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Ramos SM, Glavam AP, de Brito AS, Kubo TTA, Tukamoto G, Sampaio DDCP, de Sá LV. Prone Myocardial Perfusion Imaging and Breast Attenuation: A Phantom Study. Curr Med Imaging 2020; 16:70-79. [DOI: 10.2174/1573405614666181017121453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 11/22/2022]
Abstract
Background:
Soft tissue attenuation artifacts are the most common cause of misinterpretation
in myocardial perfusion Imaging (MPI). Few studies assessing the value of prone imaging
in women have been published. Breast attenuation artifacts can be present in up to 40% of the MPI
studies in women.
Objectives:
This study aimed at evaluating the potential impact of prone MPI on breast attenuation,
with a critical analysis of activity optimization and breast size influence.
Methods:
MPI of an Anthropomorphic Torso Phantom with silicone breast prostheses and
equivalent adipose tissue was compared to a standard MPI database.
Results:
A medical qualitative and semiquantitative analysis demonstrated higher uptake in the LV
anterior segments in the prone position for all injected activities. An artificial myocardium lesion
was diagnosable in the right segment in all images, which shows that prone positioning would not
mask a true lesion and it assists the cardiologist with a more accurate analysis. These results
showed that it is possible to optimize the activity to be injected by up to 55.6% when using combined
supine-prone images.
Conclusion:
Prone position has a high impact on the interpretation of MPI in female patients since
it reduces the breast attenuation artifacts, and optimizes the radiation protection of the patient and
all staff involved in the procedure, making it more cost-effective.
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Affiliation(s)
- Susie Medeiros Oliveira Ramos
- Radiology Department, Federal University of Rio de Janeiro (UFRJ), Clementino Fraga Filho University Hospital, Rio de Janeiro, Brazil
| | - Adriana Pereira Glavam
- Nuclear Medicine Department, Clínica de Diagnóstico Por Imagem - Diagnósticos da América SA (CDPI/DASA), Rio de Janeiro, Brazil
| | - Adriana Soares Xavier de Brito
- Nuclear Medicine Department, Clínica de Diagnóstico Por Imagem - Diagnósticos da América SA (CDPI/DASA), Rio de Janeiro, Brazil
| | - Tadeu Takao Almodovar Kubo
- Nuclear Medicine Department, Clínica de Diagnóstico Por Imagem - Diagnósticos da América SA (CDPI/DASA), Rio de Janeiro, Brazil
| | - Gustavo Tukamoto
- Nuclear Medicine Department, Clínica de Diagnóstico Por Imagem - Diagnósticos da América SA (CDPI/DASA), Rio de Janeiro, Brazil
| | - Debora da Cunha Pereira Sampaio
- Medical Physics Department, Institute of Radiation Protection and Dosimetry - IRD, Brazilian Nuclear Energy Commission-CNEN, Rio de Janeiro, Brazil
| | - Lidia Vasconcellos de Sá
- Medical Physics Department, Institute of Radiation Protection and Dosimetry - IRD, Brazilian Nuclear Energy Commission-CNEN, Rio de Janeiro, Brazil
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Is Attenuation Correction for Myocardial Perfusion Imaging Underutilized? CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9346-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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3
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Gender differences in the evaluation of coronary artery disease with a cadmium-zinc telluride camera. Eur J Nucl Med Mol Imaging 2013; 40:1542-8. [PMID: 23703458 DOI: 10.1007/s00259-013-2449-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Coronary artery disease remains one of the most significant causes of morbidity and mortality among women. The published literature shows the importance of standard single photon emission computed tomography in the evaluation of women with known or suspected ischaemic heart disease, in terms of target intervention and clinical treatment. The purpose of the present study was to ascertain the diagnostic accuracy of cadmium-zinc-telluride (CZT) myocardial perfusion imaging according to gender, within a prospective database of patients with known or suspected coronary artery disease, using coronary angiography as the reference standard. METHODS Included in the study were 309 consecutive patients, of whom 248 were men (80 %), with known or suspected coronary artery disease and who had been referred to our laboratory for stress-rest myocardial perfusion imaging. All patients underwent coronary angiography within 30 days. All patients underwent a single-day stress-rest low-dose ultrafast protocol. Fifteen minutes after the end of the stress (dose range 185 to 222 MBq of (99m)Tc-tetrofosmin), all patients underwent the first scan with an acquisition time of 7 min. The rest scan (dose range 370 to 444 MBq of (99m)Tc-tetrofosmin) was acquired from 30 min to 45 min after injection, with an acquisition time of 6 min. Images were visually inspected, and summed stress scores (SSS) and summed rest scores (SRS) were obtained. RESULTS Image quality was graded "good" or better in more than 90 % of patients. On coronary angiography, left main trunk stenosis, left anterior descending artery stenosis, left circumflex artery stenosis and right coronary artery stenosis were seen in 3, 155 , 142 and 131 patients, respectively. In women, the mean SSS and SRS were 8 ± 5 and 3 ± 1, respectively. Semiquantitative regional and global SSS were good discriminants of coronary artery disease, and the overall area under the receiver operator characteristic (ROC) curve was 0.822 (95 % CI 0.685 - 0.959). The value was comparable to that obtained in men (overall ROC area 0.884, 95 % CI 0.836 - 0.933). CONCLUSION A low-dose protocol with a CZT camera can be routinely used in women with known or suspected coronary artery disease without loss of accuracy and with lower radiation exposure of the patients.
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Akalın EN, Yaylalı O, Kıraç FS, Yüksel D, Kılıç M. The Role of Myocardial Perfusion Gated SPECT Study in Women with Coronary Artery Disease: A Correlative Study. Mol Imaging Radionucl Ther 2013; 21:69-74. [PMID: 23486759 PMCID: PMC3590968 DOI: 10.4274/mirt.359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 07/10/2012] [Indexed: 12/28/2022] Open
Abstract
Objective: We aimed to evaluate the role of gated myocardial perfusion SPECT (MPS) and to investigate whether only the invasive coronary angiography (CAG) is sufficient in the diagnosis of the coronary artery disease (CAD) in women. Material and Methods: Sixty-four women (62±10 years) with known CAD were included in this study. They had echocardiography (ECHO), stress/rest gated MPS and invasive CAG. Coronary stenosis as of > 50 % in invasive CAG was accepted as significant. Gated MPS data were compared with invasive CAG and ECHO. Results: Invasive CAG results were abnormal in 34 patients, and normal in 30 cases. Myocardial ischemia was detected by gated MPS in 22/ 30 cases with normal invasive CAG, 6 had mild coronary stenosis in major coronary arteries ranging from 30% to 50% in invasive CAG. 16/ 22 women were diagnosed as metabolic syndrome according to MetSend Diagnostic Criteria and only 8 of 30 patients with normal invasive CAG had false positive MPS data on the reevaluation by a nuclear cardiologist. Conclusion: We think that invasive coronary angiography method is not sufficient alone in the diagnosis of CAD in women. Gated MPS study is recommended to achieve the final decision for myocardial ischemia in the cases with CAD and raw data must always be evaluated to avoid attenuation artifacts. Conflict of interest:None declared.
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5
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Abstract
Nuclear cardiology has made significant advances since the first reports of planar scintigraphy for the evaluation of left ventricular perfusion and function. While the current "state of the art" of gated myocardial perfusion single-photon emission computed tomographic (SPECT) imaging offers invaluable diagnostic and prognostic information for the evaluation of patients with suspected or known coronary artery disease (CAD), advances in the cellular and molecular biology of the cardiovascular system have helped to usher in a new modality in nuclear cardiology, namely, molecular imaging. In this review, we will discuss the current state of the art in nuclear cardiology, which includes SPECT and positron emission tomographic evaluation of myocardial perfusion, evaluation of left ventricular function by gated myocardial perfusion SPECT and gated blood pool SPECT, and the evaluation of myocardial viability with PET and SPECT methods. In addition, we will discuss the future of nuclear cardiology and the role that molecular imaging will play in the early detection of CAD at the level of the vulnerable plaque, the evaluation of cardiac remodeling, and monitoring of important new therapies including gene therapy and stem cell therapy.
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6
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Mieres JH, Rosman DR, Shaw LJ. The role of myocardial perfusion imaging in special populations: women, diabetics, and heart failure. Semin Nucl Med 2005; 35:52-61. [PMID: 15645394 DOI: 10.1053/j.semnuclmed.2004.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiovascular disease and its manifestations remain a major worldwide public health problem. Despite significant advances in diagnosis and treatment, coronary artery disease remains the leading cause of death of men and women in the developed world. Early and accurate diagnosis of coronary artery disease is crucial if men and women are to have improved outcomes. The continuous and dramatic growth in the field of nuclear cardiology during the past 2 decades has accounted for its central role in the clinical evaluation of patients with known or suspected coronary heart disease. The development of electrocardiogram-gated single photon emission tomography has facilitated the expansion of nuclear cardiology studies from the evaluation of myocardial perfusion alone to the evaluation of both perfusion and ventricular function data in a single study. Myocardial perfusion imaging with electrocardiogram-gated single photon emission tomography, with its ability to provide information about the physiologic significance of coronary stenosis, left ventricular function, and risk assessment of patients with coronary artery disease, is ideally suited for the diagnostic and prognostic evaluation of the patient who is at high to intermediate risk for ischemic heart disease.
