Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease

Impact of cardiac size on diagnostic performance of single-photon emission computed tomography myocardial perfusion imaging: insights from the REgistry of Fast Myocardial Perfusion Imaging with NExt generation single-photon emission computed tomography

AIMS

Variation in diagnostic performance of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has been observed, yet the impact of cardiac size has not been well characterized. We assessed whether low left ventricular volume influences SPECT MPI's ability to detect obstructive coronary artery disease (CAD) and its interaction with age and sex.

METHODS AND RESULTS

A total of 2066 patients without known CAD (67% male, 64.7 ± 11.2 years) across nine institutions underwent SPECT MPI with solid-state scanners followed by coronary angiography as part of the REgistry of Fast Myocardial Perfusion Imaging with NExt Generation SPECT. Area under receiver-operating characteristic curve (AUC) analyses evaluated the performance of quantitative and visual assessments according to cardiac size [end-diastolic volume (EDV); <20th vs. ≥20th population or sex-specific percentiles], age (<75 vs. ≥75 years), and sex. Significantly decreased performance was observed in patients with low EDV compared with those without (AUC: population 0.72 vs. 0.78, P = 0.03; sex-specific 0.72 vs. 0.79, P = 0.01) and elderly patients compared with younger patients (AUC 0.72 vs. 0.78, P = 0.03), whereas males and females demonstrated similar AUC (0.77 vs. 0.76, P = 0.67). The reduction in accuracy attributed to lower volumes was primarily observed in males (sex-specific threshold: EDV 0.69 vs. 0.79, P = 0.01). Accordingly, a significant decrease in AUC, sensitivity, specificity, and negative predictive value for quantitative and visual assessments was noted in patients with at least two characteristics of low EDV, elderly age, or male sex.

CONCLUSION

Detection of CAD with SPECT MPI is negatively impacted by small cardiac size, most notably in elderly and male patients.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Sex differences in diagnostic modalities of coronary artery disease: Evidence from coronary microcirculation

Although atherosclerosis is usually considered a disease of the large arteries, risk factors for atherosclerosis also trigger structural and functional abnormalities at a microvascular level. In cardiac disease, microvascular dysfunction is especially relevant in women, among whom the manifestation of ischemic disease due to impaired coronary microcirculation is more common than in men. This sex-specific clinical phenotype has important clinical implications and, given the higher pre-test probability of coronary microvascular dysfunction in females, different diagnostic modalities should be used in women compared to men. In this review, we summarize invasive and non-invasive diagnostic modalities to assess coronary microvascular function, ranging from catheter-based evaluation of endothelial function to Doppler echocardiography and positron emission tomography. Moreover, we discuss different clinical settings in which microvascular disease plays an important role, underlining the importance of choosing the right diagnostic modality depending on the sex of the patients.

Relationship between sexual differences and cardiovascular risk factors in the prevalence of asymptomatic coronary disease

BACKGROUND

This study investigated the sexual differences of coronary artery disease (CAD) prevalence and its association with cardiovascular risk factors in the asymptomatic population.

METHODS

In total 6434 asymptomatic participants without known CAD (1740 women and 4694 men) underwent coronary computed tomography angiography (CCTA). The prevalence of significant CAD (diameter stenosis ≥50%) and other CCTA findings were compared by sex, and its influence on CAD was investigated in groups stratified by the number of cardiovascular risk factors, including age (>55 years), hypertension, diabetes, dyslipidemia, and current smoking.

RESULTS

The prevalence of current smokers, hypertension, and diabetes were higher in men than women. The mean coronary artery calcium score was 13.1 ± 58.4 for women and 51.1 ± 158.2 for men; the coronary atherosclerosis burden indices were significantly higher in men than women. Significant CAD was identified in 65 women (3.7%) and 429 men (9.1%), showing a significant association (adjusted odds ratio [OR] 2.38, P < 0.001). The relatively higher risk for significant CAD in men was observed in patients with fewer risk factors, and the risk difference was not significant in patients with many risk factors (adjusted ORs: 7.69, 3.37, 1.71, 1.31, and 0.88 in patients with 0, 1, 2, 3, and 4-5 risk factors, respectively). The association between sex and risk factor groups was significant (P < 0.001).

