Diagnosis CVD in Women Module
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Diagnosis CVD in Women Module

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  • This slide set was updated April 2008.
  • SLIDE INFORMATION SOURCES: Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002; 9:303-307. Goldberg RJ, O’Donnell C, Yarzebski J, et al. Sex differences in symptoms presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998; 136:189-195. Coronary artery disease presents more frequently with atypical symptoms in women compared to men (1,2). Gender, race, and other perceptions may affect physicians’ assessment of whether a patient has CHD. Studies using tapes of actresses reading from a script describing CHD symptoms have shown that physicians are less likely to assess CHD in African American women compared to white women and men, and in women with a “hysterical” style compared to those with a more “business-like” presentation(1). (1) Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002; 9:303-307. (2) Goldberg RJ, O’Donnell C, Yarzebski J, et al. Sex differences in symptoms presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998; 136:189-195.
  • SLIDE INFORMATION SOURCES: Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002; 9:303-307, Greenland P, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Circulation 2007; 115:402-326. A variety of tests may be used both for the diagnosis of ischemic heart disease and for risk stratification of known or suspected CHD(1) . Each of the commonly used methods evaluates a different component of cardiac anatomy or physiology (1) . Specific aspects of each technique explain the differences in the accuracy for the method and its value for different population groups(1)(2). Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002; 9:303-307. (2) Greenland P, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Circulation 2007; 115:402-326.
  • SLIDE INFORMATION SOURCE: Claire Duvernoy, M.D., personal communication March 2005.
  • SLIDE INFORMATION SOURCE: Kwok Y, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol 1999; 83 :660-666. This meta-analysis found that exercise ECG is less accurate in women than in men (1). Mechanisms such as digoxin-like effect of estrogen, different catecholamine response to exercise in women, a higher incidence of mitral valve prolapse, and different chest wall anatomy in women have also been proposed as explanations for accuracy differences (1) . In addition, methods for performing the exercise ECG were developed using men, and the thresholds for abnormal were established almost exclusively in men (1). (1) Kwok Y, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol 1999; 83 :660-666.
  • SLIDE INFORMATION SOURCE: Nishimura RA, Gibbons RJ, Blockner JF, Tajik AJ. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005. Stress may be provided by exercise or pharmacologically (1). (1) Nishimura RA, Gibbons RJ, Blockner JF, Tajik AJ. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005.
  • SLIDE INFORMATION SOURCE: Hansen CL, et al. Lower diagnostic accuracy of thallium-201 SPECT myocardial perfusion imaging in women: an effect of smaller chamber size. J Am Coll Cardiol 1996; 28(: 1214-1219. Hansen et al. compared diagnostic accuracy of Tl-201 SPECT for CAD in 129 normals (60 women, 69 men) and 154 pts w/ CAD (47 women, 107 men)(1). Overall accuracy of the test was lower in women(1). When the studies were stratified by the size of the left ventricle, it appeared that size of the left ventricle, rather than gender, was determining factor for accuracy. Women’s tests were less accurate because their hearts were, on average, smaller (1). The authors attributed this decreased accuracy to a greater effect of image blurring in smaller hearts (1) (1) Hansen CL, et al. Lower diagnostic accuracy of thallium-201 SPECT myocardial perfusion imaging in women: an effect of smaller chamber size. J Am Coll Cardiol 1996; 28: 1214-1219.
  • SLIDE INFORMATION SOURCE: Travin MI, et al. J Nucl Cardiol 2000; 7:213-220. This graphic shows the results for women in a study of 107 unselected pts (58 women, 49 men) who underwent Tc-99 sestamibi SPECT dipyridamole SPECT imaging and cardiac catheterization within a 6 month time period(1). In this study, the accuracy of dipyridamole sestamibi SPECT imaging was similar. The sensitivity of dipyridamole sestamibi SPECT imaging in detecting disease of the left anterior descending (LAD) artery was better in women(1). (1) Travin MI, Katz, MS, Moulton AW, et al. J Nucl Cardiol 2000; 7:213-220.
  • SLIDE GRAPHIC SOURCE: Courtesy of EG DePuey, M.D. Shown here are short-axis myocardial perfusion images from a female patient which demonstrate decreased uptake in the anterior wall both during stress (first and third rows) and at rest (second and fourth rows), suggestive of a prior anterior wall MI(1). (1) Image description by Claire Duvernoy, M.D., personal communication, March, 2005.
  • SLIDE GRAPHIC SOURCE: Courtesy of EG DePuey, M.D. Shown here is the same patient, with perfusion studies divided into end-diastole and end-systole, show that the anterior defect is probably an artifact, because at end-systole, the anterior wall thickens well, and no longer demonstrates decreased uptake(1). (1) Image description by Claire Duvernoy, M.D., personal communication, March, 2005.
  • SLIDE INFORMATION SOURCE: Nishimura RA, et al. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005. Stress may be provided by exercise or pharmacologically (1). Dobutamine infusion can be used to assess myocardial viability by using low dose, followed by higher doses of the drug. Viable myocardium demonstrates increased contractility at low doses of dobutamine, followed by decreased contractility at higher doses(1). (1) Nishimura RA, et al. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005.
  • SLIDE INFORMATION SOURCE: Nishimura RA, et al. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005.
