Coronary Artery Disease in Women
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- A 65-year-old female presented to the emergency room with sudden onset of chest pain, pressure, nausea, vomiting, shortness of breath, and lightheadedness. - Her medical history included hypertension, diabetes, and hyperlipidemia. Diagnostic tests found elevated cardiac enzymes and EKG changes consistent with a heart attack. - She was started on medications and transferred for further treatment, where imaging found apical ballooning syndrome, also known as stress-induced cardiomyopathy or "broken heart syndrome". This occurs when emotional or physical stress causes transient left ventricular dysfunction mimicking a heart attack.
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Coronary Artery Disease in Women
- 1. Credit: Slides Based on Presentation from Dr. Jennifer Mieres New York University School of Medicine
- 6. 137 109 18 3.9 22 1.0 244 8.6 2.1 1.0 11.7 14.8 34.3 390 CPK: 152 MB: 13.6 Trop: 1.9 AST:29 TP: 6.1 ALT: 24 Alb: 3.0 Bili: 1.1/0.4
- 9. Leading Causes of Death for All Males and Females US 2004 A Total CVD (Preliminary) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease Source: CDC/NCHS/AHA Deaths in thousands
- 10. *2004 statistics are preliminary ; NCEP, National Cholesterol Education Program http://www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed July 31, 2006 Thom T, et al. Circulation . 2007;113:e85-151 Year 400 420 440 460 480 500 520 1980 1985 1990 1995 2000 2004 Deaths in thousands Males Females NCEP I NCEP II NCEP III
- 15. Increasing Public Awareness of Heart Disease in Women: NHLBI, AHA and Womenheart The National Coalition for Women with Heart Disease. www.womenheart.org
- 17. CAD, coronary artery disease Burke AP, et al. Circulation . 1998;97:2110-2116. Age Plaque morphology Coronary artery stenosis Associated risk factor < 50 years plaque erosion minimal cigarette smoking > 50 years vulnerable plaque rupture severe hypercholesterolemia
- 20. Milner et al: Am J Cardiol, 1999 % Dyspnea Nausea Indigestion Dizziness Fatigue Sweating Arm/ Vomiting Fainting Shoulder/pain Women Men
- 23. ASNC Patient Management Strategy for CT Imaging & SPECT In Asymptomatic, Int-High Framingham Risk Low FRS Int-High FRS SPECT CCS > 400 or 90th %ile CCS <100 or <75 th %ile CCS > 100<400 or > 75 th <90 th %ile Cath - ? CTA Primary Prevention EBT-CT Mod-Severe Abnml Low Risk Mildly Abnml Primary Prevention Consider Re-Testing 3-5 Yrs Secondary Prevention Consider Re-Testing 2-3 Yrs Medical Rx Consider Re-Testing 1-2 Yrs Highlighted box indicates patients treated to secondary prevention goals Source: Shaw LJ, Berman DS, Bax JJ, Brown KA, Cohen MC, Hendel RC, Mahmarian JJ, Williams KA, Ziffer JA. The complementary roles of nuclear cardiology and cardiac CT in the current healthcare environment. J Nuc Cardiol 2005;12:131-142.
- 24. Source: Kwok AJC 1999, klocke et al JACC,, Shaw Eur Heart J 2005 Mar;26(5):447-56.
- 25. Improved CAD Detection & Prognostication through Visualization of Wall Motion, Perfusion, & Function SPECT Imaging: Visualize Wall Motion, Perfusion, & Function Echo Imaging: Visualize Wall Motion & Function
- 27. Follow-up (Years) 3.0 2.5 2.0 1.5 1.0 .5 0.0 Cumulative Survival 1.00 .95 .90 .85 .80 Nondiabetics Diabetics p<0.00001 Source: Giri S, et al. Circulation. 2002;105:32-40. Re-Test @ ~1-1.5 years
- 28. 39 y/o AAF Multiple Risk Factors Chest Pain Stress Perfusion
- 30. Arterial Wall Atherosclerosis Symptomatic Luminal Obstruction Courtesy LJ Shaw, PhD; Cedars-Sinai Medical Center
- 33. Noninvasive Coronary anatomy: evaluation of coronary stenosis ( calcified and non-calcified plaque and the vessel wall) CTA LM/LAD CATH LM/LAD
- 56. Percentage of Men with one vessel, two vessel, three vessel left main or no CAD on coronary angiography Reference: JACC 2003;41:158-68 N indicates Normal or <50% stenosis; one-vessel, two-vessel, three-vessel disease; LM: Left main disease
- 57. Percentage of Women with one vessel, two vessel, three vessel left main or no CAD on coronary angiography Reference: JACC 2003;41:158-68 N indicates Normal or <50% stenosis; one-vessel, two-vessel, three-vessel disease; LM: Left main disease
- 63. 1. Chest discomfort or uncomfortable pressure, fullness, squeezing or pain in the center of the chest that lasts longer than a few minutes, or comes and goes. 2. Spreading pain to one or both arms, back, jaw, or stomach. 3. Cold sweats and nausea .
