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Cardiovascular Disease in Women Module IV: Diagnosis Diagnosis of Coronary Artery Disease in Women Drawbacks and Difficulties in Diagnosis Presentation in Women Diagnostic Testing Challenges Diagnosis of Coronary Artery Disease in Women

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diagnosis of coronary artery disease in women
Diagnosis of Coronary Artery Disease in Women
  • Drawbacks and Difficulties in Diagnosis
    • Presentation in Women
    • Diagnostic Testing Challenges
diagnosis of coronary artery disease in women3
Diagnosis of Coronary Artery Disease in Women
  • Chest pain is experienced by most women with CHD, but non-chest pain presentations are more common in women than men
  • Other Presenting Symptoms
    • Upper abdominal pain, fullness, burning sensation
    • Shortness of breath
    • Nausea
    • Neck, back, jaw pain
  • Associations
    • Precipitated by exertion
    • Precipitated by emotional distress

Source: Charney 2002, Goldberg 1998

testing for ischemic heart disease in women and factors to consider
Testing for Ischemic Heart Diseasein Women and Factors to Consider

Source: Charney 2002, Greenland 2007

drawbacks of diagnostic imaging in women
Drawbacks of Diagnostic Imaging in Women
  • Low exercise capacity – likelihood of reaching adequate pressure rate product
    • Solution: Pharmacologic stress testing
  • Breast attenuation artifact – higher false positive imaging studies
    • Solution: Gated acquisition; attenuation correction for nuclear imaging
    • Solution: Echocardiography
  • Lower pretest probability of CAD – higher false positive rate
    • Solution: Integrate clinical variables, risk factors, into decision-making process

Source: Duvernoy, personal communication

value of the exercise ecg in women
Value of the Exercise ECG in Women

77

80

70

68

70

61

60

50

Men

40

Women

30

20

10

0

Sensitivity

Specificity

Source: Kwok 1999

principles of nuclear cardiac stress testing
Principles of Nuclear Cardiac Stress Testing
  • Normal response:Myocardial blood flow demonstrated by injected radioisotopes is increased above the resting condition
  • Ischemia:With fixed stenoses, myocardial perfusion does not increase with stress in the territory supplied by the stenosed artery, demonstrated by inhomogeneous distribution of the radioisotope
  • Scar from myocardial infarction: Fixed inhomogeneous distribution of the radioisotope at both rest and with stress
  • Photons are emitted in all directions from the point of origin
    • Attenuation of images occurs in obese patients, and from breast tissue

Source: Nishimura 2005

diagnostic accuracy of thallium 201 spect myocardial perfusion imaging in men and women
Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women

P < 0.05

Source: Hansen 1996

slide9
Sensitivity and Specificity of Dipyridamole SPECT Imaging in Identifying Individual Coronary Stenoses and Multivessel Disease in Women

Source: Travin 2000

breast attenuation
Breast Attenuation

Image Courtesy of EG DePuey MD

breast attenuation continued
Breast Attenuation (continued)

Image Courtesy of EG DePuey MD

principles of stress echocardiography
Principles of Stress Echocardiography
  • Normal response:
    • Increased left ventricular contractility
    • Hyperdynamic wall motion
  • Ischemia:
    • New wall motion abnormality with stress
    • Decreased ejection fraction
    • Increase in end-systolic volume
  • Scar from myocardial infarction:
    • Fixed wall motion abnormality with rest and stress

Source: Nishimura 2005

principles of stress echocardiography13
Principles of Stress Echocardiography
  • Valvular heart disease evaluation may be performed as well
  • Need good acoustic window

Source: Nishimura 2005

value of stress echocardiography compared to stress ecg in women
Value of Stress Echocardiography Compared to Stress ECG in Women

**

*

*P < 0.004 vs. Echo

**Old P < 0.005 vs. Echo

Source: Marwick 1995

sensitivity and specificity of dobutamine stress echocardiography for the diagnosis of cad in women
Sensitivity and Specificity of Dobutamine Stress Echocardiography for the Diagnosis of CAD in Women

*

* Higher in women than in men P < 0.05

Source: Elhendy 1997

chd differences in presentation and findings in women compared to men
Lower prevalence of MI

More severe CHF

More severe angina

Less angiographic CAD

More ostial lesions

More microvascular dysfunction?

Abnormal vasomotor tone?

More endothelial dysfunction?