CONCLUSIONS

In the asymptomatic population, a significantly higher CAD prevalence was noted in men than women. However, women with a high number of cardiovascular risk factors showed a CAD prevalence similar to that of men.

Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI

BACKGROUND

Stress cardiac MRI permits comprehensive evaluation of patients with known or suspected chronic coronary syndromes (CCS). The impact of sex on the use of invasive cardiac angiography (ICA) after vasodilator stress cardiac MRI is unclear.

PURPOSE

To evaluate the impact of sex on ICA use after vasodilator stress cardiac MRI.

STUDY TYPE

Retrospective.

POPULATION

A total of 6229 consecutive patients (age [mean ± standard deviation] 65.2 ± 11.5 years, 38.1% women).

FIELD STRENGTH/SEQUENCE

A 5-T; a steady-state free-precession cine sequence; stress first-pass perfusion imaging; late enhancement imaging.

ASSESSMENT

Patients underwent vasodilator stress cardiac MRI for known or suspected CCS. The ischemic burden (at stress first-pass perfusion imaging) was computed (17-segment model).

STATISTICAL TESTS

Multivariate logistic regression was used to evaluate the potential differential association between ischemic burden and use of cardiac MRI-related ICA across sex.

RESULTS

A total of 1109 (17.8%) patients were referred to ICA, among which there were significantly more men (762, 19.7%) than women (347, 14.6%). Overall, after multivariate adjustment, female sex was not associated with lower use of ICA (odds ratio [OR] = 0.99; confidence interval [CI] 95%: 0.84-1.18, P = 0.934). However, significant sex differences were detected across ischemic burden. Whereas women with nonischemic vasodilator stress cardiac MRI (0 ischemic segments) were less commonly submitted to ICA (OR = 0.49; CI 95%: 0.35-0.69) in patients with ischemia (>1 ischemic segment), adjusted use of ICA was more frequent in women than men (OR = 1.27; CI 95%: 1.1-1.5).

DATA CONCLUSIONS

In patients with known or suspected CCS submitted to undergo vasodilator stress cardiac MRI, cardiac MRI-related ICA may be overused in men without ischemia. Furthermore, ICA referral in patients with negative ischemia resulted in greater odds of revascularization in men.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 5.

Sex differences in machine learning computed tomography-derived fractional flow reserve

Coronary computed tomography angiography (CCTA) derived machine learning fractional flow reserve (ML-FFR_CT) can assess the hemodynamic significance of coronary artery stenoses. We aimed to assess sex differences in the association of ML-FFR_CT and incident cardiovascular outcomes. We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and single photon emission computed tomography (SPECT). Obstructive stenosis was defined as ≥ 70% stenosis severity in non-left main vessels or ≥ 50% in the left main coronary. ML-FFR_CT was computed using a machine learning algorithm with significant stenosis defined as ML-FFR_CT < 0.8. The primary outcome was a composite of death or non-fatal myocardial infarction (D/MI). Our study population consisted of 471 patients with mean (SD) age 65 (13) years, 53% men, and multiple comorbidities (78% hypertension, 66% diabetes, 81% dyslipidemia). Compared to men, women were less likely to have obstructive stenosis by CCTA (9% vs. 18%; p = 0.006), less multivessel CAD (4% vs. 6%; p = 0.25), lower prevalence of ML-FFR_CT < 0.8 (39% vs. 44%; p = 0.23) and higher median (IQR) ML-FFR_CT (0.76 (0.53-0.86) vs. 0.71 (0.47-0.84); p = 0.047). In multivariable adjusted models, there was no significant association between ML-FFR_CT < 0.8 and D/MI [Hazard Ratio 0.82, 95% confidence interval (0.30, 2.20); p = 0.25 for interaction with sex.]. In a high-risk cohort of symptomatic patients who underwent CCTA and SPECT testing, ML-FFR_CT was higher in women than men. There was no significant association between ML-FFR_CT and incident mortality or MI and no evidence that the prognostic value of ML-FFR_CT differs by sex.