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Affiliation(s)
- Jennifer H Mieres
- Division of Cardiology, North Shore University Hospital, Manhasset, NY 11030, USA.
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7
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Maganti K, Rigolin VH. Stress echocardiography versus myocardial SPECT for risk stratification of patients with coronary artery disease. Curr Opin Cardiol 2004; 18:486-93. [PMID: 14597890 DOI: 10.1097/00001573-200311000-00010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Diagnostic testing using noninvasive imaging has become an integral part of risk stratification in patients with coronary artery disease. It is important to understand the integral strengths and weaknesses between the different modalities of stress testing and to apply accurately the type of test the clinical scenario demands. RECENT FINDINGS There have been tremendous advances made in the field of cardiac imaging. Both myocardial perfusion imaging and stress echocardiographic techniques continue to evolve and play an important role in the assessment of patients with coronary artery disease. SUMMARY In this review the authors discuss the relative merits of both stress echocardiography and myocardial single photon emission computed tomographic imaging for diagnosis and risk stratification of patients with coronary artery disease.
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Affiliation(s)
- Kameswari Maganti
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Chicago, Illinois, USA
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8
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Mieres JH, Rosman DR, Shaw LJ. The clinical role of stress myocardial perfusion imaging in women with suspected coronary artery disease. Curr Cardiol Rep 2003; 6:27-31. [PMID: 14662095 DOI: 10.1007/s11886-004-0062-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cardiovascular disease remains the number one cause of mortality for women in the United States, with coronary artery disease (CAD) accounting for 54% of all cardiovascular deaths. CAD claims the lives of more than 250,000 women each year and is therefore the single largest killer of American women. For several decades, the under-representation of women in clinical trials led to both a lack of available sex-specific evidence and a generalized misconception that CAD was a "man's disease." In actuality, not only are women vulnerable to CAD, they typically develop it 10 to 15 years later than men. Furthermore, sex differences exist in the mortality rates of women and men with CAD, such that once CAD is present in women, they have worse outcomes than their male counterparts. Consequently, early and accurate diagnosis of CAD is crucial for reducing mortality rates in women. Stress myocardial perfusion imaging (MPI) using contemporary techniques has been shown to have significant value in the diagnosis and prognosis of CAD in women. In the risk assessment of women with an intermediate clinical pretest likelihood of CAD, using MPI with exercise or pharmacologic stress has been shown to add incremental value to clinical variables or exercise electrocardiogram stress testing alone. This review discusses the clinical role of stress MPI in the management of women with suspected CAD.
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Affiliation(s)
- Jennifer H Mieres
- North Shore University Hospital, Division of Cardiology, 300 Community Drive, Manhasset, NY 11030, USA.
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9
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Mieres JH, Shaw LJ. Stress Myocardial Perfusion Imaging in the Diagnosis and Prognosis of Women with Suspected Coronary Artery Disease. Cardiol Rev 2003; 11:330-6. [PMID: 14650385 DOI: 10.1097/01.crd.0000088275.80332.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Coronary artery disease is the single largest killer of women in the United States and claims the lives of more than 250,000 women each year. For several decades, there was the misperception that coronary artery disease was a "man's disease." The fact is that women are indeed vulnerable to coronary artery disease; however, they typically develop the disease 10 to 15 years later than men. Once coronary artery disease is evident, women have worse outcomes as compared with men.Therefore, early and accurate diagnosis of coronary artery disease is crucial for reducing heart disease mortality in women. Stress myocardial perfusion imaging using contemporary techniques has been shown to have significant value in the diagnosis and prognosis of coronary artery disease in women. Myocardial perfusion imaging with exercise or pharmacologic stress has been shown to add incremental value to the use of clinical variables or exercise electrocardiogram stress testing alone in the risk stratification of women with an intermediate clinical pretest likelihood of coronary artery disease. This review provides an overview of the role of stress myocardial perfusion imaging in the clinical evaluation of women with suspected coronary artery disease.
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Affiliation(s)
- Jennifer H Mieres
- North Shore University Hospital, Division of Cardiology, Manhasset, NY 11030, USA.
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10
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Sánchez Luis C, Suárez Fernández C. Patología cardiovascular de la mujer. HIPERTENSION Y RIESGO VASCULAR 2003. [DOI: 10.1016/s1889-1837(03)71375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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11
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Mieres JH, Shaw LJ, Hendel RC, Miller DD, Bonow RO, Berman DS, Heller GV, Mieres JH, Bairey-Merz CN, Berman DS, Bonow RO, Cacciabaudo JM, Heller GV, Hendel RC, Kiess MC, Miller DD, Polk DM, Shaw LJ, Smanio PE, Walsh MN. American Society of Nuclear Cardiology consensus statement: Task Force on Women and Coronary Artery Disease--the role of myocardial perfusion imaging in the clinical evaluation of coronary artery disease in women [correction]. J Nucl Cardiol 2003; 10:95-101. [PMID: 12569338 DOI: 10.1067/mnc.2003.130362] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jennifer H Mieres
- American Society of Nuclear Cardiology, Bethesda, MD 20814-1699, USA
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12
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Bokhari S, Bergmann SR. The effect of estrogen compared to estrogen plus progesterone on the exercise electrocardiogram. J Am Coll Cardiol 2002; 40:1092-6. [PMID: 12354433 DOI: 10.1016/s0735-1097(02)02111-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the effect of estrogen compared to estrogen plus progesterone on the stress electrocardiogram (ECG) in relationship to stress-gated myocardial perfusion imaging (MPI) in postmenopausal women. BACKGROUND It is generally recognized that estrogen may cause false positive ST depressions on the stress ECG. The effects of estrogen plus progesterone are not known. This study was performed to define the effects of these agents on the stress ECG correlated with results from MPI. METHODS We evaluated 140 postmenopausal women-31 not taking any hormone replacement therapy (HRT); 75 taking estrogen alone; and 34 taking estrogen plus progesterone. Women with a history of coronary artery disease (CAD), cardiomyopathy, or an abnormal resting ECG were excluded. All women underwent a symptom-limited treadmill test and MPI. RESULTS The overall sensitivity and specificity of the stress ECG compared to MPI in women not taking HRT was 54% and 78%, respectively. In women taking estrogen or estrogen plus progesterone, the sensitivity was unchanged. The power to detect clinically meaningful sensitivity difference (10%) was poor (p = 0.09). The specificity was reduced to 46% (p < 0.01) in women on estrogen therapy. In women taking estrogen plus progesterone, specificity was 80%. CONCLUSIONS Our results suggest that estrogen increases the false positive rate of the stress ECG. This decreased specificity is countered by co-administration of progesterone. Nonetheless, because the sensitivity of the stress ECG is only 50% to 57% in postmenopausal women, women at risk should have imaging in conjunction with stress for the optimal detection of CAD.
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Affiliation(s)
- Sabahat Bokhari
- Division of Cardiology, Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York 10032, USA.
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13
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Abstract
Coronary artery disease (CAD) is the leading cause of death in women. More women than men die of CAD each year, and unlike men, the death rate has not declined for women but has remained stable over the last 20 years. Despite these statistics, much less is known about the prevention, diagnosis, or treatment of CAD in women. The noninvasive diagnosis of CAD in women is difficult secondary to differences in physiology, etiology, presenting symptoms, risk factor prevalence, comorbid conditions, hormonal status, and body habitus between women and men. Echocardiography and Tc-99m sestamibi single photon emission computed tomography imaging are two noninvasive imaging techniques commonly combined with exercise or pharmacologic agents (dobutamine, adenosine, dipyridamole) that have recently evolved to address these differences. These evolutions and the role of both techniques in the diagnosis and prognosis of women with CAD will be reviewed in this article.