CHD: Differences in Presentation and Findings in Women Compared to Men

Source: Jacobs 2003

cardiac catheterization indications for presumed known cad acc aha guidelines
Cardiac Catheterization Indications for Presumed/Known CAD: ACC/AHA Guidelines
  • To determine the presence and extent of obstructive coronary artery disease (CAD) when diagnosis … cannot be reasonably excluded by noninvasive testing
  • To assess the feasibility and appropriateness of revascularization
  • To assess treatment results … progression or regression of coronary atherosclerosis

Source: Scanlon 1999

principles of coronary calcium cac scoring by ct
Principles of Coronary Calcium (CAC) Scoring by CT
  • Highly sensitive technique for detecting coronary calcium
  • Scans are obtained in less than one minute, during one to two breath-holding sequences
  • Results reported as a coronary calcium score
  • Highly sensitive for detecting CAD, low specificity, overall accuracy of approximately 70%
  • African Americans may have less coronary calcification, despite similar risk profiles as whites and more subsequent cardiac events

Source: O’Rourke 2000, Doherty 1999, Greenland 2007

slide19
Sensitivity and Specificity of Electron-Beam Computed Tomography for Detection of Obstructive Coronary Artery Disease in Women

Source: Devries 1995

coronary calcium cac scoring by ct not routinely recommended acc aha consensus
Coronary Calcium (CAC) Scoring by CT Not Routinely Recommended: ACC/AHA Consensus
  • CAC measurement is not recommended for screening of the general population, or for evaluation of patients at low CHD risk
  • CAC measurement is not recommended for evaluation of patients with high CHD risk
  • CAC measurement may be reasonable to evaluate intermediate risk patients (10%-20% 10 year risk of CHD event), because such patients may be reclassified to a higher risk status based on a high coronary calcium score
  • There is not enough evidence to compare CAC measurement to other methods of cardiac testing at this time

Source: Greenland 2007

principles of cardiac magnetic resonance imaging cmr in the detection of chd
Principles of Cardiac Magnetic Resonance Imaging (CMR) in the Detection of CHD
  • Static and cine images are obtained using electrocardiographic triggering, often with a short breath-hold of 10-15 seconds
  • Myocardial perfusion can be evaluated by injecting gadolinium and continuously scanning as contrast passes through the heart and into the myocardium
  • Myocardial viability can be assessed by delayed imaging after gadolinium injection; infarcted tissue retains contrast
  • Magnetic resonance angiography (MRA) of coronary arteries is limited because of the small size of vessels and complex motion during the cardiac cycle
  • Vasodilators and dobutamine can be used to provide stress imaging

Source: Nishimura 2005, Hendel 2006

principles of cardiac magnetic resonance imaging cmr in the detection of chd22
Principles of Cardiac Magnetic Resonance Imaging (CMR) in the Detection of CHD
  • Pacemakers, implantable defibrillators, and certain aneurysm clips are current contraindications (pacemakers and implantable defibrillators are being studied)
  • Indications evolving, evidence to compare to other modalities for detection of CHD does not currently exist
  • Ethnic and gender differences in cardiac magnetic resonance imaging have not been investigated

Source: Nishimura 2005, Hendel 2006

women and chd what test to order when
Women and CHD: What Test to Order When
  • For new-onset symptoms, resting, or rapidly worsening symptoms, women should be referred immediately to the emergency department for evaluation
  • Women with symptoms of acute coronary syndrome should be instructed to call 911, and should be transported to the hospital via ambulance, rather than by friends or relatives

Source: Anderson 2007

women and chd what test to order when24
Women and CHD: What Test to Order When
  • For women at high or intermediate risk of coronary artery disease, consider treadmill echocardiogarphy or nuclear perfusion imaging
  • For women unable to exercise, consider dobutamine stress echocardiography or adenosine or dipyridamole nuclear imaging
  • In high risk women with typical symptoms of coronary artery disease, consider referral to a cardiologist
  • For high risk women, consider cardiac catheterization if symptoms persist despite negative non-invasive imaging

Source: Anderson 2007, Klocke 2003, Douglas 2008, Duvernoy 2005

women and chd what test to order when25
Women and CHD: What Test to Order When
  • A stepwise approach beginning with conventional exercise testing may be considered for women who:
    • Are at low or intermediate risk for coronary artery disease
    • Are able to exercise
    • Have an electrocardiogram that can be interpreted during stress testing
  • An image-enhanced test may be more predictive in women than conventional electrocardiogram stress testing, and may also be more cost effective in women at intermediate risk for CHD

Source: Anderson 2007, Klocke 2003, Douglas 2008,Mieres 2005