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  • 1. Cardiovascular Disease in Women Module IV: Diagnosis
  • 2. Diagnosis of Coronary Artery Disease in Women
    • Drawbacks and Difficulties in Diagnosis
      • Presentation in Women
      • Diagnostic Testing Challenges
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women P < 0.05 Source: Hansen 1996
  • 9. Sensitivity and Specificity of Dipyridamole SPECT Imaging in Identifying Individual Coronary Stenoses and Multivessel Disease in Women Source: Travin 2000
  • 10. Breast Attenuation Image Courtesy of EG DePuey MD
  • 11. Breast Attenuation (continued) Image Courtesy of EG DePuey MD
  • 12. 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
  • 13. Principles of Stress Echocardiography
      • Valvular heart disease evaluation may be performed as well
      • Need good acoustic window
    Source: Nishimura 2005
  • 14. Value of Stress Echocardiography Compared to Stress ECG in Women Source: Marwick 1995 *P < 0.004 vs. Echo **Old P < 0.005 vs. Echo * **
  • 15. 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 *
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. Sensitivity and Specificity of Electron-Beam Computed Tomography for Detection of Obstructive Coronary Artery Disease in Women Source: Devries 1995 ≥
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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