Sex-Specific Considerations in the Presentation, Diagnosis, and Management of Ischemic Heart Disease: JACC Focus Seminar 2/7

There are sex-related differences in the epidemiology, presentation, diagnostic testing, and management of ischemic heart disease in women compared with men. The adjusted morbidity and mortality are persistently higher, particularly in younger women and Blacks. Women have more angina but less obstructive coronary artery disease, which affects delays in presentation and diagnosis and testing accuracy. The nonbiological factors play a significant role in access to care, ischemic heart disease management, and guideline adherence. Future research focus includes sex-specific outcomes, characterization of the biological differences, and implementation science around quality of clinical care.

Nuclear Cardiology in Women and Underrepresented Minority Populations

PURPOSE OF REVIEW

To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD.

RECENT FINDINGS

Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.

Clinical value of resting cardiac dual-energy CT in patients suspected of coronary artery disease

BACKGROUND

Rest/stress myocardial CT perfusion (CTP) has high diagnostic value for coronary artery disease (CAD), but the additional value of resting CTP especially dual-energy CTP (DE-CTP) beyond coronary CT angiography (CCTA) in chest pain triage remains unclear. We aimed to evaluate the diagnostic accuracy of resting myocardial DE-CTP, and additional value in detecting CAD beyond CCTA (obstructive stenosis: ≥ 50%) in patients suspected of CAD.

METHODS

In this prespecified subanalysis of 54 patients, we included patients suspected of CAD referred to invasive coronary angiography (ICA). Diagnostic accuracy of resting myocardial DE-CTP in detecting myocardial perfusion defects was assessed using resting ¹³N-ammonia positron emission tomography (PET) as the gold standard. Diagnostic accuracy of cardiac dual-energy CT in detecting flow-limiting stenoses (justifying revascularization) by CCTA combined with resting myocardial DE-CTP, using ICA plus resting ¹³N-ammonia PET as the gold standard. The CCTA and DE-CTP datasets derived from a single-phase scan performed with dual-energy mode.

RESULTS

For detecting myocardial perfusion defects, DE-CTP demonstrated high diagnostic accuracy with a sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of 95.52%, 85.93%, and 0.907 on a per-segment basis. For detecting flow-limiting stenoses by CCTA alone, sensitivity, specificity, and AUC were 100%, 56.47%, and 0.777 respectively on a per-vessel basis. For detecting flow-limiting stenoses by CCTA combined with resting myocardial DE-CTP, sensitivity, specificity, and AUC were 96.10%, 95.29% and 0.956 respectively on a per-vessel basis. Additionally, CCTA combined with resting myocardial DE-CTP detected five patients (9%) with no obstructive stenosis but with myocardial perfusion defects confirmed by ICA plus ¹³N-ammonia PET.

CONCLUSIONS

Resting cardiac DE-CTP demonstrates a high diagnostic accuracy in detecting myocardial perfusion defects and provides an additional clinical value by reducing rates of false-positive and false-negative patients beyond CCTA in patients suspected of CAD.

Cardiovascular magnetic resonance in women with cardiovascular disease: position statement from the Society for Cardiovascular Magnetic Resonance (SCMR)

This document is a position statement from the Society for Cardiovascular Magnetic Resonance (SCMR) on recommendations for clinical utilization of cardiovascular magnetic resonance (CMR) in women with cardiovascular disease. The document was prepared by the SCMR Consensus Group on CMR Imaging for Female Patients with Cardiovascular Disease and endorsed by the SCMR Publications Committee and SCMR Executive Committee. The goals of this document are to (1) guide the informed selection of cardiovascular imaging methods, (2) inform clinical decision-making, (3) educate stakeholders on the advantages of CMR in specific clinical scenarios, and (4) empower patients with clinical evidence to participate in their clinical care. The statements of clinical utility presented in the current document pertain to the following clinical scenarios: acute coronary syndrome, stable ischemic heart disease, peripartum cardiomyopathy, cancer therapy-related cardiac dysfunction, aortic syndrome and congenital heart disease in pregnancy, bicuspid aortic valve and aortopathies, systemic rheumatic diseases and collagen vascular disorders, and cardiomyopathy-causing mutations. The authors cite published evidence when available and provide expert consensus otherwise. Most of the evidence available pertains to translational studies involving subjects of both sexes. However, the authors have prioritized review of data obtained from female patients, and direct comparison of CMR between women and men. This position statement does not consider CMR accessibility or availability of local expertise, but instead highlights the optimal utilization of CMR in women with known or suspected cardiovascular disease. Finally, the ultimate goal of this position statement is to improve the health of female patients with cardiovascular disease by providing specific recommendations on the use of CMR.