Editor's Notes
- Despite advances in the detection and management of cardiovascular disease (CVD) in recent years, CVD risk remains under-recognized in many special populations, including women, African Americans, Hispanics, diabetics, and obese individuals According to the American Heart Association (AHA), mortality statistics (from the Centers for Disease Control and Prevention [CDC] and the National Center for Health Statistics [NCHS]) reveal a decline in cardiovascular disease (CVD)-related deaths in men over the past 2 decades. This decline may correlate with the start of the National Cholesterol Education Program (NCEP) initiative and promotion of earlier, more aggressive cholesterol management programs. Over this same time period, CVD-related mortality in women has not declined appreciably. According to the most recent AHA Heart Disease and Stroke Statistics, CVD-related mortality data for the year 2003 (preliminary) indicate 483,842 deaths in women compared with 426,772 deaths in men [Thom, pe87] . References Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA . 2001;285:2486-2497. Thom T, Haase N, Rosamond W, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation . 2006;113:e85-151. http://www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed July 2006
- Female autopsy cases evaluated for the effect of traditional atherosclerosis risk factors on mechanisms of sudden cardiac death in women reveal distinct patterns of risk factors and plaque morphology, depending on menopausal status. In the study by Burke and colleagues, vulnerable plaque rupture with severe coronary stenosis was associated with elevated cholesterol and age >50 years, while plaque erosion with minimal vessel narrowing was more frequent in younger women <50 years of age who smoked. The intriguing implication in these findings is that while the etiology of the acute thrombotic event in sudden cardiac death may be the same in post-menopausal women and in men, this etiology is different in pre-menopausal women. Reference Burke AP, Farb A, Malcom GT, Liang Y, Smialek J, Virmani R. Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women. Circulation . 1998;97:2110-2116.
- Gender differences in CAD etiology and clinical presentation extend to mortality risk as well, highlighting the importance of early recognition, despite confounding or absent symptoms, and timely management of CAD in women. References Heart Attack Symptoms and Warning Signs. http://www.americanheart.org/presenter.jhtml?identifier=4595. Accessed June 15, 2006. Albert CM, Chae CU, Grodstein F, Rose LM, Rexrode KM, Ruskin JN, Stampfer MJ, Manson JE. Prospective study of sudden cardiac death among women in the United States. Circulation . 2003;107:2096-2101. Womena and Heart Disease Fact Sheet. http://www.womenheart.org/information/WH_fact_sheet_print.html. Accessed June 12, 2006.
- Contemporary techniques of echo and nuclear SPECT imaging ( incorporating contrast with echo and attenuation correction and gated SPECT =high sensitivity and specificity for detecting physiologically significant disease.
- Standard diagnostic tests, including angiography, reveal that for many women ischemic heart disease is not associated with luminal obstruction but rather with atypical plaque accumulation along the walls of the major coronary arteries, perhaps reflecting one of several forms of atherosclerotic disease – that, in women, are modulated by reproductive hormones. Approximately 50% of women referred for suspected ischemia do not have obstructive disease but are still at risk for future events and continued symptoms [Lerman pS61] . Therefore, among women referred for diagnosis of suspected ischemia, caution is warranted in the face of nonobstructive angiograms or results of noninvasive tests whose findings could be erroneously construed as falsely positive. References Bairey Merz CN, Shaw LJ, Reis SE, et al; WISE Investigators. Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol. 2006;47(3 Suppl):S21-S29. Lerman A, Sopko G. Women and cardiovascular heart disease: clinical implications from the Women's Ischemia Syndrome Evaluation (WISE) Study. Are we smarter? J Am Coll Cardiol. 2006;47(3 Suppl):S59-S62.
- Reference Lerman A, Sopko G. Women and cardiovascular heart disease: clinical implications from the Women's Ischemia Syndrome Evaluation (WISE) Study. Are we smarter? J Am Coll Cardiol. 2006;47(3 Suppl):S59-S62.
- The gated portion of the SPECT study allows both the visual and quantitative assessment of left ventricular function. These measures include left ventricular ejection fraction and end-diastolic and end-systolic volumes. In addition, this modality achieves excellent visualization of both the endocardial and epicardial surfaces, allowing for the evaluation of left ventricular wall motion and wall thickening. In this scan, the top row represents 3 short axis images (apical, mid, and basal short-axis slices) and the bottom row represents the mid, horizontal, and vertical long-axis slices.