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14
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Kane GC, Hauser MF, Behrenbeck TR, Miller TD, Gibbons RJ, Christian TF. Impact of gender on rest Tc-99m sestamibi-gated left ventricular ejection fraction. Am J Cardiol 2002; 89:1238-41. [PMID: 12008188 DOI: 10.1016/s0002-9149(02)02317-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Garvan C Kane
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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15
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Mobasseri S, Hendel RC. Cardiac imaging in women: use of radionuclide myocardial perfusion imaging and echocardiography for acute chest pain. Cardiol Rev 2002; 10:149-60. [PMID: 12047793 DOI: 10.1097/00045415-200205000-00003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evidence for the value of noninvasive cardiac imaging in patients for the detection of ischemic heart disease has traditionally come from trials using male patients. The application of such technology for women is often presumptive. Because there is an overall lower prevalence of ischemic heart disease in women, difference in body habitus, and smaller heart size, cardiac imaging in women presents unique challenges for imaging specialists and cardiologists. With the introduction of technetium-99 meters perfusion agents, gated single-photon emission computed tomography, and attenuation correction, myocardial perfusion imaging (MPI) in women has achieved a high sensitivity and specificity for the detection of coronary artery disease similar to that observed in men. With harmonic imaging and myocardial contrast agents, two-dimensional echocardiography offers comparable diagnostic accuracy in women. More importantly, MPI and stress echocardiography have prognostic value in predicting future cardiovascular events. The severity and extent of the single-photon emission computed tomography myocardial perfusion defects independently predict future cardiovascular events. Myocardial perfusion rest imaging during acute chest pain has a 99% negative predictive value of subsequent cardiovascular events, and a positive study MPI is the most important predictor for future cardiac events. Both MPI and stress echocardiography can direct high-risk patients to more invasive management or selectively identify lower-risk patients, allowing safe discharge from the emergency department and unnecessary hospitalization. Using a triage approach incorporating MPI or rest echocardiography in patients with acute chest pain results in significant cost savings. However, data on rest imaging in women during acute chest pain are still lacking.
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Affiliation(s)
- Sara Mobasseri
- Section of Cardiology, Department of Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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16
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Abstract
Coronary artery disease (CAD) is a major health care challenge, and is the leading cause of death amongst women. Both the delay in the clinical manifestations of CAD and 'atypical' symptomatology in women complicates both diagnosis and treatment strategies in this population. It appears that the age-adjusted prevalence of all-cause angina (effort, unstable, etc.) appears to be greater in women than men, although stenotic lesions are demonstrated less frequently. There are a number of factors that complicates the diagnosis and identification of CAD in women, including more diffuse anginal symptoms, a lower initial detection rate of myocardial ischemia by traditional methods, lower rates of interventional procedures, and lastly, potential differences in the pathophysiology of myocardial ischemia. The lower sensitivity and specificity of many diagnostic techniques including ECG and various imaging technologies contributes significantly to these findings. The increased presence of syndrome X in post-menopausal women may reflect an increased likelihood of microcirculatory disease, where the 'gold standard' angiography fails to detect the presence of disease. Thus nonepicardial coronary stenotic disease may be largely undetected by most studies, rendering many positive ECG stress results unverifiable. The increased co-morbidity seen with CAD in women further complicates diagnosis and interventional results. Combined, these factors act to falsely lower the post-test likelihood of disease in women, adding to the existing gender bias in the diagnosis and referral rates for treatment of CAD in women. The lower precision of disease detection in women contributes to the perception that women have less exertional angina than men, despite evidence to the contrary.
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Affiliation(s)
- J Goodman
- Faculty of Physical Education and Health, University of Toronto, Ontario, Canada
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17
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Peng NJ, Mar GY, Liu CP, Jao GH, Lee D, Liang HL, Tsay DG, Chen CC, Liu RS. Does inadequate exercise lower the accuracy of myocardial perfusion scintigraphy? Nucl Med Commun 2001; 22:625-9. [PMID: 11403172 DOI: 10.1097/00006231-200106000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The predictive accuracy of exercise myocardial perfusion scintigraphy (EMPS) in detecting coronary artery disease (CAD) in patients who fail to achieve an adequate level of exercise is not clear. This investigation was carried out in order to compare the sensitivity, specificity and accuracy of EMPS in adequate exercise patients with those in inadequate exercise patients. We have retrospectively compared the results of EMPS with coronary angiography (CAG). One hundred and forty-eight patients with both tests within 6 weeks were included. Adequate exercise was defined as > or = 85% maximally predicted heart rate for age. The overall sensitivity and specificity of EMPS to detect CAD were 92.5% (74/80) and 75%, (51/68), respectively. The sensitivity and specificity in adequate exercise patients were 94.1% (32/34) and 67.6% (23/34), whereas those in inadequate exercise patients were 91.3% (42/46) and 82.4% (28/34). The accuracy was 80.9% (55/68) and 87.5% (70/80), respectively. Patients with inadequate exercise had lower sensitivity but higher specificity of EMPS for detecting CAD, and achieved a higher accuracy than those with adequate exercise.
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Affiliation(s)
- N J Peng
- Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Taiwan.
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18
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Miller TD, Roger VL, Milavetz JJ, Hopfenspirger MR, Milavetz DL, Hodge DO, Gibbons RJ. Assessment of the exercise electrocardiogram in women versus men using tomographic myocardial perfusion imaging as the reference standard. Am J Cardiol 2001; 87:868-73. [PMID: 11274942 DOI: 10.1016/s0002-9149(00)01528-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The exercise electrocardiogram (ECG) is widely believed to be less accurate in women, primarily due to a high prevalence of false-positive tests. The purpose of this study was to examine the relative accuracy of the exercise ECG in women versus men in 8,671 patients (3,213 women, 5,458 men) using myocardial perfusion imaging as the reference standard. More women (14%) than men (10%) had a false-positive ECG (p <0.001), but the absolute difference was relatively small. The false-negative rate was considerably lower in women (17% vs 32%, p <0.001). Compared with men, women had lower test sensitivity (30% vs 42%, p <0.001) and positive predictive value (34% vs 70%, p <0.001) but higher specificity (82% vs 78%, p = 0.002), negative predictive value (78% vs 52%, p <0.001), and accuracy (69% vs 58%, p <0.001). In patients with a false-negative exercise ECG, "high-risk" scans were less prevalent in women (12% vs 19%, p <0.001). In the smaller subset of patients referred for coronary angiography (205 women, 838 men), the false-positive electrocardiographic rate was again higher in women (13% vs 7%, p = 0.003), but neither specificity (69% vs 74%, p = NS) nor accuracy (60% vs 66%, p = NS) was different between the sexes. Thus, the percentage of patients with a false-positive exercise ECG was higher in women than men but low in absolute terms (<15%) for both sexes. Test specificity was not lower in women. These results suggest that gender should not be a major determinant for selecting stress imaging over standard treadmill testing.
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Affiliation(s)
- T D Miller
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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19
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Panza JA. Transesophageal echocardiography with stress for the evaluation of patients with coronary artery disease. Cardiol Clin 1999; 17:501-20, viii-ix. [PMID: 10453295 DOI: 10.1016/s0733-8651(05)70093-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Echocardiography permits a comprehensive assessment of resting regional and global left ventricular function, the presence and extent of inducible myocardial ischemia, and the identification of myocardial viability. Accordingly, stress echocardiography has become a valuable tool for the evaluation of patient with known or suspected coronary artery disease. In some patients however, a suboptimal transthoracic echocardiogram may limit the performance of interpretation of the test. Transesophageal echocardiography in combination with stress has been recently used for the evaluation of patients with coronary artery disease. This technique is semi-invasive, more time-consuming, and requires a greater degree of expertise on the part of the personnel assisting with the test. In general, complications and side-effects are self-limited and rarely affect the diagnostic accuracy of the test. Based on its ability to provide high quality images, transesophageal stress echocardiography should be considered in patients who have suboptimal transthoracic ultrasound window for the quantitative assessment of myocardial wall-thickening in clinical investigations of ischemic heart disease.
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Affiliation(s)
- J A Panza
- Section of Echocardiography, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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Abstract
To determine the accuracy of the exercise electrocardiogram (ECG), exercise thallium, and exercise echocardiogram (echo) for the diagnosis of coronary artery disease in women, English language studies published between 1966 and 1995 were identified through a MEDLINE search. Studies that contained data on at least 50 women who underwent both an exercise test and coronary angiography were examined. Studies were reviewed for sensitivity, specificity, and methodologic characteristics by 2 independent reviewers. Nineteen studies met the inclusion criteria for exercise electrocardiography, 5 studies for exercise thallium, and 3 studies for exercise echo. The exercise ECG had a weighted mean sensitivity, specificity, and a likelihood ratio (LR) of 0.61 (95% confidence intervals 0.54 to 0.68), 0.70 (0.64 to 0.75), (+) LR 2.25 (1.84 to 2.66), (-) LR 0.55 (0.47 to 0.62), respectively. The exercise thallium had a weighted mean sensitivity, specificity, and LRs of 0.78 (0.72 to 0.83), 0.64 (0.51 to 0.77), (+) LR 2.87 (1.0 to 4.96), (-) LR 0.36 (0.27 to 0.45). The exercise echo had a weighted mean sensitivity, specificity, and LRs of 0.86 (0.75 to 0.96), 0.79 (0.72 to 0.86), (+) LR 4.29 (2.93 to 5.65), (-) LR 0.18 (0.05 to 0.31). Thallium subset analysis revealed that studies using planar imaging were more specific than those using tomographic imaging. Thus, currently available exercise tests are only moderately sensitive and specific for the diagnosis of coronary artery disease in women.