Chronic Coronary Syndromes in Women: Challenges in Diagnosis and Management

Sex matters in science. This particularly applies to ischemic heart disease, which displays key differences in pathophysiology, presentation, and effectiveness in diagnostic strategies and management between women and men. However, underrepresentation of women in randomized trials has led to an evidence gap in clinical practice. Nevertheless, it has become clear that women present with a higher burden of symptoms and comorbidities, experience worse outcomes, but are less likely to have flow-limiting stenosis in epicardial coronary arteries than men. A major contributor to this paradox is coronary microvascular disease, a heterogeneous disorder with multifactorial etiology that predominantly affects women. There is a significant interplay between coronary microvascular disease, obstructive coronary artery disease, and the cardiovascular risk associated with it, with impaired vasomotor function often preceding the development of advanced atheroma. This novel concept has recently been referred to as chronic coronary syndromes, which better meets the female phenotype of ischemic heart disease, questioning current management recommendations that still largely apply to flow-limiting stenoses in epicardial coronary arteries typically found in men. The goal of this review is to highlight the most recent scientific advances in understanding chronic coronary syndromes in women. It provides practical advice with focus on challenges in diagnosis and management, and discusses perspectives towards the implementation of sex-specific, safer, and more effective therapeutic strategies.

Heart disease in women: a narrative review

Cardiovascular disease is the worldwide leading cause of death in women. Biological differences between the sexes, a result of genetic, epigenetic and sex hormone-mediated factors, are complex and incompletely understood. These differences are compounded by socio-cultural factors and together account for the variation in the prevalence, presentation and natural history of cardiovascular disease between men and women. Although there is growing recognition of sex-specific determinants of outcomes, women remain under-represented in clinical trials, and sex-disaggregated diagnostic and management strategies are not currently recommended in clinical guidelines. Women remain more likely to experience delays in diagnosis, to be treated less aggressively and to have worse outcomes. As a consequence, cardiovascular disease in women remains understudied, underdiagnosed and undertreated. This review will focus on female-specific characteristics of cardiovascular disease and how these may impact on anaesthetic and peri-operative risk assessment and care. We highlight significant differences between the sexes in the natural history of cardiovascular disease, including those disease entities that are more common in women, such as sudden coronary artery dissection or microvascular dysfunction. Given the rapidly rising incidence of maternal cardiovascular disease and associated complications, special consideration is given to the risk assessment and management of these conditions during pregnancy. Increased awareness of these issues has the potential to improve the effectiveness of the multidisciplinary heart team and ultimately improve the care provided to women.

Cardiovascular disease in women: insights from magnetic resonance imaging

The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.

Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE

OBJECTIVES

This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFR_CT) according to sex.

BACKGROUND

Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFR_CT improves sex-based patient management decisions compared to CCTA alone is unknown.

METHODS

Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFR_CT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFR_CT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates.

RESULTS

A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFR_CT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFR_CT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFR_CT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFR_CT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFR_CT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm³/g vs. 24.76 ± 7.22 mm³/g; p < 0.0001) that is associated with higher FFR_CT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFR_CT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284).

CONCLUSIONS

FFR_CT differs between the sexes, as women have a higher FFR_CT for the same degree of stenosis. In FFR_CT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFR_CT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).

Even "WISE-R?"-an Update on the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation

PURPOSE OF REVIEW

For over 20 years, the Women's Ischemia Syndrome Evaluation (WISE), a program sponsored by the National Heart, Lung, and Blood Institute, has explored diverse and important aspects of ischemic heart disease in women.

