1
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Randazzo MJ, Elias P, Poterucha TJ, Sharir T, Fish MB, Ruddy TD, Kaufmann PA, Sinusas AJ, Miller EJ, Bateman T, Dorbala S, Di Carli M, Castillo M, Liang JX, Miller RJH, Dey D, Berman DS, Slomka PJ, Einstein AJ. 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. Eur Heart J Cardiovasc Imaging 2024; 25:996-1006. [PMID: 38445511 PMCID: PMC11210974 DOI: 10.1093/ehjci/jeae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
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.
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Affiliation(s)
- Michael J Randazzo
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Pierre Elias
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 622 West 168th Street, PH 10-203, New York, NY 10032, USA
| | - Timothy J Poterucha
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 622 West 168th Street, PH 10-203, New York, NY 10032, USA
| | - Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Centers, Tel Aviv, Israel
| | - Matthews B Fish
- Sacred Heart Medical Center, Oregon Heart and Vascular Institute, Springfield, OR, USA
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Timothy Bateman
- Cardiovascular Imaging Technologies LLC, Kansas City, MO, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Marcelo Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michelle Castillo
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 622 West 168th Street, PH 10-203, New York, NY 10032, USA
| | - Joanna X Liang
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew J Einstein
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 622 West 168th Street, PH 10-203, New York, NY 10032, USA
- Department of Radiology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 622 West 168th Street, PH 10-203, New York, NY 10032, USA
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2
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Almeida AG, Grapsa J, Gimelli A, Bucciarelli-Ducci C, Gerber B, Ajmone-Marsan N, Bernard A, Donal E, Dweck MR, Haugaa KH, Hristova K, Maceira A, Mandoli GE, Mulvagh S, Morrone D, Plonska-Gosciniak E, Sade LE, Shivalkar B, Schulz-Menger J, Shaw L, Sitges M, von Kemp B, Pinto FJ, Edvardsen T, Petersen SE, Cosyns B. Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology. Eur Heart J Cardiovasc Imaging 2024; 25:e116-e136. [PMID: 38198766 DOI: 10.1093/ehjci/jeae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
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.
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Affiliation(s)
- Ana G Almeida
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Julia Grapsa
- Cardiology Department, Guys and St Thomas NHS Trust, London, UK
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Hospitals, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, UCLouvain, Brussels, Belgium
- Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Nina Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Bernard
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France
- Service de Cardiologie, CHRU de Tours, Tours, France
| | - Erwan Donal
- CHU Rennes, Inserm, LTSI-UMR 1099, University of Rennes, Rennes, France
| | - Marc R Dweck
- Centre for Cardiovascular Science, Chancellors Building, Little France Crescent, Edinburgh, UK
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Krassimira Hristova
- Center for Cardiovascular Diseases, Faculty of Medicine, Sofia University, Sofia, Bulgaria
| | - Alicia Maceira
- Ascires Biomedical Group, Valencia, Spain
- Department of Medicine, Health Sciences School, UCH-CEU University, Valencia, Spain
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Sharon Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, NS, Canada
| | - Doralisa Morrone
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | | | - Leyla Elif Sade
- Cardiology Department, University of Baskent, Ankara, Turkey
- UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jeanette Schulz-Menger
- Charité ECRC Medical Faculty of the Humboldt University Berlin and Helios-Clinics, Berlin, Germany
- DZHK, Partner site Berlin, Berlin, Germany
| | - Leslee Shaw
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai New York, NY, USA
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBERCV, Barcelona, Spain
| | - Berlinde von Kemp
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Fausto J Pinto
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Bernard Cosyns
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
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Civieri G, Kerkhof PLM, Montisci R, Iliceto S, Tona F. Sex differences in diagnostic modalities of coronary artery disease: Evidence from coronary microcirculation. Atherosclerosis 2023; 384:117276. [PMID: 37775426 DOI: 10.1016/j.atherosclerosis.2023.117276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/16/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Peter L M Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, the Netherlands
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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4