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Affiliation(s)
- Y Kwok
- Department of Medicine, University of California, San Francisco, USA
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21
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Abstract
Rather than the introduction of a heralded technologic advancement in cardiac SPECT imaging challenging the accuracy of PET perfusion imaging, the commercial introduction of attenuation correction has been met with at least as many negative as positive reports. Some studies have reported significant improvements in specificity or specificity and sensitivity, especially for high-risk patterns of coronary artery disease; others have reported no improvement or a decrease in accuracy resulting from the introduction of troublesome artifacts. Although this review has attempted to emphasize the positive aspects of attenuation-corrected cardiac SPECT perfusion imaging and the potential for improved patient care it may provide, several negative reports continue to appear. Still there has been sufficient positive data reported to suggest that with fully developed, accurate, and robust correction methods, significant gains in SPECT assessments of the presence and extent of CHD, patient risk, and myocardial viability can be anticipated. Ultimately attenuation correction for cardiac SPECT should have a positive impact on the management of patients with coronary artery disease with important savings in lives and health care dollars.
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Affiliation(s)
- J R Corbett
- Department of Internal Medicine, The University of Michigan Medical Center, Ann Arbor, USA
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22
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Elhendy A, van Domburg RT, Bax JJ, Nierop PR, Geleijnse ML, Ibrahim MM, Roelandt JR. Noninvasive diagnosis of coronary artery stenosis in women with limited exercise capacity: comparison of dobutamine stress echocardiography and 99mTc sestamibi single-photon emission CT. Chest 1998; 114:1097-104. [PMID: 9792583 DOI: 10.1378/chest.114.4.1097] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To compare the accuracy of dobutamine stress echocardiography (DSE) and simultaneous 99mTc sestamibi (MIBI) single-photon emission CT (SPECT) imaging for the diagnosis of coronary artery stenosis in women. PATIENTS Seventy women with limited exercise capacity referred for evaluation of myocardial ischemia. METHODS DSE (up to 40 microg/kg/min) was performed in conjunction with stress MIBI SPECT. Resting MIBI images were acquired 24 h after the stress test. Ischemia was defined as new or worsened wall motion abnormalities confirmed by DSE and as reversible perfusion defects confirmed by MIBI. Significant coronary artery disease was defined as > or = 50% luminal diameter stenosis. RESULTS DSE was positive for ischemia in 35 of 45 patients with coronary artery stenosis and in 2 of 25 patients without coronary artery stenosis (sensitivity = 78% CI, 68 to 88; specificity = 92% CI, 85 to 99; and accuracy = 83% CI, 74 to 92). A positive MIBI study for ischemia occurred in 29 patients with coronary artery stenosis and in 7 patients without coronary artery stenosis (sensitivity = 64% CI, 53 to 76; specificity = 72% CI, 61 to 83; and accuracy = 67% CI, 56 to 78 [p < 0.05 vs DSE]). In the 59 vascular regions with coronary artery stenosis, the regional sensitivity of DSE was higher than MIBI (69% CI, 62 to 77 vs 51% CI, 42 to 59, p < 0.05), whereas specificity in the 81 vascular regions without significant stenosis was similar (89% CI, 84 to 94 vs 88% CI, 82 to 93, respectively). CONCLUSION DSE is a useful noninvasive method for the diagnosis of coronary artery stenosis in women and provides a higher overall and regional diagnostic accuracy than dobutamine MIBI SPECT in this particular population.
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Affiliation(s)
- A Elhendy
- Thoraxcenter, University Hospital Rotterdam-Dijkzigt, Erasmus University, The Netherlands
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23
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Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey KR, Gersh BJ. Gender differences in use of stress testing and coronary heart disease mortality: a population-based study in Olmsted County, Minnesota. J Am Coll Cardiol 1998; 32:345-52. [PMID: 9708459 DOI: 10.1016/s0735-1097(98)00229-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to examine the utilization of exercise stress testing in relation to age and gender in a population-based setting. BACKGROUND The utilization of noninvasive procedures has been shown to be associated with the subsequent use of invasive procedures. Yet, there are no population-based data on the utilization of stress testing; in particular, although gender differences in the use of invasive procedures have been reported, the use of noninvasive procedures has not been examined in relation to gender. METHODS In Olmsted County, Minnesota, passive surveillance of the medical care of the community is provided through the Rochester Epidemiology Project. A population-based cohort of Olmsted County residents undergoing exercise tests was identified. The medical records of residents with prevalent and incident exercise tests in 1987 and 1988 were reviewed. For persons with an initial test (incidence cohort), data on clinical presentation, test indications and results were abstracted. Stress test utilization rates were calculated, and crude rates were directly adjusted to the age distribution of the 1980 U.S. population. To help interpret patterns of use at the population level, coronary heart disease mortality rates (International Classification of Diseases, 9th revision, codes 410 to 414) were calculated (crude and directly adjusted to the overall age distribution of the 1980 U.S. population) and used as an indicator of coronary disease burden. RESULTS A total of 2,624 tests were performed. The crude utilization rate (per 100,000) was 1,888 for men and 703 for women (rate ratio for men over women 2.7, 95% confidence interval [CI] 2.5 to 2.9); it remained significantly higher in men across all age strata. The crude incidence rate (per 100,000) of initial stress tests was 1,112 for men and 517 for women (rate ratio 2.2, 95% CI 1.9 to 2.4). For both men and women, the incidence increased with age; however, incidence remained lower in women in all age strata. At the time that they underwent an initial test, women were more symptomatic and had poorer exercise performance than men. The rate ratio of men over women for coronary heart disease mortality was 1.1 (95% CI 0.9 to 1.2). The age-adjusted rate ratios for stress test utilization were 2.8 (95% CI 2.5 to 3.0), and that for coronary heart disease mortality was 1.9 (95% CI 1.7 to 2.2). CONCLUSIONS These population-based data show that during the study period, the utilization of stress testing in Olmsted County was lower in women than in men. Women in the incidence cohort were older and more symptomatic and had poorer exercise performance than men. Such differences should be considered when examining the utilization of subsequent invasive procedures according to gender.
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Affiliation(s)
- V L Roger
- Mayo Medical Center, Rochester, Minnesota 55905, USA.
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24
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Janerot-Sjöberg B, Ekberg S, Areskog M, Nylander E, Swahn E. Quantitative digital evaluation of myocardial exercise thallium-201 single-photon emission tomography in post-menopausal women. CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 1998; 18:169-77. [PMID: 9649904 DOI: 10.1046/j.1365-2281.1998.00090.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Quantitative computerized analysis of data from myocardial thallium-201 (201Tl) single-photon emission tomography (SPET) may improve the diagnostic accuracy of coronary heart disease. The reference ranges for post-menopausal women are, however, limited and obtained mainly from patients. To compare reference values from healthy post-menopausal women and to improve the quantitative analysis, 20 women (10 patients with coronary heart disease and previous infarction and 10 age-matched healthy volunteers) were examined immediately post exercise and after a delay. A nine-segment 'bull's-eye' model was used for analysis. At visual evaluation, reproducibility was high (93%), no false-positive results were obtained and in 70% of the patients the SPET was interpreted as abnormal. Using reported reference values for quantitative analysis, all the healthy women had an abnormal result. New reference values based on three different methods of 'normalization' were calculated: the relative activity of segment 3 set to 100%, the segment with the highest activity set to 100% and a least-squares method. They all differed significantly from those that had previously been reported. The frequencies of agreement between visual and quantitative analysis were 84-92% and were highest when segment 3 was used as a reference, but in this case only 40% of the patients with coronary heart disease had an abnormal SPET. Using the least-squares method for handling digital information, the SD of the normal values decreased and 90% of the patients with coronary heart disease were accurately diagnosed. These results provide quantitative digital reference values for healthy post-menopausal women. They verify that quantitative analysis is in diagnostic agreement with visual evaluation, stress the need for local verification of reference ranges and suggest a least-square normalization method for the analysis.
