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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 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