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Oliveira GMMD, Almeida MCCD, Rassi DDC, Bragança ÉOV, Moura LZ, Arrais M, Campos MDSB, Lemke VG, Avila WS, Lucena AJGD, Almeida ALCD, Brandão AA, Ferreira ADDA, Biolo A, Macedo AVS, Falcão BDAA, Polanczyk CA, Lantieri CJB, Marques-Santos C, Freire CMV, Pellegrini D, Alexandre ERG, Braga FGM, Oliveira FMFD, Cintra FD, Costa IBSDS, Silva JSN, Carreira LTF, Magalhães LBNC, Matos LDNJD, Assad MHV, Barbosa MM, Silva MGD, Rivera MAM, Izar MCDO, Costa MENC, Paiva MSMDO, Castro MLD, Uellendahl M, Oliveira Junior MTD, Souza OFD, Costa RAD, Coutinho RQ, Silva SCTFD, Martins SM, Brandão SCS, Buglia S, Barbosa TMJDU, Nascimento TAD, Vieira T, Campagnucci VP, Chagas ACP. Position Statement on Ischemic Heart Disease - Women-Centered Health Care - 2023. Arq Bras Cardiol 2023; 120:e20230303. [PMID: 37556656 PMCID: PMC10382148 DOI: 10.36660/abc.20230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | | | | | - Celi Marques-Santos
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Hospital São Lucas Rede D'Or São Luis, Aracaju, SE - Brasil
| | | | - Denise Pellegrini
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | - Fabiana Goulart Marcondes Braga
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Lara Terra F Carreira
- Cardiologia Nuclear de Curitiba, Curitiba, PR - Brasil
- Hospital Pilar, Curitiba, PR - Brasil
| | | | | | | | | | | | | | | | | | | | | | - Marly Uellendahl
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | - Ricardo Quental Coutinho
- Faculdade de Ciências Médicas da Universidade de Pernambuco (UPE), Recife, PE - Brasil
- Hospital Universitário Osvaldo Cruz da Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | | | - Sílvia Marinho Martins
- Pronto Socorro Cardiológico de Pernambuco da Universidade de Pernambuco (PROCAPE/UPE), Recife, PE - Brasil
| | | | - Susimeire Buglia
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | - Thais Vieira
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Rede D'Or, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
| | | | - Antonio Carlos Palandri Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Centro Universitário Faculdade de Medicina ABC, Santo André, SP - Brasil
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5
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Vergallo R, Volpe M. A gender issue in the diagnostic imaging work-up of stable coronary artery disease? Insights from DISCHARGE. Eur Heart J 2023; 44:340-341. [PMID: 36493383 DOI: 10.1093/eurheartj/ehac720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS San Martino Hospital, Viale Benedetto XV, 616132 Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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6
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Relationship between sexual differences and cardiovascular risk factors in the prevalence of asymptomatic coronary disease. Int J Cardiol 2023; 370:1-7. [PMID: 36414046 DOI: 10.1016/j.ijcard.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/06/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
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.
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Palau P, Núñez J, Monmeneu JV, Lopez-Lereu MP, Gavara J, Rios-Navarro C, de Dios E, Perez-Sole N, Marcos-Garces V, Domínguez E, Moratal D, Canoves J, Miñana G, Chorro FJ, Bodi V. Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI. J Magn Reson Imaging 2022; 56:1680-1690. [PMID: 35344231 DOI: 10.1002/jmri.28163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Patricia Palau
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jose V Monmeneu
- Cardiovascular Unit, ASCIRES Biomedical Group, Valencia, Spain
| | | | - Jose Gavara
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Elena de Dios
- Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Nerea Perez-Sole
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Victor Marcos-Garces
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | | | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Joaquim Canoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Francisco Javier Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
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8
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Sex differences in machine learning computed tomography-derived fractional flow reserve. Sci Rep 2022; 12:13861. [PMID: 35974055 PMCID: PMC9381799 DOI: 10.1038/s41598-022-17875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/02/2022] [Indexed: 11/08/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) derived machine learning fractional flow reserve (ML-FFRCT) can assess the hemodynamic significance of coronary artery stenoses. We aimed to assess sex differences in the association of ML-FFRCT 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-FFRCT was computed using a machine learning algorithm with significant stenosis defined as ML-FFRCT < 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-FFRCT < 0.8 (39% vs. 44%; p = 0.23) and higher median (IQR) ML-FFRCT (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-FFRCT < 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-FFRCT was higher in women than men. There was no significant association between ML-FFRCT and incident mortality or MI and no evidence that the prognostic value of ML-FFRCT differs by sex.