RECENT FINDINGS

Women with symptoms and signs of ischemia but no significant epicardial obstructive coronary artery disease (INOCA) were documented to be at elevated risk for recurrent angina hospitalization, major adverse cardiac events, death, and health resource consumption rivaling those with obstructive coronary disease. WISE investigators have advanced our understanding of cardiovascular outcomes, systemic manifestations, psychological variables, socioeconomic factors, genetic contributions, hormonal status, advanced imaging, coronary functional findings, biomarkers, patient-reported outcomes, and treatments pertaining to women with this disease entity. This review delves into the WISE findings subsequent to a prior review1, postulates directions for future research, and asks are we "Even 'WISE-R?'".

Impact of sex-specific differences in calculating the pretest probability of obstructive coronary artery disease in symptomatic patients: a coronary computed tomographic angiography study

Objectives

Little is known about the impact of sex-specific differences in calculating the pretest probability (PTP) of obstructive coronary artery disease. We sought to determine whether the calculation of PTP differ by sex in symptomatic patients referred to coronary computed tomographic angiography (CCTA).

Patients and methods

The characteristics of 5777 men and women who underwent CCTA were compared. For each patient, PTP was calculated according to the updated Diamond–Forrester method (UDFM) and the Duke clinical score (DCS), respectively. Follow-up clinical data were also recorded. Area under the receiver operating characteristic curve, integrated discrimination improvement, net reclassification improvement, and the Hosmer–Lemeshow goodness-of-fit statistic were used to assess the models’ performance.

Results

The area under the receiver operating characteristic curve of UDFM and DCS showed little difference in men (0.782 vs. 0.785, P=0.4708) and women (0.668 vs. 0.654, P=0.1255), and calibration of neither model was satisfactory. Compared with UDFM, DCS showed positive integrated discrimination improvement (10% in men, P<0.0001, and 8% in women, P<0.0001, respectively), net reclassification improvement (12.17% in men, P<0.0001, and 27.19% in women, P<0.0001, respectively), and obviously reduced unnecessary noninvasive testing for women with negative CCTA.

Conclusion

Although the performance of neither model was favorable, DCS offered a more accurate calculation of PTP than UDFM and application of DCS instead of UDFM would result in a significant decrease in inappropriate testing, especially in women.

Sex Differences in 1-Year Health Status Following Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction: Results From the China PEACE Prospective Study

Background

Sex differences in health status outcomes after percutaneous coronary intervention among patients without acute myocardial infarction are not well described.

Methods and Results

A total of 2237 patients (33.4% women) without acute myocardial infarction undergoing percutaneous coronary intervention were enrolled from 39 Chinese tertiary hospitals in the PEACE (China Patient‐centered Evaluative Assessment of Cardiac Events) prospective percutaneous coronary intervention study. Data were collected immediately before and 1 year following percutaneous coronary intervention. Health status was measured using the disease‐specific Seattle Angina Questionnaire (SAQ) Angina Frequency and Quality of Life domains, as well as the SAQ Summary Score. Among the study population, women were older, more often single, had lower levels of education, and had a higher prevalence of cardiac risk factors such as hypertension and diabetes mellitus. Women had lower mean 1‐year SAQ Angina Frequency scores (mean±SD, 91.0±17.3 versus 93.9±13.3; P<0.01), SAQ Quality of Life scores (mean±SD, 67.3±23.0 versus 70.6±21.6; P<0.01), and SAQ Summary Scores (mean±SD, 81.6±13.8 versus 84.8±11.9; P<0.01), a difference of marginal clinical significance that persisted after multivariable adjustment. A slightly larger improvement in the SAQ Summary Score was observed in women as compared with men (20.9±22.6 versus 18.5±21.3; P=0.007) in unadjusted analysis. However, women were less likely to achieve clinically significant improvement in SAQ Angina Frequency (adjusted odds ratio, 0.67; 95% CI, 0.45–1.00) and SAQ Quality of Life (adjusted odds ratio, 0.73; 95% CI, 0.56–0.96) after adjustment.

Conclusions

There were no clinically significant differences in 1‐year health status outcomes and improvement in health status by sex among patients without acute myocardial infarction following percutaneous coronary intervention. However, female sex was associated with poorer 1‐year health status and a lower likelihood of experiencing clinically improvement in health status.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624922.