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Affiliation(s)
- B Janerot-Sjöberg
- Department of Clinical Physiology, Linköping University Hospital, Sweden
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25
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26
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Laurienzo JM, Cannon RO, Quyyumi AA, Dilsizian V, Panza JA. Improved specificity of transesophageal dobutamine stress echocardiography compared to standard tests for evaluation of coronary artery disease in women presenting with chest pain. Am J Cardiol 1997; 80:1402-7. [PMID: 9399711 DOI: 10.1016/s0002-9149(97)00702-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The detection of coronary artery disease (CAD) by noninvasive methods has been hindered in women by the high rate of false-positive results. To determine the feasibility and accuracy of transesophageal dobutamine stress echocardiography for identification of CAD in women, we studied 84 patients (age 51 +/- 11 years) who underwent symptom-limited exercise treadmill testing, exercise thallium-201 scintigraphy, and coronary angiography for evaluation of anginal chest pain. Of the 84 patients, 62 had normal coronary arteries or nonsignificant coronary lesions, and 22 had significant stenosis of > or = 1 major coronary artery. During treadmill exercise, repolarization changes were observed in 16 of 21 patients with CAD and in 19 of 60 patients with normal coronary arteries. With thallium scintigraphy, a reversible defect was observed in 19 of 22 patients with CAD and in 12 of 60 patients with normal coronary arteries. Regional wall motion abnormalities during dobutamine infusion developed in 18 of 22 patients with CAD and in none of the 62 patients with normal coronary arteries. All 3 tests had similar sensitivity for detection of CAD (76% for exercise treadmill test, 86% for thallium scintigraphy, and 82% for transesophageal dobutamine stress echocardiography). However, transesophageal dobutamine stress echocardiography had significantly higher specificity than the other 2 tests (100% vs 68% for exercise treadmill test and 80% for thallium scintigraphy; p = 0.0001). Thus, transesophageal dobutamine stress echocardiography is accurate for evaluation of CAD among women presenting with chest pain; its use should be considered when more conventional tests are equivocal or technically suboptimal.
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Affiliation(s)
- J M Laurienzo
- Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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27
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Tribouilloy C, Peltier M, Senni M, Colas L, Rey JL, Lesbre JP. Multiplane transoesophageal echocardiographic detection of thoracic aortic plaque is a marker for coronary artery disease in women. Int J Cardiol 1997; 61:269-75. [PMID: 9363743 DOI: 10.1016/s0167-5273(97)00162-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study was conducted to examine if the multiplane transoesophageal echocardiographic detection of atherosclerotic plaque in the thoracic aorta could predict the absence or the presence and the severity of significant coronary artery disease in women. Its association with coronary disease is attractive and may have great influence on foregoing routine preoperative cardiac catheterization in patients with valvular heart disease but no data are available in women. METHODS Clinical and angiographic features and transoesophageal echocardiographic findings were prospectively analysed in 111 women. RESULTS In 24 women with significant coronary disease, 20 had thoracic aortic plaque on transoesophageal echocardiographic studies. In contrast, aortic plaque existed in only 12 of the remaining 87 women with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque had a sensitivity of 83%, a specificity of 86%, a positive and negative predictive values of 62% and 95%, respectively for the detection of significant coronary disease. There was a significant relation between the severity and the extent of atherosclerotic lesions and the angiographic coronary score (P<0.0001). Multivariate logistic regression analysis revealed that aortic plaque was the most significant independent marker of coronary disease (odds ratio=27.9; 95% confidence interval=5.5-131.6; P<0.0001). CONCLUSIONS This prospective study indicates that multiplane transoesophageal echocardiographic examination of thoracic atherosclerotic plaque is a marker for coronary disease in women and especially a powerful predictor of absence of significant coronary artery disease. Transoesophageal echocardiographic aortic examination might be used with risk factors and angina symptoms to discuss the need for preoperative coronary angiography in women with valvular heart disease.
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Affiliation(s)
- C Tribouilloy
- Department of Cardiology, South Hospital, University of Picardie, Amiens, France
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28
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Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1997; 96:2468-82. [PMID: 9337227 DOI: 10.1161/01.cir.96.7.2468] [Citation(s) in RCA: 434] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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29
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Azpitarte Almagro J, Arós Borau F, Cabadés O'Callaghan A, López Bescós L, Valls Grima F. [Role of noninvasive examinations in the management of ischemic cardiopathy. V. Noninvasive examinations in the management of patients with chronic ischemic cardiopathy]. Rev Esp Cardiol 1997; 50:145-56. [PMID: 9132874 DOI: 10.1016/s0300-8932(97)73197-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the last few years the has been an enormous development in noninvasive testing in the field of clinical cardiology. In fact, excellent monographs on each one of these techniques have been published elsewhere, but fewer publications exist that treat the topic of their indications and use in an integrated way, except for in the most common clinical situations. In this paper, the treatment of patients who present chest pain, stable and unstable angina is discussed, including the study of postinfarction patients. Furthermore, the role of noninvasive tests in the detection of coronary heart disease in women and in patients with left bundle branch block is thoroughly analyzed; as well as their usefulness after surgical or percutaneous coronary revascularization and in patients with peripheral vascular disease.
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30
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Taillefer R, DePuey EG, Udelson JE, Beller GA, Latour Y, Reeves F. Comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi SPECT imaging (perfusion and ECG-gated SPECT) in detecting coronary artery disease in women. J Am Coll Cardiol 1997; 29:69-77. [PMID: 8996297 DOI: 10.1016/s0735-1097(96)00435-4] [Citation(s) in RCA: 224] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This prospective study was conducted in 115 women to directly compare the sensitivity and specificity of thallium-201 (Tl-201), technetium-99m (Tc-99m) sestamibi perfusion and Tc-99m sestamibi electrocardiographic (ECG)-gated single-photon emission computed tomographic (SPECT) studies for detection of coronary artery disease (CAD). BACKGROUND Data on the comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi perfusion imaging for the detection of CAD, specifically in women, are very limited. METHODS Eighty-five patients with suspected CAD, scheduled for coronary angiography, and 30 volunteers with a pretest likelihood of < or = 5% for CAD were evaluated. Within 1 week, each patient underwent Tl-201 and Tc-99m sestamibi SPECT imaging procedures (both perfusion and gated SPECT imaging). Treadmill stress testing was used in 78 patients and dipyridamole in the remaining 37 patients. All images were interpreted by three observers in a blinded manner (consensus reading). Technetium-99m sestamibi SPECT studies were read without and then with ECG gating. Technetium-99m sestamibi gated SPECT studies were used to differentiate scar tissue from soft tissue attenuation artifact. RESULTS The overall sensitivities for detecting > or = 50% and > or = 70% stenoses were 75.0% and 84.3%, respectively, for Tl-201, and 71.9% and 80.4%, respectively, for Tc-99m sestamibi perfusion studies (p = 0.48). The specificity for lesions > or = 50% was 61.9% for Tl-201 and 85.7% for Tc-99m sestamibi perfusion (p = 0.07), whereas for lesions > or = 70% it was 58.8% for Tl-201 and 82.4% for Tc-99m sestamibi perfusion (p = 0.01). When the 34 patients with a normal coronary angiogram were added to the group of 30 normal volunteers, the "specificity" for lesions > or = 70% was 67.2% for Tl-201, 84.4% for Tc-99m sestamibi SPECT perfusion (p = 0.02) and 92.2% for Tc-99m sestamibi gated SPECT (p = 0.0004). CONCLUSIONS Both Tl-201 SPECT and Tc-99m sestamibi SPECT perfusion studies had a similar sensitivity for the detection of CAD in women. However, Tc-99m sestamibi SPECT perfusion imaging shows a significantly better specificity, which is further enhanced by the use of ECG gating.
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Affiliation(s)
- R Taillefer
- Department of Nuclear Medicine, Hotel-Dieu De Montreal, Quebec, Canada
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31
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Hansen CL, Crabbe D, Rubin S. Lower diagnostic accuracy of thallium-201 SPECT myocardial perfusion imaging in women: an effect of smaller chamber size. J Am Coll Cardiol 1996; 28:1214-9. [PMID: 8890818 DOI: 10.1016/s0735-1097(96)00304-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We attempted to formally compare the diagnostic accuracy of thallium-201 single-photon emission computed tomographic (SPECT) myocardial perfusion imaging in men and women and the effect of chamber size on accuracy. BACKGROUND The diagnostic accuracy of conventional exercise testing has been shown to be lower in women. Less is known about the relative accuracy of perfusion imaging. Because of smaller body size, women have a smaller heart size than men, a factor that may reduce accuracy. METHODS We identified 323 patients undergoing thallium-201 SPECT myocardial perfusion imaging who either had < 5% probability of coronary artery disease (CAD) by Bayesian analysis or who underwent cardiac catheterization within 60 days of stress testing. Patients with documented history of infarction, coronary artery bypass grafting, pathologic Q waves on the electrocardiogram, left bundle branch block or nonischemic cardiomyopathy were not included. We performed strict quantitative analysis, and receiver operating characteristic (ROC) curves were generated and the area under the curve was calculated for men and women. A size index was generated from the number of short-axis slices and average radius of each slice, and the group was classified as having a large or a small chamber size. The ROC areas of men and women with a large and a small chamber size were then compared. RESULTS Diagnostic accuracy was lower in women than in men (ROC are 0.82 vs. 0.93, p < 0.05) despite similar values for peak heart rate and rate-pressure product and similar severity of CAD. There was a greater difference in accuracy between patients with a large versus a small chamber size (ROC area 0.94 vs. 0.73, p < 0.01) despite similar levels of exercise and severity of CAD. When we compared men and women in groups stratified by chamber size, we could not detect a significant difference between ROC area values of men and women (large: 0.94 men, 0.93 women, p = 0.77, power to detect difference in area of 0.15 = 91%; small: 0.79 men, 0.72 women, p = 0.58, power to detect difference in area of 0.15 = 35%). CONCLUSIONS The diagnostic accuracy of thallium SPECT myocardial perfusion imaging is lower in women than in men. Most of the difference appears to be due to smaller left ventricular chamber size in women, although a small residual gender effect in smaller heart sizes cannot be entirely excluded. It is proposed that the most likely cause for this difference is the relatively greater effect of imaging blurring on smaller hearts.