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9
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Solola Nussbaum S, Henry S, Yong CM, Daugherty SL, Mehran R, Poppas A. Sex-Specific Considerations in the Presentation, Diagnosis, and Management of Ischemic Heart Disease: JACC Focus Seminar 2/7. J Am Coll Cardiol 2022; 79:1398-1406. [PMID: 35393022 PMCID: PMC9009217 DOI: 10.1016/j.jacc.2021.11.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/04/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Sade Solola Nussbaum
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sonia Henry
- Department of Cardiology, Zucker School of Medicine at Hofstra/Norwell, North Shore University Hospital, Manhasset, New York, USA
| | - Celina Mei Yong
- Division of Cardiology, Department of Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Stacie L Daugherty
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Athena Poppas
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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10
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Bullock-Palmer RP, Peix A, Aggarwal NR. Nuclear Cardiology in Women and Underrepresented Minority Populations. Curr Cardiol Rep 2022; 24:553-566. [PMID: 35262873 DOI: 10.1007/s11886-022-01673-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Renee P Bullock-Palmer
- Department of Cardiology, Deborah Heart and Lung Center, Trenton Road, Browns Mills, NJ, 08015, USA.
| | - Amalia Peix
- Institute of Cardiology and Cardiovascular Surgery, La Habana, Havana, Cuba
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, 55902, USA
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11
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Li W, Yu F, Liu M, Yan C. Clinical value of resting cardiac dual-energy CT in patients suspected of coronary artery disease. BMC Med Imaging 2022; 22:32. [PMID: 35220940 PMCID: PMC8883697 DOI: 10.1186/s12880-022-00761-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/22/2022] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Wenhuan Li
- grid.24696.3f0000 0004 0369 153XDepartment of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Fangfang Yu
- grid.24696.3f0000 0004 0369 153XDepartment of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Mingxi Liu
- grid.24696.3f0000 0004 0369 153XDepartment of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Chengxi Yan
- grid.413259.80000 0004 0632 3337Department of Radiology, Xuanwu Hospital of Capital Medical University, No. 45, Chang-Chun Street, Xicheng District, Beijing, 100053 China
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12
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Kuneman JH, Bax JJ. Sex differences in coronary artery disease. Neth Heart J 2021; 29:486-489. [PMID: 34505968 PMCID: PMC8455752 DOI: 10.1007/s12471-021-01619-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- J H Kuneman
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands. .,Turku Heart Centre, University of Turku and Turku University Hospital, Turku, Finland.
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13
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Ordovas KG, Baldassarre LA, Bucciarelli-Ducci C, Carr J, Fernandes JL, Ferreira VM, Frank L, Mavrogeni S, Ntusi N, Ostenfeld E, Parwani P, Pepe A, Raman SV, Sakuma H, Schulz-Menger J, Sierra-Galan LM, Valente AM, Srichai MB. Cardiovascular magnetic resonance in women with cardiovascular disease: position statement from the Society for Cardiovascular Magnetic Resonance (SCMR). J Cardiovasc Magn Reson 2021; 23:52. [PMID: 33966639 PMCID: PMC8108343 DOI: 10.1186/s12968-021-00746-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/17/2021] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol, UK
- Bristol National Institute of Health Research (NIHR) Biomedical , Research Centre, Bristol, UK
- University Hospitals Bristol, Bristol, UK
- University of Bristol, Bristol, UK
| | - James Carr
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Vanessa M Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- Medical College of Wisconsin, Wisconsin, USA
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
- Kapodistrian University of Athens, Athens, Greece
| | - Ntobeko Ntusi
- University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio C.N.R., Pisa, Italy
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University, Indianapolis, USA
| | - Hajime Sakuma
- Department of Radiology, Mie University School of Medicine, Mie, Japan
| | - Jeanette Schulz-Menger
- harite Hospital, University of Berlin, Berlin, Germany
- HELIOS-Clinics Berlin-Buch, Berlin, Germany
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14
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Meyer MR. Chronic Coronary Syndromes in Women: Challenges in Diagnosis and Management. Mayo Clin Proc 2021; 96:1058-1070. [PMID: 33814074 DOI: 10.1016/j.mayocp.2020.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/16/2020] [Accepted: 09/18/2020] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Matthias R Meyer
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland; Division of Gender Medicine, Institute of Primary Care, University of Zurich, Switzerland.
