Cardiovascular Disease in WomenModule 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 Diseasein Women and Factors to Consider

Technique Assessment Issues in Women

Angiography Coronary anatomy

Less focal disease

Coronary CT Coronary calcification

Less well-validated than other techniques

Echocardiography Regional wall motion

Reader expertise variable

Nuclear Cardiology Regional blood flow

Attenuation issues

Source: Charney 2002, Greenland 2007

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

6861

7770

0

10

20

30

40

50

60

70

80

Sensitivity Specificity

MenWomen

Source: Kwok 1999

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

tissueSource: Nishimura 2005

Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women

0.870.93

00.10.20.30.40.50.60.70.80.9

1

Men Women

Diagnostic Accuracy [Area under

receiver operating characteristic (ROC)

curve]

Men

Women

P < 0.05

Source: Hansen 1996

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

84

50

6878

92

7570 63

0102030405060708090

100

Overall Left AnteriorDecending

LeftCircumflex

Artery

RightCoronary

Artery

%SensitivitySpecificity

Source: Travin 2000

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

81 80 8177

5664

0102030405060708090

100

Sensitivity Specificity Accuracy

%

Echo

ECG

Source: Marwick 1995

*P < 0.004 vs. Echo

**Old P < 0.005 vs. Echo

***

Sensitivity and Specificity of Dobutamine Stress Echocardiography for the Diagnosis of CAD in Women

7682

94

0

10

20

30

40

50

60

70

80

90

100

Sensitivity Specificity Accuracy

%

Source: Elhendy 1997

* Higher in women than in men P < 0.05

*

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 Electron-Beam Computed Tomography for Detection of Obstructive Coronary Artery Disease in Women

100 100

7572

15

55

30

95

0

20

40

60

80

100

Age < 60 yrs. Age 60yrs.

%

Sensitivity

Specificity

PositivePredicitive ValueNegativePredictive Value

Source: Devries 1995

≥

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