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Affiliation(s)
- C L Hansen
- Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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Slavich GA, Guerra UP, Morocutti G, Fioretti PM, Fresco C, Orlandi C, Orsolon PG, Forster T, Feruglio GA. Feasibility of simultaneous Tc99m sestamibi and 2D-echo cardiac imaging during dobutamine pharmacologic stress. Preliminary results in a female population. INTERNATIONAL JOURNAL OF CARDIAC IMAGING 1996; 12:113-8. [PMID: 8864790 DOI: 10.1007/bf01880742] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Feasibility of simultaneous 2D-Echo and SPECT Tc99m Sestamibi imaging during dobutamine infusion was evaluated in a female population with suspected coronary artery disease and scheduled for diagnostic coronary angiography. A total of 49 consecutive subjects were studied. Patients under continuous ECG and 2D-Echo monitoring underwent standard dobutamine infusion at increasing doses to a diagnostic end-point. Tc99m Sestamibi was administered at the peak of the dobutamine effect. With this approach, 35 patients were identified correctly by 2D-Echo (Sensitivity = 60.1%; Specificity = 83.3%; Agreement = 71.4%; k = 0.43). Perfusion imaging with Tc99m Sestamibi resulted in correctly identifying 41 patients (Sensitivity = 83%; Specificity = 84%; Agreement = 83.6%; k = 0.67). Combining information obtained from the two tests resulted in increased specificity (92%) and decreased sensitivity (64%). Simultaneous assessment of perfusion and function with Tc99m Sestamibi and 2D-Echo imaging during dobutamine administration is easily performed without added risk or discomfort to the patient. Tc99m Sestamibi appeared to be slightly superior to 2D-Echo for the detection of CAD in this population, but the difference does not reach conventional statistical significance. The combined use of the two independent tests did not substantially improve the diagnostic accuracy of each method.
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Affiliation(s)
- G A Slavich
- Istituto di Cardiologia, Ospedale di Udine, Italia
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Geleijnse ML, Elhendy A, van Domburg RT, Cornel JH, Reijs AE, Fioretti PM. Prognostic significance of normal dobutamine-atropine stress sestamibi scintigraphy in women with chest pain. Am J Cardiol 1996; 77:1057-61. [PMID: 8644657 DOI: 10.1016/s0002-9149(96)00131-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To evaluate the prognostic value of normal dobutamine-atropine technetium-99m sestamibi single-photon emission computed tomography (SPECT) perfusion imaging in women with chest pain and inability to perform an adequate exercise test, 80 women with a normal scintigram were followed up for 23 +/- 13 months. Mean age of the patients was 61 +/- 12 years. Nine patients (11%) had a low probability (< 10%) of coronary artery disease, 43 (54%) had an intermediate probability (10% to 80%) of disease, and 28 (35%) had a high probability (>80%) of disease (including 19 patients with known coronary artery disease). During follow-up, no major cardiac events (cardiac death or nonfatal myocardial infarction) occurred. One patient with known coronary disease underwent coronary bypass surgery after 3 months, and 1 patient with a 91% pretest likelihood of coronary disease underwent coronary angioplasty after 7 months. Thus, the overall incidence of (soft) cardiac events during the follow-up period was 2 of 80 patients, or 1.3%/year. It is concluded that normal dobutamine-atropine technetium-99m sestamibi SPECT perfusion imaging in women with chest pain implies an excellent prognosis, even in women with high pretest likelihood of coronary disease.
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Affiliation(s)
- M L Geleijnse
- Thoraxcentre and the Department of Nuclear Medicine, University Hospital Rotterdam-Dijkzigt and Erasmus University, Rotterdam, The Netherlands
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Moriel M, Benhorin J, Brown MW, Raubertas RF, Severski PK, Van Voohees L, Bodenheimer MM, Tzivoni D, Wackers FJ, Mass AJ. Detection and significance of myocardial ischemia in women versus men within six months of acute myocardial infarction or unstable angina. The Multicenter Myocardial Ischemia Research Group. Am J Cardiol 1996; 77:798-804. [PMID: 8623730 DOI: 10.1016/s0002-9149(97)89172-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ischemia detection after an acute coronary event predicts subsequent cardiac events. However, gender-related aspects in the prevalence and prognostic significance of ischemia detection after an acute coronary event have not been reported. Noninvasive tests, which included resting 12-lead electrocardiogram (ECG), 24-hour ambulatory ECG, exercise ECG, and thallium-201 stress scintigraphy were performed in 936 stable patients (224 women and 712 men) 1 to 6 months (average 2.7) after an acute coronary event (i.e., myocardial infarction or unstable angina). Primary end points during an average follow-up of 23 months included cardiac death, nonfatal myocardial infarction, and unstable angina, while restricted end points included the first 2. Ischemia detection was significantly less frequent among women than among men on 24-hour ambulatory ECG, exercise ECG, and thallium-201 stress scintigraphy. Primary end points occurred in 19.2% of women and in 19% of men, and restricted end points occurred in 5.8% of women versus 8%. of men (p = NS). Cox analyses revealed that gender and its interaction with each of the ischemia tests did not contribute to the prediction of the primary or restricted end points. We conclude that in stable patients 1 to 6 months after an acute coronary event, ischemia detection by noninvasive tests was significantly less prevalent in women than in men. However, subsequent cardiac event rates in women were similar to those observed in men, and there was no gender-ischemic detection interaction regarding subsequent events.
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Affiliation(s)
- M Moriel
- The Jesselson Heart Institute, Shaare Zedek Medical Center, Jerusalem, Israel
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Amanullah AM, Kiat H, Friedman JD, Berman DS. Adenosine technetium-99m sestamibi myocardial perfusion SPECT in women: diagnostic efficacy in detection of coronary artery disease. J Am Coll Cardiol 1996; 27:803-9. [PMID: 8613606 DOI: 10.1016/0735-1097(95)00550-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study sought to assess the diagnostic efficacy of adenosine technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) in a consecutive series of female patients. BACKGROUND The utility of adenosine myocardial perfusion SPECT for the detection of coronary artery disease is not well defined in women because most studies have described a predominantly male population with a high prevalence of coronary artery disease. METHODS Of the 201 consecutive female patients in the study group who had undergone adenosine Tc-99m sestamibi myocardial perfusion SPECT, 130 had coronary angiography within 2 months of the nuclear test, and the other 71 had a low likelihood (<10%, mean [+/-SD] 5 +/- 3%) of coronary artery disease. The SPECT protocol used separate acquisition of rest thallium-201 and adenosine Tc-99m sestamibi and was visually analyzed in 20 segments with a semiquantitative five-point scoring system (0=normal; 4=absent uptake). RESULTS The normalcy rate in patients with a low likelihood of coronary artery disease was 93% (66 of 71). Among the catheterized group, the overall sensitivity, specificity and predictive accuracy of adenosine sestamibi SPECT for detecting coronary artery disease (> or = to 50% diameter stenosis) were 93% (87 of 94), 78% (28 of 36) and 88% (115 of 130), respectively. In the 103 patients without a prior myocardial infarction, the sensitivity, specificity and predictive accuracy were 91% (61 of 67), 78% (28 of 36) and 86% (89 of 103), respectively, for detecting > or = to 50% diameter stenosis. Of particular interest, the sensitivity and specificity were as high in patients with nonanginal symptoms (93% and 69%, respectively) as in patients with angina (92% and 83%, respectively, p=NS). The sensitivity and specificity among patients with a relatively low (<25%), intermediate (between 25% and 75%) or high prescan likelihood of coronary artery disease (>75%) were similar: 82% and 82%, 93% and 73%, and 95% and 100%, respectively. The sensitivity and specificity for detecting individual diseased vessels (> or = to 50% diameter stenosis) were, respectively, 76% and 81% for the left anterior descending coronary artery, 44% and 90% for the left circumflex coronary artery and 75% and 77% for the right coronary artery. CONCLUSIONS Adenosine Tc-99m sestamibi SPECT is an efficient protocol with high sensitivity and specificity for the detection of coronary artery disease in women irrespective of presenting symptoms or pretest likelihood of coronary artery disease and a high normalcy rate. These findings are of particular clinical relevance because chest pain, anginal or otherwise, has been shown to be a frequent but a less specific marker for coronary artery disease among female patients.
