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  1. 1. Cardiovascular Disease in Women Module IV: Diagnosis
  2. 2. Diagnosis of Coronary Artery Disease in Women <ul><li>Drawbacks and Difficulties in Diagnosis </li></ul><ul><ul><li>Presentation in Women </li></ul></ul><ul><ul><li>Diagnostic Testing Challenges </li></ul></ul>
  3. 3. Diagnosis of Coronary Artery Disease in Women <ul><li>Chest pain is experienced by most women with CHD, but non-chest pain presentations are more common in women than men </li></ul><ul><li>Other Presenting Symptoms </li></ul><ul><ul><li>Upper abdominal pain, fullness, burning sensation </li></ul></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Neck, back, jaw pain </li></ul></ul><ul><li>Associations </li></ul><ul><ul><li>Precipitated by exertion </li></ul></ul><ul><ul><li>Precipitated by emotional distress </li></ul></ul>Source: Charney 2002, Goldberg 1998
  4. 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. 5. Drawbacks of Diagnostic Imaging in Women <ul><li>Low exercise capacity –  likelihood of reaching adequate pressure rate product </li></ul><ul><ul><li>Solution: Pharmacologic stress testing </li></ul></ul><ul><li>Breast attenuation artifact – higher false positive imaging studies </li></ul><ul><ul><li>Solution: Gated acquisition; attenuation correction for nuclear imaging </li></ul></ul><ul><ul><li>Solution: Echocardiography </li></ul></ul><ul><li>Lower pretest probability of CAD – higher false positive rate </li></ul><ul><ul><li>Solution: Integrate clinical variables, risk factors, into decision-making process </li></ul></ul>Source: Duvernoy, personal communication
  6. 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. 7. Principles of Nuclear Cardiac Stress Testing <ul><li>Normal response: Myocardial blood flow demonstrated by injected radioisotopes is increased above the resting condition </li></ul><ul><li>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 </li></ul><ul><li>Scar from myocardial infarction: Fixed inhomogeneous distribution of the radioisotope at both rest and with stress </li></ul><ul><li>Photons are emitted in all directions from the point of origin </li></ul><ul><ul><li>Attenuation of images occurs in obese patients, and from breast tissue </li></ul></ul>Source: Nishimura 2005
  8. 8. Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women P < 0.05 Source: Hansen 1996
  9. 9. Sensitivity and Specificity of Dipyridamole SPECT Imaging in Identifying Individual Coronary Stenoses and Multivessel Disease in Women Source: Travin 2000
  10. 10. Breast Attenuation Image Courtesy of EG DePuey MD
  11. 11. Breast Attenuation (continued) Image Courtesy of EG DePuey MD
  12. 12. Principles of Stress Echocardiography <ul><li>Normal response: </li></ul><ul><ul><li>Increased left ventricular contractility </li></ul></ul><ul><ul><li>Hyperdynamic wall motion </li></ul></ul><ul><li>Ischemia: </li></ul><ul><ul><li>New wall motion abnormality with stress </li></ul></ul><ul><ul><li>Decreased ejection fraction </li></ul></ul><ul><ul><li>Increase in end-systolic volume </li></ul></ul><ul><li>Scar from myocardial infarction: </li></ul><ul><ul><li>Fixed wall motion abnormality with rest and stress </li></ul></ul>Source: Nishimura 2005
  13. 13. Principles of Stress Echocardiography <ul><ul><li>Valvular heart disease evaluation may be performed as well </li></ul></ul><ul><ul><li>Need good acoustic window </li></ul></ul>Source: Nishimura 2005
  14. 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. 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. 16. CHD: Differences in Presentation and Findings in Women Compared to Men <ul><ul><li>Lower prevalence of MI </li></ul></ul><ul><ul><li>More severe CHF </li></ul></ul><ul><ul><li>More severe angina </li></ul></ul><ul><ul><li>Less angiographic CAD </li></ul></ul><ul><ul><li>More ostial lesions </li></ul></ul><ul><ul><li>More microvascular dysfunction? </li></ul></ul><ul><ul><li>Abnormal vasomotor tone? </li></ul></ul><ul><ul><li>More endothelial dysfunction? </li></ul></ul>Source: Jacobs 2003
  17. 17. Cardiac Catheterization Indications for Presumed/Known CAD: ACC/AHA Guidelines <ul><li>To determine the presence and extent of obstructive coronary artery disease (CAD) when diagnosis … cannot be reasonably excluded by noninvasive testing </li></ul><ul><li>To assess the feasibility and appropriateness of revascularization </li></ul><ul><li>To assess treatment results … progression or regression of coronary atherosclerosis </li></ul>Source: Scanlon 1999
