Diagnosis CVD in Women Module
-
Upload
cardiacinfo -
Category
Documents
-
view
251 -
download
0
Transcript of Diagnosis CVD in Women Module
Cardiovascular Disease in WomenModule 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 Diseasein Women and Factors to Consider
Technique Assessment Issues in Women
Angiography Coronary anatomy
Less focal disease
Coronary CT Coronary calcification
Less well-validated than other techniques
Echocardiography Regional wall motion
Reader expertise variable
Nuclear Cardiology Regional blood flow
Attenuation issues
Source: Charney 2002, Greenland 2007
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
6861
7770
0
10
20
30
40
50
60
70
80
Sensitivity Specificity
MenWomen
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
tissueSource: Nishimura 2005
Diagnostic Accuracy of Thallium-201 SPECT Myocardial Perfusion Imaging in Men and Women
0.870.93
00.10.20.30.40.50.60.70.80.9
1
Men Women
Diagnostic Accuracy [Area under
receiver operating characteristic (ROC)
curve]
Men
Women
P < 0.05
Source: Hansen 1996
Sensitivity and Specificity of Dipyridamole SPECT Imaging in Identifying Individual Coronary Stenoses and Multivessel Disease in Women
84
50
6878
92
7570 63
0102030405060708090
100
Overall Left AnteriorDecending
LeftCircumflex
Artery
RightCoronary
Artery
%SensitivitySpecificity
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
81 80 8177
5664
0102030405060708090
100
Sensitivity Specificity Accuracy
%
Echo
ECG
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
7682
94
0
10
20
30
40
50
60
70
80
90
100
Sensitivity Specificity Accuracy
%
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
100 100
7572
15
55
30
95
0
20
40
60
80
100
Age < 60 yrs. Age 60yrs.
%
Sensitivity
Specificity
PositivePredicitive ValueNegativePredictive Value
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