coronary artery disease (CAD) (strength of recommendation [SOR]: A, multiple prospective cohort studies). However, stress echocardiography and nuclear medicine perfusion testing are still the best well-tested and readily available alternatives in light of the newness of MDCT and concerns regarding its use (SOR: A, meta-analysis and cohort studies).
Standard exercise treadmill testing (ETT) doesn’t adequately exclude or confirm CAD in women (SOR: A, multiple prospective cohort studies).
Evidence summary
A prospective cohort study of 96 symptomatic women, average age 55.8 years, who were referred for coronary angiography, examined the accuracy of ETT compared with the gold standard of conventional coronary angiography.1 Sensitivity, specificity, and diagnostic accuracy were comparatively low for ETT (TABLE). The authors concluded that ETT has limited diagnostic value in women with suspected CAD. Myocardial perfusion imaging (MPI) is more predictive of CAD, as a prospective cohort study of 68 symptomatic women demonstrated.2
TABLE
Suspect CAD in your female patient? Here’s how various tests compare with coronary angiography
| Test | Number of subjects | Sensitivity (95% CI) | Specificity (95% CI) | LR+(95% CI) | LR-(95% CI) | Diagnostic accuracy* |
|---|---|---|---|---|---|---|
| ETT1 | 96 | 31% (17%-49%) | 52% (40%-64%) | 0.65 (0.36-1.18) | 1.32 (0.95-1.84) | 46% |
| ETT2 | 68 | 33% (21%-48%) | 74% (53%-87%) | 1.28 (0.57-2.81) | 0.90 (0.66-1.24) | 47% |
| MPI2 | 68 | 80% (66%-89%) | 78% (58%-90%) | 3.68 (1.67-8.10) | 0.26 (0.14-0.48) | 79% |
| DSE3 | 901 | 72% (67%-76%) | 88% (85%-91%) | 5.97 (4.64-7.68) | 0.32 (0.28-0.37) | 80% |
| 64-slice MDCT4 | 123 | 99% (93%-100%) | 75% (62%-84%) | 3.91 (2.54-6.01) | 0.01 (0.00-0.17) | 88% |
| 40-slice MDCT5 | 21 | 73% (51%-96%) | 83% (53%-100%) | 4.39 (0.72-27.02) | 0.32 (0.13-0.80) | 76% |
| 16-slice MDCT6 | 70 | 89% (67%-97%) | 88% (77%-95%) | 7.61 (3.53-16.38) | 0.12 (0.03-0.44) | 89% |
| CAD, coronary artery disease; CI, confidence interval; DSE, dobutamine stress echocardiography; ETT, exercise treadmill testing; LR+, positive likelihood ratio; LR-, negative likelihood ratio; MDCT, multidetector computed tomography; MPI, myocardial perfusion imaging. *Diagnostic accuracy=true positive + true negative out of total number of subjects. | ||||||
A meta-analysis of 14 studies that compared dobutamine stress echocardiography with conventional coronary angiography in 901 women found an overall sensitivity of 72% and specificity of 88% for echocardiography.3
MDCT has high accuracy, but also some limitations
Three prospective cohort studies compared 64-, 40-, and 16-slice MDCT with conventional coronary angiography in 123, 21, and 70 symptomatic women, respectively, and each study demonstrated high sensitivity and specificity for MDCT in diagnosing CAD.4-6 Diagnostic accuracy was similar among slice techniques. The studies had multiple limitations, including location (potential population bias), patient symptoms, and setting (potential referral bias).
All the studies of MDCT included symptomatic patients from cardiologists or tertiary care centers in Europe and Israel, potentially lessening the technique’s generalizability to many clinical settings. Moreover, the availability of MDCT is limited, especially compared with stress echocardiogram and MPI.
MDCT requires a heart rate <60 to 70 beats per minute, which necessitates giving beta-blockers to patients with higher heart rates; not all patients can tolerate the medication or lower heart rate. MDCT also requires giving intravenous contrast media to visualize the coronary arteries and exposes the patient to a high level of radiation.