  18. 18. Principles of Coronary Calcium (CAC) Scoring by CT <ul><li>Highly sensitive technique for detecting coronary calcium </li></ul><ul><li>Scans are obtained in less than one minute, during one to two breath-holding sequences </li></ul><ul><li>Results reported as a coronary calcium score </li></ul><ul><li>Highly sensitive for detecting CAD, low specificity, overall accuracy of approximately 70% </li></ul><ul><li>African Americans may have less coronary calcification, despite similar risk profiles as whites and more subsequent cardiac events </li></ul>Source: O’Rourke 2000, Doherty 1999, Greenland 2007
  19. 19. Sensitivity and Specificity of Electron-Beam Computed Tomography for Detection of Obstructive Coronary Artery Disease in Women Source: Devries 1995 ≥
  20. 20. Coronary Calcium (CAC) Scoring by CT Not Routinely Recommended: ACC/AHA Consensus <ul><ul><li>CAC measurement is not recommended for screening of the general population, or for evaluation of patients at low CHD risk </li></ul></ul><ul><ul><li>CAC measurement is not recommended for evaluation of patients with high CHD risk </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>There is not enough evidence to compare CAC measurement to other methods of cardiac testing at this time </li></ul></ul>Source: Greenland 2007
  21. 21. Principles of Cardiac Magnetic Resonance Imaging (CMR) in the Detection of CHD <ul><li>Static and cine images are obtained using electrocardiographic triggering, often with a short breath-hold of 10-15 seconds </li></ul><ul><li>Myocardial perfusion can be evaluated by injecting gadolinium and continuously scanning as contrast passes through the heart and into the myocardium </li></ul><ul><li>Myocardial viability can be assessed by delayed imaging after gadolinium injection; infarcted tissue retains contrast </li></ul><ul><li>Magnetic resonance angiography (MRA) of coronary arteries is limited because of the small size of vessels and complex motion during the cardiac cycle </li></ul><ul><li>Vasodilators and dobutamine can be used to provide stress imaging </li></ul>Source: Nishimura 2005, Hendel 2006
  22. 22. Principles of Cardiac Magnetic Resonance Imaging (CMR) in the Detection of CHD <ul><li>Pacemakers, implantable defibrillators, and certain aneurysm clips are current contraindications (pacemakers and implantable defibrillators are being studied) </li></ul><ul><li>Indications evolving, evidence to compare to other modalities for detection of CHD does not currently exist </li></ul><ul><li>Ethnic and gender differences in cardiac magnetic resonance imaging have not been investigated </li></ul>Source: Nishimura 2005, Hendel 2006
  23. 23. Women and CHD: What Test to Order When <ul><li>For new-onset symptoms, resting, or rapidly worsening symptoms, women should be referred immediately to the emergency department for evaluation </li></ul><ul><li>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 </li></ul>Source: Anderson 2007
  24. 24. Women and CHD: What Test to Order When <ul><li>For women at high or intermediate risk of coronary artery disease, consider treadmill echocardiogarphy or nuclear perfusion imaging </li></ul><ul><li>For women unable to exercise, consider dobutamine stress echocardiography or adenosine or dipyridamole nuclear imaging </li></ul><ul><li>In high risk women with typical symptoms of coronary artery disease, consider referral to a cardiologist </li></ul><ul><li>For high risk women, consider cardiac catheterization if symptoms persist despite negative non-invasive imaging </li></ul>Source: Anderson 2007, Klocke 2003, Douglas 2008, Duvernoy 2005
  25. 25. Women and CHD: What Test to Order When <ul><li>A stepwise approach beginning with conventional exercise testing may be considered for women who: </li></ul><ul><ul><li>Are at low or intermediate risk for coronary artery disease </li></ul></ul><ul><ul><li>Are able to exercise </li></ul></ul><ul><ul><li>Have an electrocardiogram that can be interpreted during stress testing </li></ul></ul><ul><li>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 </li></ul>Source: Anderson 2007, Klocke 2003, Douglas 2008,Mieres 2005