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15
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de Marvao A, Alexander D, Bucciarelli-Ducci C, Price S. Heart disease in women: a narrative review. Anaesthesia 2021; 76 Suppl 4:118-130. [PMID: 33682102 DOI: 10.1111/anae.15376] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- A de Marvao
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - D Alexander
- Department of Cardiac Anaesthesia, Royal Brompton Hospital, London, UK
| | - C Bucciarelli-Ducci
- Bristol Heart Institute, Bristol NIHR Cardiovascular Research Centre, University of Bristol and University Hospitals Bristol NHS Trust, Bristol, UK
| | - S Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
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16
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Wenger NK. Cardiovascular Disease in Women: Understanding the Journey. Clin Chem 2021; 67:24-29. [PMID: 33393996 DOI: 10.1093/clinchem/hvaa297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Nanette K Wenger
- Emory University School of Medicine, Atlanta, GA; Emory Heart and Vascular Center, Atlanta, GA; and Emory Women's Heart Center, Atlanta, GA
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17
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Bucciarelli-Ducci C, Ostenfeld E, Baldassarre LA, Ferreira VM, Frank L, Kallianos K, Raman SV, Srichai MB, McAlindon E, Mavrogeni S, Ntusi NAB, Schulz-Menger J, Valente AM, Ordovas KG. Cardiovascular disease in women: insights from magnetic resonance imaging. J Cardiovasc Magn Reson 2020; 22:71. [PMID: 32981527 PMCID: PMC7520984 DOI: 10.1186/s12968-020-00666-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol National Institute of Health Research (NIHR) Biomedical Research Centre, University Hospitals Bristol and University of Bristol, Bristol, UK
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Getingevägen 5, SE-22185 Lund, Sweden
| | | | - Vanessa M. Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- University of Texas Medical Branch, Galveston, TX USA
| | | | | | | | - Elisa McAlindon
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
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18
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Fairbairn TA, Dobson R, Hurwitz-Koweek L, Matsuo H, Norgaard BL, Rønnow Sand NP, Nieman K, Bax JJ, Pontone G, Raff G, Chinnaiyan KM, Rabbat M, Amano T, Kawasaki T, Akasaka T, Kitabata H, Binukrishnan S, Rogers C, Berman D, Patel MR, Douglas PS, Leipsic J. Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE. JACC Cardiovasc Imaging 2020; 13:2576-2587. [PMID: 32861656 DOI: 10.1016/j.jcmg.2020.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) 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 FFRCT 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 FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT 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 FFRCT. 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 FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT ≤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 FFRCT 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 FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284). CONCLUSIONS FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-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 FFRCT 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).
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Affiliation(s)
| | - Rebecca Dobson
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Hitoshi Matsuo
- Wakayama Medical University, Wakayama, Japan; Gifu Heart Center, Gifu, Japan
| | | | | | - Koen Nieman
- Stanford University Medical Center, Palo Alto, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
| | - Gilbert Raff
- William Beaumont Hospital, Royal Oaks, Michigan, USA
| | | | - Mark Rabbat
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | | | | | | | | | - Daniel Berman
- Cedars Sinai Medical Centre, Beverly Hills, California, USA
| | - Manesh R Patel
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Barsky L, Merz CNB, Wei J, Shufelt C, Handberg E, Pepine C, Rutledge T, Reis S, Doyle M, Rogers W, Shaw L, Sopko G. Even "WISE-R?"-an Update on the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation. Curr Atheroscler Rep 2020; 22:35. [PMID: 32556630 PMCID: PMC7388776 DOI: 10.1007/s11883-020-00852-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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?'".
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Affiliation(s)
- Lili Barsky
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, 90048, USA.