Notably, all studies of ETT, MPI, stress echocardiography, and MDCT enrolled symptomatic patients, limiting their evaluation as screening tools.
Recommendations
The American Heart Association recommends testing symptomatic women with a Framing-ham risk score of 10% or greater. A 2005 consensus statement allows providers to rely on local practices and available tests, with the caveat that ETT is the preferred initial test.7
The American College of Radiology expert consensus panel recommends the use of stress nuclear imaging and chest radiography to evaluate patients with chronic chest pain and suspected CAD; the recommendation does not specify testing method based on sex.8
1. Lewis JF, McGorray S, Lin L, et al. Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J. 2005;149:527-533.
2. Bokhari S, Shahzad A, Bergmann SR. Superiority of exercise myocardial perfusion imaging compared with the exercise ECG in the diagnosis of coronary artery disease. Coron Artery Dis. 2008;19:399-404.
3. Geleijnse ML, Krenning BJ, Soliman OI, et al. Dobutamine stress echocardiography for the detection of coronary artery disease in women. Am J Cardiol. 2007;99:714-717.
4. Meijboom WB, Weustink AC, Pugliese F, et al. Comparison of diagnostic accuracy of 64-slice computed tomography coronary angiography in women versus men with angina pectoris. Am J Cardiol. 2007;100:1532-1537.
5. Halon DA, Gaspar T, Adawi S, et al. Uses and limitations of 40 slice multi-detector row spiral computed tomography for diagnosing coronary lesions in unselected patients referred for routine invasive coronary angiography. Cardiology. 2007;108:200-209.
6. Shivalkar B, Goovaerts I, Salgado RA, et al. Multislice cardiac computed tomography in symptomatic middle-aged women. Ann Med. 2007;39:290-297.
7. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.
8. Gerson DS, Rybicki FJ, Yucel EK, et al. and the Expert Panel on Cardiac Imaging. Chronic chest pain—suspected cardiac origin (online publication). Reston, Va: American College of Radiology; 2006. Available at: www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/
ChronicChestPainNoEvidenceofMyocardialIschemiaInfarctionUpdateinProgressDoc7.aspx. Accessed April 13, 2009.
1. Lewis JF, McGorray S, Lin L, et al. Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J. 2005;149:527-533.
2. Bokhari S, Shahzad A, Bergmann SR. Superiority of exercise myocardial perfusion imaging compared with the exercise ECG in the diagnosis of coronary artery disease. Coron Artery Dis. 2008;19:399-404.
3. Geleijnse ML, Krenning BJ, Soliman OI, et al. Dobutamine stress echocardiography for the detection of coronary artery disease in women. Am J Cardiol. 2007;99:714-717.
4. Meijboom WB, Weustink AC, Pugliese F, et al. Comparison of diagnostic accuracy of 64-slice computed tomography coronary angiography in women versus men with angina pectoris. Am J Cardiol. 2007;100:1532-1537.
5. Halon DA, Gaspar T, Adawi S, et al. Uses and limitations of 40 slice multi-detector row spiral computed tomography for diagnosing coronary lesions in unselected patients referred for routine invasive coronary angiography. Cardiology. 2007;108:200-209.
6. Shivalkar B, Goovaerts I, Salgado RA, et al. Multislice cardiac computed tomography in symptomatic middle-aged women. Ann Med. 2007;39:290-297.
7. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.
8. Gerson DS, Rybicki FJ, Yucel EK, et al. and the Expert Panel on Cardiac Imaging. Chronic chest pain—suspected cardiac origin (online publication). Reston, Va: American College of Radiology; 2006. Available at: www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/
ChronicChestPainNoEvidenceofMyocardialIschemiaInfarctionUpdateinProgressDoc7.aspx. Accessed April 13, 2009.
Evidence-based answers from the Family Physicians Inquiries Network