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Affiliation(s)
- A M Amanullah
- Department of Medicine, Nuclear Cardiology, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Hendel RC, Chen MH, L'Italien GJ, Newell JB, Paul SD, Eagle KA, Leppo JA. Sex differences in perioperative and long-term cardiac event-free survival in vascular surgery patients. An analysis of clinical and scintigraphic variables. Circulation 1995; 91:1044-51. [PMID: 7850940 DOI: 10.1161/01.cir.91.4.1044] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Little information is available regarding the occurrence of perioperative and late cardiac events in women with vascular disease. The current study was performed to examine whether sex-specific differences exist in these outcomes in a large population of vascular surgery patients and to determine the value of clinical and dipyridamole thallium variables in predicting myocardial infarction and cardiac death. METHODS AND RESULTS Preoperative dipyridamole thallium imaging was performed in 567 vascular surgery patients, including 380 men and 187 women. The incidence of nonfatal myocardial infarction and cardiac death was noted during the perioperative period and during a follow-up period of 50 +/- 5 months. Fixed and reversible thallium perfusion abnormalities were more common in men than in women (P < .001 and P = .004, respectively). Perioperative cardiac event rates were similar in men and women, 8.4% and 7.5%, respectively (P = .07). A transient thallium defect was associated with an increased risk of cardiac events by 3.9-fold in men (CI, 1.5 to 10.2) and 5.5-fold in women (CI, 1.4 to 22). Various clinical factors also were predictive of events but demonstrated substantial sex differences. For example, dipyridamole-induced ST-segment depression was strongly associated with perioperative events in men but not in women. There were 22 nonfatal myocardial infarctions and 29 cardiac deaths in men during the follow-up period, with comparable event rates noted for women. Cardiac event-free survival rates also were similar for men and women (P = .40). Multivariate analysis demonstrated that a history of heart failure was an important prognostic variable for both sexes, as was a fixed thallium defect. Significant sex differences in the predictive value of other clinical factors for late cardiac events was apparent. CONCLUSIONS The present study demonstrates that (1) thallium perfusion defects are more common in men; (2) transient thallium defects are associated with perioperative myocardial infarction and cardiac death in both sexes; (3) long-term survival rates after vascular surgery are similar between men and women; (4) a fixed perfusion defect is predictive of late cardiac events in women, with a trend noted in men; and (5) sex-specific differences were noted with regard to the prognostic value of various clinical risk factors. Therefore, dipyridamole thallium plays a significant role in the assessment of perioperative and long-term prognosis for both male and female vascular surgery patients. On the basis of these observations, modifications in risk stratification based on sex may be appropriate for men and women with vascular disease.
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Affiliation(s)
- R C Hendel
- Department of Medicine, Northwestern University Medical School, Chicago, Ill 60611
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Loutfi I, Singh A. Myocardial perfusion defects resulting from conditions other than atherosclerosis. Semin Nucl Med 1994; 24:354-6. [PMID: 7817205 DOI: 10.1016/s0001-2998(05)80024-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- I Loutfi
- Division of Nuclear Medicine, University of Missouri Hospital and Clinics, Columbia
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Williams MJ, Marwick TH, O'Gorman D, Foale RA. Comparison of exercise echocardiography with an exercise score to diagnose coronary artery disease in women. Am J Cardiol 1994; 74:435-8. [PMID: 8059721 DOI: 10.1016/0002-9149(94)90898-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study compares the accuracy of the routine exercise electrocardiogram, exercise score, and exercise echocardiography for the diagnosis of coronary artery disease (CAD) in women. Seventy women with a pretest probability of 53 +/- 30% for CAD were stressed using a maximal symptom-limited bicycle exercise protocol. Significant ST-segment change was defined by a depression of > 0.1 mV 0.06 second after the J point. The exercise score was calculated from ST response, heart rate, and workload using an equation derived from a multivariate model. A positive stress echocardiogram was defined by development of a new or worsening wall motion abnormality. The results were compared with the presence or absence of significant (> 50% diameter) stenoses at angiography. Exercise echocardiography identified 29 of the 33 patients (88%) with CAD, compared with 22 (67%) using ST analysis alone, and 20 (61%) using the exercise score (both p < 0.05 vs exercise echocardiography). The specificity of exercise echocardiography (84%) and the multivariate score (73%) were comparable, and exceeded that of the ST analysis (51%) in 37 patients without CAD (p < 0.01). The accuracy of exercise echocardiography (86%) exceeded that of the exercise score (67%, p = 0.01) and ST analysis (59%, p < 0.01). Among all 70 patients, an intermediate (20% to 80%) probability of coronary disease was identified in 21 patients on the basis of exercise echocardiography, in 38 based on the multivariate score, and in 38 based on the ST analysis alone. Exercise echocardiography is more sensitive than the exercise score, and more sensitive and specific than ST-segment analysis for the diagnosis of CAD in women.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M J Williams
- Cardiology Department, St. Mary's Hospital Medical School, London, England
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Bryant BA, Limacher MC. EXERCISE TESTING IN SELECTED PATIENT GROUPS. Prim Care 1994. [DOI: 10.1016/s0095-4543(21)00472-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lehtinen R, Sievänen H, Uusitalo A, Niemelä K, Turjanmaa V, Malmivuo J. Performance characteristics of various exercise ECG classifiers in different clinical populations. J Electrocardiol 1994; 27:11-22. [PMID: 8120473 DOI: 10.1016/s0022-0736(05)80105-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To improve the diagnostic power of the exercise electrocardiographic test in detecting myocardial ischemia, the authors have recently developed a diagnostic method called multivariate ST-segment/heart rate (ST/HR) analysis (MUSTA). The goal of this study was to evaluate the validity of MUSTA in different clinical populations and to compare its performance characteristics with ST-segment depression, the ST/HR slope, and the delta ST/HR index in these populations. The computerized exercise electrocardiographic measurements were performed on 1,507 cases, and 382 patients were selected as the study population: 161 with significant coronary artery disease according to coronary angiography and 221 with a low likelihood of coronary artery disease. The diagnostic accuracy of MUSTA in the pooled population was 77.7% (297 out of 382 patients), which was clearly better than the accuracy of 69.6% (266 out of 382 patients) using the conventional ST-segment depression criterion of 0.10 mV in detecting coronary artery disease and exercise-induced myocardial ischemia. According to receiver operating characteristics analysis, MUSTA had significantly better diagnostic power than the other classifiers. These findings suggest that multivariate and compartmental analysis methods like MUSTA can further improve the clinical importance of the exercise electrocardiogram.
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Affiliation(s)
- R Lehtinen
- Ragnar Granit Institute, Tampere University of Technology, Finland
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Krishnan R, Lu J, Zhu YY, Dae MW, Botvinick EH. Myocardial perfusion scintigraphy in left bundle branch block: a perspective on the issue from image analysis in a clinical context. Am Heart J 1993; 126:578-86. [PMID: 8362712 DOI: 10.1016/0002-8703(93)90407-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Among selected study populations, myocardial perfusion scintigraphy (MPS) in patients with left bundle branch block (LBBB) has been reported to show a low specificity for the diagnosis of coronary disease. However, the stress electrocardiogram (ECG) is nondiagnostic in this setting. To place this method in its appropriate clinical context, we evaluated MPS in all 69 consecutive patients with LBBB studied with scintigraphy for clinical reasons during a 4-year period. Among 32 patients who underwent coronary angiography for clinical indications, per patient sensitivity, 96%; per vessel sensitivity, 84%, 50%, and 100% for left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA) involvement, respectively; and per vessel specificity, 95% and 68% for LCX and RCA disease, respectively, were not significantly different from those previously published for the method in patients without LBBB. Although per patient specificity, 38%, and specificity, 39%, for LAD disease were low, the predictive value of a positive test remained relatively high (83%) owing to the small number of patients selected for angiography, in part based on scintigraphic findings, with normal coronary anatomy. In addition to a possible specific pathophysiologic cause related to LBBB, apparent perfusion abnormalities in the LAD distribution may relate to generic conditions that can make scintigraphic interpretation ambiguous, often in the anterior distribution, regardless of the clinical setting. Additionally, the apparent lack of scintigraphic specificity in the LAD distribution could relate in part to a selection bias toward catheterization of patients with induced scintigraphic abnormalities, especially in the LAD distribution.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R Krishnan
- Department of Medicine, University of California, San Francisco 94143-0252
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Affiliation(s)
- N K Wenger
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303
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Sjöberg BJ, Swahn E, Wranne B. Exertional hemodynamics in women with chest pain--an aortic Doppler ultrasound study. Clin Cardiol 1993; 16:480-6. [PMID: 8358881 DOI: 10.1002/clc.4960160605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Aortic ultrasound Doppler recordings of stroke volume, maximal flow velocity, and acceleration can be used to assess central hemodynamic effects of exercise in coronary artery disease (CAD) and left ventricular dysfunction. We wanted to evaluate the time course and amplitude of changes in aortic Doppler ultrasound parameters in women during supine exercise and the potential diagnostic value of a submaximal supine exercise test. For this purpose, 18 women who had undergone coronary angiography because of incapacitating chest pain (10 with significant coronary stenoses and previous myocardial infarction, 8 without stenoses or infarction) were compared with 10 healthy controls. Pathological electrocardiographic (ECG) ST-segment depression during supine exercise was common in all groups. In the control group, a significant increase of stroke volume (10%), maximal aortic flow velocity (27%), and acceleration (43%) occurred at low load during exercise. Women with CAD showed no increase and a lower cardiac output during exercise, indicating left ventricular dysfunction. Women with syndrome X resembled the controls but had a higher maximal flow velocity at rest, which may indicate hyperdynamic circulation. We conclude that a test up to 40% of seated maximal load is valuable and often sufficient when assessing the hemodynamic effects of supine exercise by Doppler ultrasound in terms of stroke volume, maximal flow velocity, and acceleration. By characterizing left ventricular function in groups of female patients where false-positive stress ECG reactions are common, Doppler ultrasound may contribute to the understanding and clinical management of women with chest pain.