  • SLIDE INFORMATION SOURCE: Marwick TH, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol 1995; 26: 335-341. This study showed significantly higher specificity and overall accuracy for stress echocardiography as compared to conventional exercise treadmill testing, in a female population(1). (1) Marwick TH, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol 1995; 26: 335-341.
  • SLIDE INFORMATION SOURCE: Elhendy A, et al. Gender differences in the accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease. Am J Cardiol 1997; 80: 1414-1418. This graph represents the results of a study of 306 consecutive women and men who underwent dobutamine stress echocardiography for evaluation of CAD and coronary angiography within three months(1). The authors postulated that the greater accuracy of the study in women compared to men might be due to their better response to dobutamine (women more frequently achieved target heart rate), better imaging because of decreased chest wall thickness, and fewer false positives because of thinner myocardium (1). (1) Elhendy A, et al. Gender differences in the accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease. Am J Cardiol 1997; 80: 1414-1418.
  • SLIDE INFORMATION SOURCE: Jacobs AK. Coronary revascularization in women in 2003: sex revisited. Circulation 2003. 107(3):375-377.
  • SLIDE INFORMATION SOURCE: Scanlon PJ, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. Circulation 1999; 99: 2345-2357. Cardiac catheterization is considered the “gold standard” for the diagnosis of coronary artery disease(1). (1) Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002; 9:303-307.
  • SLIDE INFORMATION SOURCE: O’Rourke RA, et al. American College of Cardiology/American Heart Association expert consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. J Am Coll Cardiol 2000; 36:326-340.; Doherty TM. Racial differences in the significance of coronary calcium in asymptomatic black and white subjects with coronary risk factors. J Am Coll Cardiol 1999; 35:787-794.; Greenland P, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Circulation 2007; 115:402-326.
  • SLIDE INFORMATION SOURCE: Devries S, et al. Influence of age and gender on the presence of coronary calcium detected by ultrafast computed tomography. J Am Coll Cardiol 1995; 25:76-82. This slide demonstrates data from a study of 70 women and 70 men with suspected coronary artery disease who underwent cardiac catheterization within nine months of electron beam computed topography(1). Of note, although high coronary calcium scores correlate with obstructive CAD, there was little correlation with degree of angiographic disease(1). Coronary atherosclerosis is more likely to be associated with calcification in men, compared to women. This is because women under the age of 60 years with atherosclerosis do not demonstrate the same patterns of calcification seen in older women and men with CAD(1). The specificity of EBCT is low, and is lower with advancing age. Because of the lower overall prevalence of CAD in women, false positive rates are higher(1). (1) Devries S, et al. Influence of age and gender on the presence of coronary calcium detected by ultrafast computed tomography. J Am Coll Cardiol 1995; 25:76-82.
  • SLIDE INFORMATION SOURCE: Greenland P, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Circulation 2007; 115:402-326.
  • SLIDE INFORMATION SOURCE: Nishimura RA, et al. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005, Hendel RC, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48: 1475-97.
  • SLIDE INFORMATION SOURCE: Nishimura RA, et al. Noninvasive cardiac imaging: echocardiography, nuclear cardiology, and MRI/CT imaging in DL Kasper, E Braunwald, AS Fauci, SL Hauser, DL Longo, JL Jameson, eds. Harrison’s Principles of Internal Medicine, 16th ed. New York; McGraw Hill, 2005, Hendel RC, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48: 1475-97.
  • SLIDE INFORMATION SOURCE: Anderson JL, et al. ACC/AHA 2007 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 2007; 50: e1-157.
  • SLIDE INFORMATION SOURCE:SLIDE INFORMATION SOURCE: Anderson JL, et al. ACC/AHA 2007 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 2007; 50: e1-157, Klocke KJ et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging-executive summary. J Am Coll Cardiol 2003, 42: 1318-33, Douglas PS, ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography, Circulation 2008, 117: 1478-97, personal communication Claire Duvernoy, M.D., 2005. Magnetic resonance imaging is also an option, if available (1) (1) Anderson JL, et al. ACC/AHA 2007 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 2007; 50: e1-157. (1)
  • SLIDE INFORMATION SOURCE:SLIDE INFORMATION SOURCE: Anderson JL, et al. ACC/AHA 2007 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 2007; 50: e1-157, Klocke KJ et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging-executive summary. J Am Coll Cardiol 2003, 42: 1318-33, Douglas PS, ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography, Circulation 2008, 117: 1478-97, Mieres JH, 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.

Diagnosis CVD in Women Module Diagnosis CVD in Women Module Presentation Transcript

  • 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 Source: Charney 2002, Greenland 2007 Attenuation issues Regional blood flow Nuclear Cardiology Reader expertise variable Regional wall motion Echocardiography Less well-validated than other techniques Coronary calcification Coronary CT Less focal disease Coronary anatomy Angiography Issues in Women Assessment Technique
  • 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 68 61 77 70 0 10 20 30 40 50 60 70 80 Sensitivity Specificity Men Women 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 tissue
    Source: Nishimura 2005
  • Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women P < 0.05 Source: Hansen 1996
  • Sensitivity and Specificity of Dipyridamole SPECT Imaging in Identifying Individual Coronary Stenoses and Multivessel Disease in Women 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 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 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 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