Heart rate reserve during pharmacological stress is a significant negative predictor of impaired coronary flow reserve in women

PURPOSE

Evidence to date has failed to adequately explore determinants of cardiovascular risk in women with coronary microvascular dysfunction (CMVD). Heart rate responses to adenosine mirror autonomic activity and may carry important prognostic information for the diagnosis of CMVD.

METHODS

Hemodynamic changes during adenosine stress were analyzed in a propensity-matched cohort of 404 patients (202 women, mean age 65.9 ± 11.0) who underwent clinically indicated myocardial perfusion ¹³N-ammonia Positron-Emission-Tomography (PET) at our institution between September 2013 and May 2017.

RESULTS

Baseline heart rate (HR) was significantly higher in patients with abnormal coronary flow reserve (CFR, p < 0.001 vs normal CFR). Accordingly, a blunted HR response to adenosine (=reduced heart rate reserve, %HRR) was seen in patients with abnormal CFR, with a most pronounced effect being observed in female patients free of myocardial ischemia (45.9 ± 34.9 vs 26.5 ± 18.0, p < 0.001 in women and 29.1 ± 16.9 vs 24.3 ± 21.7, p = 0.15 in men). Hence, a fully-adjusted multivariate logistic regression model identified HRR as the strongest negative predictor of reduced CFR in women free of myocardial ischemia, but not in men. Accordingly, receiver operating characteristics (ROC) curves for the presence of reduced CFR revealed that a %HRR <35 was a powerful predictor for abnormal CFR with a sensitivity of 81% and a specificity of 60% in women.

CONCLUSION

A blunted HRR <35% is associated with abnormal CFR in women. Taking into account HR responses during stress test in women may help to risk stratify the heterogeneous female population of patients with non-obstructive coronary artery disease (CAD).

Noninvasive Evaluation of Symptomatic Women with Suspected Coronary Artery Disease

Cardiovascular disease (CVD) is the leading cause of death in the United States, yet several factors make it challenging to diagnose in women. Although women have more frequent chest pain than men, atypical symptoms such as nausea, dyspnea, and fatigue make it difficult to determine their risk of coronary artery disease (CAD) before testing. Current guidelines recommend exercise electrocardiography (ex-ECG) as the initial test in symptomatic women with intermediate pretest probability who can exercise and have a normal resting ECG; however, treadmill ex-ECG testing has a significantly lower positive predictive value in women. In addition, women often have nonobstructive CAD in conjunction with microvascular dysfunction and other cardiovascular abnormalities that can decrease the accuracy of all noninvasive tests. The following provides an overview of exercise ECG, echocardiography, SPECT imaging, and various other available modalities and examines their effectiveness in diagnosing and managing symptomatic women with suspected CAD.

Age- and sex-dependent changes in sympathetic activity of the left ventricular apex assessed by 18F-DOPA PET imaging

BACKGROUND

Sexual dimorphism in cardiac sympathetic outflow has recently gained attention in the context of Takotsubo cardiomyopathy. Previous studies suggest that there are sex- and age-dependent differences in peripheral autonomic control, however, data on cardiac-specific sympathetic activation in aged women and men are lacking.

METHODS AND RESULTS

Regional quantitative analysis of cardiac fluorine-18 (18F)- Dihydroxyphenylalanine (DOPA) uptake was retrospectively performed in 133 patients (69 females, mean age 52.4±17.7 years) referred for assessment of neuroendocrine tumours (NET) by Positron-Emission-Tomography. Cardiac 18F-DOPA uptake was significantly higher in women as compared to men (1.33±0.21 vs. 1.18±0.24, p<0.001). This sex-difference was most pronounced in the apical region of the left ventricle (LV, 1.30±0.24 in women vs. 1.13±0.25 in men, p<0.001) and in individuals >55 years of age (1.39±0.25 in women vs. 1.09±0.24 in men, p<0.001). Women showed a prominent increase in myocardial 18F-DOPA uptake with age with the strongest increase seen in the LV apical region (r = 0.34, p = 0.004). Accordingly, sex and age were selected as significant predictors of LV apical 18F-DOPA uptake in a stepwise linear regression model. No age-dependent changes of cardiac 18F-DOPA uptake were observed in men or in the right ventricular region.