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Affiliation(s)
- B J Sjöberg
- Department of Clinical Physiology, Linköping Heart Center, University Hospital, Sweden
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Abstract
In the United States, coronary artery disease (CAD) kills equal numbers of men and women, and is the leading cause of death in women. Except at the oldest ages, the prevalence of disease is lower in women than in men. This low prevalence decreases the accuracy of all noninvasive testing methods, making the noninvasive diagnosis of CAD in women more difficult. Perhaps because of this increased difficulty in diagnosis and the prognosis of women with angina has been perceived to be "benign," invasive testing has been used less often in women. Since the morbidity and mortality are greater in women compared with men with manifest CAD (i.e., myocardial infarction and coronary artery bypass grafting), an understanding of the strengths and limitations of noninvasive testing in women is critical. Due to the lower prevalence of CAD in women, symptoms of CAD (i.e., chest pain) and noninvasive tests (graded exercise treadmill) are less reliable with lower positive predictive values. Recent studies suggest using imaging techniques to improve the diagnostic sensitivity and specificity of noninvasive testing. This article will review the current literature regarding noninvasive diagnosis of CAD in women, including the use of stress echocardiography and thallium imaging in women. Detailed statistical descriptions of study populations are necessary so that study results can be accurately applied and interpreted in the general population.
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Affiliation(s)
- E E Gordon
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City 52242
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Chae SC, Heo J, Iskandrian AS, Wasserleben V, Cave V. Identification of extensive coronary artery disease in women by exercise single-photon emission computed tomographic (SPECT) thallium imaging. J Am Coll Cardiol 1993; 21:1305-11. [PMID: 8473634 DOI: 10.1016/0735-1097(93)90301-g] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The aim of this study was to examine the ability of exercise single-photon emission computed tomographic (SPECT) thallium imaging to identify high risk women with left main or three-vessel coronary artery disease using a stepwise discriminant analysis. BACKGROUND Previous studies have used statistical methods to identify high risk men with coronary artery disease. Only limited data are available in women. METHODS Exercise SPECT thallium imaging and coronary arteriography were performed for evaluation of chest pain in 243 women. Group 1 comprised 58 women with left main or three-vessel coronary disease and group 2 comprised 185 women with no or one- or two-vessel disease. Stepwise discriminant analysis was used to determine predictors of left main or three-vessel disease. RESULTS On univariate analysis, women in group 1 were older (p < 0.03) and had a lower exercise work load (p < 0.02), lower exercise heart rate (p < 0.004), higher prevalence rate of diabetes mellitus (p < 0.0003) and more multivessel thallium abnormality (p < 0.0001) compared with women in group 2. On multivariate analysis, only multivessel thallium abnormality (F = 43) and exercise heart rate (F = 6) were independent predictors of left main or three-vessel coronary disease. A model based on these two variables separated the women into three risk groups: 99 patients with 9%, 70 patients with 23% and 74 patients with 45% prevalence of left main or three-vessel disease (p < 0.0001). CONCLUSIONS High risk women with left main or three-vessel coronary disease can be identified by exercise SPECT thallium imaging.
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Affiliation(s)
- S C Chae
- Philadelphia Heart Institute, Presbyterian Medical Center, Pennsylvania 19104
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Affiliation(s)
- M E Tavel
- Department of Medicine, Indiana Heart Institute, St. Vincent Hospital, Indianapolis
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Kong BA, Shaw L, Miller DD, Chaitman BR. Comparison of accuracy for detecting coronary artery disease and side-effect profile of dipyridamole thallium-201 myocardial perfusion imaging in women versus men. Am J Cardiol 1992; 70:168-73. [PMID: 1626502 DOI: 10.1016/0002-9149(92)91270-e] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous dipyridamole planar thallium-201 imaging is a safe and effective test for detection and prognosis of coronary artery disease (CAD) in the general population. The relative diagnostic accuracy and side-effect profile of dipyridamole thallium-201 stress imaging in women is not defined. Forty-three consecutive female and 71 male patients who underwent dipyridamole thallium-201 imaging (0.56 mg/kg) within 3 months of cardiac catheterization were studied. Scans were considered abnormal if fixed or reversible perfusion defects were detected. Stenosis severity of greater than or equal to 50% luminal diameter reduction of any artery defined CAD. Overall sensitivity for detection of CAD was 0.87 in women and 0.94 in men; specificity was 0.58 in women and 0.63 in men (p = not significant). Sensitivity for detection of 1-vessel CAD was 0.60 in women and 0.94 in men (p = 0.001). The sensitivity for detection of multivessel CAD (with or without surgical revascularization) was 1.0 and 0.94 in women and men, respectively. Adverse effects were reported in 62% of women and in 38% of men (p = 0.01). There was no significant difference in the incidences of chest pain, headache, nausea, flushing or electrocardiographic changes. The incidences of severe ischemia and dizziness were higher in women. Possible explanations for this difference in adverse effects include gender differences in the volume of distribution of dipyridamole due to varied fat-to-muscle ratios and different subjective nocioceptive sensitivities to the effects of dipyridamole. Overall sensitivity and specificity are comparable between the sexes.
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Affiliation(s)
- B A Kong
- University Medical Center, Department of Internal Medicine, St. Louis, Missouri
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Zaret BL, Wackers FJ. Myocardial perfusion scintigraphy as an aid in understanding electrocardiographic changes of ischemia and infarction. Ann N Y Acad Sci 1990; 601:107-18. [PMID: 2221682 DOI: 10.1111/j.1749-6632.1990.tb37296.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In summary, myocardial perfusion scintigraphy with either thallium or the isonitriles has added substantially to electrocardiographic definition of both myocardial infarction and acute and chronic myocardial ischemia. Using perfusion scintigraphy, one can define infarct zones, risk zones, and the presence of reperfusion following thrombolytic therapy. When perfusion scintigraphy is combined with physiologic or pharmacologic stress, myocardial ischemia can be documented, irrespective of electrocardiographic documentation of the phenomenon. Delayed imaging may be important for defining viability even in the presence of significant Q waves. Myocardial perfusion scintigraphy provides prognostic evaluation of patients with both acute and chronic coronary syndromes. When the current cumulative experience is looked at critically, it is clear that myocardial perfusion scintigraphy has helped in the development of an understanding of the limitations of electrocardiography in the diagnostic and functional categorization of patients with acute and chronic coronary disease.
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Affiliation(s)
- B L Zaret
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06510
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Abstract
The examination of a patient with angina pectoris begins with clinical assessment. Certain clinical findings that are present only during angina, such as mitral regurgitation due to ischemia-induced papillary muscle dysfunction, may clarify an otherwise uncertain diagnosis. Electrocardiography is a useful and relatively inexpensive test for detecting evidence of ischemia in patients with suspected angina. The presence of cardiomegaly on the chest roentgenogram has adverse prognostic implications. Exercise stress testing is important in the diagnosis of coronary artery disease and also provides prognostic information. Patients should be classified into high-, intermediate-, or low-risk subsets by noninvasive techniques. Although relatively easy and inexpensive, treadmill exercise stress testing cannot be performed in all patients, and sometimes it will yield equivocal results. In these cases, radionuclide testing (with thallium scintigraphy or radionuclide angiography) can be helpful and also can identify high-risk patients. Some patients will require coronary angiography.
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