Cardiovascular Disease in Women Module IV: Diagnosis

1. Cardiovascular Disease in WomenModule 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 Diseasein Women and Factors to Consider Source: Charney 2002, Greenland 2007

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 77 80 70 68 70 61 60 50 Men 40 Women 30 20 10 0 Sensitivity Specificity 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 ** * *P < 0.004 vs. Echo **Old P < 0.005 vs. Echo Source: Marwick 1995

15. Sensitivity and Specificity of Dobutamine Stress Echocardiography for the Diagnosis of CAD in Women * * Higher in women than in men P < 0.05 Source: Elhendy 1997

16. 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? CHD: Differences in Presentation and Findings in Women Compared to Men 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