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    Diagnosis Diagnosis 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