CONCLUSION

Our study suggests that aging is related to sex-specific changes in regional cardiac sympathetic activity. Future studies will have to assess whether the increase in LV apical 18F-DOPA uptake with age in women is of pathogenic relevance for the higher susceptibility of postmenopausal women to conditions associated with increased sympathetic activity.

Technical aspects of cardiac PET/MRI

PET/MRI is a novel modality that enables to combine PET and MR images, and has significant potential to evaluate various cardiac diseases through the combination of PET molecular imaging and MRI functional imaging. Precise management of technical issues, however, is necessary for cardiac PET/MRI. This article describes several technical points, including patient preparation, MR attenuation correction, parallel acquisition of PET with MRI, clinical aspects, and image quality control.

Sex differences in the long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography

PURPOSE

Evidence to date on the unique female determinants of cardiovascular risk is inadequate. Positron Emission Tomography (PET) is considered to have the highest accuracy for the assessment of myocardial perfusion in patients with suspected coronary artery disease (CAD), but its long-term prognostic accuracy in women has not been established.

METHODS

A total of 619 consecutive patients (138 women, mean age 60.0 ± 11.8 years) underwent clinically indicated ¹³N-ammonia PET at our institution and were followed up (median 5.7 years) for major adverse cardiovascular events (MACE) including cardiac death, nonfatal myocardial infarction, hospitalization for any cardiac reason and late revascularization.

RESULTS

During follow-up, 271 patients had at least one cardiac event, including 64 cardiac deaths and 33 nonfatal myocardial infarctions. In both women and men, abnormal myocardial perfusion was associated with reduced event-free survival (log rank p < 0.001). In women, abnormal myocardial perfusion was associated with a higher risk of a worse outcome than in men (adjusted HR 4.1, 95% CI 1.8-9.0 in women; HR 2.4, 95% CI 1.5-3.8 in men; p_interaction < 0.001). In contrast, abnormal coronary flow reserve (CFR) was a significant predictor of 10-year MACE in men (p = 0.006) but not in women (p = NS). Accordingly, an interaction term of sex and abnormal myocardial perfusion or CFR was significant (p < 0.001).

CONCLUSION

While perfusion findings in ¹³N-ammonia PET provide effective risk stratification in women and men, CFR adds incremental prognostic value for long-term cardiac outcomes only in men. Refined strategies in noninvasive imaging are needed in women to improve CAD risk prediction.

The role of imaging in women with ischemic heart disease

Substantial advances and insights in medical technology and treatment strategies, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, ischemic heart disease (IHD) remains the leading cause of cardiovascular morbidity and mortality of women in the Western world. Advances in cardiovascular imaging, over the past 4 decades, have significantly improved the evaluation and management of the full spectrum of coronary atherosclerosis, which contributes to ischemic heart disease. The development of contemporary and novel diagnostic imaging techniques and tools have assumed an expanded role in the evaluation of symptomatic women to detect not only flow-limiting epicardial coronary stenosis and nonobstructive atherosclerosis, but also ischemia resulting from microvascular dysfunction. IHD is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies in women. In this article, we review the available evidence on the role of contemporary diagnostic imaging techniques in the evaluation of women with suspected IHD.

Comparative Effectiveness Trials of Imaging-Guided Strategies in Stable Ischemic Heart Disease

The evaluation of patients with suspected stable ischemic heart disease is among the most common diagnostic evaluations with nearly 20 million imaging and exercise stress tests performed annually in the United States. Over the past decade, there has been an evolution in imaging research with an ever-increasing focus on larger registries and randomized trials comparing the effectiveness of varying diagnostic algorithms. The current review highlights recent randomized trial evidence with a particular focus comparing the effectiveness of cardiac imaging procedures within the stable ischemic heart disease evaluation for coronary artery disease detection, angina, and other quality of life measures, and major clinical outcomes. Also highlighted are secondary analyses from these trials on the economic findings related to comparative cost differences across diagnostic testing strategies.

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

The role of pharmacological stress testing in women

Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.