Download Diagnosis CVD in Women Module

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
 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
Technique
Assessment
Issues in Women
Angiography
Coronary
anatomy
Coronary
calcification
Regional wall
motion
Regional blood
flow
Less focal disease
Coronary CT
Echocardiography
Nuclear Cardiology
Source: Charney 2002, Greenland 2007
Less well-validated than
other techniques
Reader expertise
variable
Attenuation issues
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
80
70
77
70
68
61
60
50
Men
Women
40
30
20
10
0
Source: Kwok 1999
Sensitivity
Specificity
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
[Area under
receiver operating
characteristic (ROC)
curve]
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0.93
Men
Women
P < 0.05
Men
Source: Hansen 1996
0.87
Women
Sensitivity and Specificity of Dipyridamole SPECT
Imaging in Identifying Individual Coronary
Stenoses and Multivessel Disease in Women
100
90
80
70
60
% 50
40
30
20
10
0
Source: Travin 2000
78
70
92
84
68
63
75
50
Overall
Left Anterior
Decending
Left
Circumflex
Artery
Sensitivity
Specificity
Right
Coronary
Artery
Breast Attenuation
Image Courtesy
of EG DePuey MD
Breast Attenuation (continued)
Image Courtesy
of EG DePuey MD
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 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
100
90
80
70
60
% 50
40
30
20
10
0
81
77
81
80
56*
64**
Echo
ECG
*P < 0.004 vs. Echo
**Old P < 0.005 vs. Echo
Sensitivity
Source: Marwick 1995
Specificity
Accuracy
Sensitivity and Specificity of Dobutamine
Stress Echocardiography for the Diagnosis
of CAD in Women
100
94
90
80
*
82
76
70
60
%
50
40
30
20
* Higher in
women than in
men P < 0.05
10
0
Sensitivity
Source: Elhendy 1997
Specificity
Accuracy
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?
Source: Jacobs 2003
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
 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
Sensitivity and Specificity of ElectronBeam Computed Tomography for
Detection of Obstructive Coronary
Artery Disease in Women
95
100
80
%
75
100
100
Sensitivity
72
55
60
40
30
15
20
0
Age < 60 yrs.
Source: Devries 1995
Age ≥ 60yrs.
Specificity
Positive
Predicitive Value
Negative
Predictive Value
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
 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 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
 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 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 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