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, 90048, USA
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, 90048, USA
| | - Eileen Handberg
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Carl Pepine
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas Rutledge
- VA San Diego Healthcare System, San Diego, CA, USA
- University of California, San Diego, CA, USA
| | - Steven Reis
- Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Doyle
- Division of Cardiology, Department of Medicine, Allegheny University of the Health Sciences, Pittsburgh, PA, USA
| | - William Rogers
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leslee Shaw
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine and New York-Presbyterian Hospital, New York, NY, USA
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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20
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Impact of sex-specific differences in calculating the pretest probability of obstructive coronary artery disease in symptomatic patients: a coronary computed tomographic angiography study. Coron Artery Dis 2020; 30:124-130. [PMID: 30629000 PMCID: PMC6369895 DOI: 10.1097/mca.0000000000000696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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21
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Zheng X, Dreyer RP, Curtis JP, Liu S, Xu X, Bai X, Li X, Zhang H, Wang S, Masoudi FA, Spertus JA, Li J, Krumholz HM. Sex Differences in 1-Year Health Status Following Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction: Results From the China PEACE Prospective Study. J Am Heart Assoc 2020; 9:e014421. [PMID: 32131687 PMCID: PMC7335522 DOI: 10.1161/jaha.119.014421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Xin Zheng
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Rachel P Dreyer
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT.,Department of Emergency Medicine Yale School of Medicine New Haven CT
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT.,Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Shuling Liu
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT
| | - Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine New Haven CT
| | - Xueke Bai
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Siming Wang
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Frederick A Masoudi
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - John A Spertus
- Department of Cardiovascular Outcomes Research Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City Kansas City MO
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, National Center for Cardiovascular Diseases Beijing People's Republic of China
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT.,Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
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Schuijf JD, Matheson MB, Ostovaneh MR, Arbab-Zadeh A, Kofoed KF, Scholte AJHA, Dewey M, Steveson C, Rochitte CE, Yoshioka K, Cox C, Di Carli MF, Lima JAC. Ischemia and No Obstructive Stenosis (INOCA) at CT Angiography, CT Myocardial Perfusion, Invasive Coronary Angiography, and SPECT: The CORE320 Study. Radiology 2020; 294:61-73. [DOI: 10.1148/radiol.2019190978] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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François CJ. "One-Stop Shop" For Evaluating Epicardial and Microvascular Coronary Artery Disease with Coronary CT Angiography and CT Myocardial Perfusion. Radiology 2019; 294:74-75. [PMID: 31747345 DOI: 10.1148/radiol.2019192363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christopher J François
- From the Department of Radiology, Cardiovascular and Thoracic Imaging Sections, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792
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24
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The Feminine Face of Ischemic Heart Disease: Challenges and Opportunities. J Am Coll Cardiol 2019; 73:694-697. [PMID: 30765036 DOI: 10.1016/j.jacc.2018.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 12/30/2022]
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25
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Ferdinand KC, Samson R. Nonobstructive Coronary Artery Disease in Women: Risk Factors and Noninvasive Diagnostic Assessment. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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26
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Henry S, Bond R, Rosen S, Grines C, Mieres J. Challenges in Cardiovascular Risk Prediction and Stratification in Women. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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27
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Heart rate reserve during pharmacological stress is a significant negative predictor of impaired coronary flow reserve in women. Eur J Nucl Med Mol Imaging 2019; 46:1257-1267. [PMID: 30648200 DOI: 10.1007/s00259-019-4265-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/04/2019] [Indexed: 12/22/2022]
Abstract
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).
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28
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Myocardial Perfusion Imaging for the Evaluation of Ischemic Heart Disease in Women. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9479-3] [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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29
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Chamsi-Pasha MA, Kurrelmeyer KM. Noninvasive Evaluation of Symptomatic Women with Suspected Coronary Artery Disease. Methodist Debakey Cardiovasc J 2018; 13:193-200. [PMID: 29744011 DOI: 10.14797/mdcj-13-4-193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
| | - Karla M Kurrelmeyer
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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30
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Age- and sex-dependent changes in sympathetic activity of the left ventricular apex assessed by 18F-DOPA PET imaging. PLoS One 2018; 13:e0202302. [PMID: 30106984 PMCID: PMC6091960 DOI: 10.1371/journal.pone.0202302] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/31/2018] [Indexed: 11/19/2022] Open
Abstract
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.
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31
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Masuda A, Nemoto A, Takeishi Y. Technical aspects of cardiac PET/MRI. J Nucl Cardiol 2018; 25:1023-1028. [PMID: 29468469 DOI: 10.1007/s12350-018-1237-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/24/2018] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Atsuro Masuda
- Department of Cardiovascular Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan.
| | - Ayaka Nemoto
- Advanced Clinical Research Center, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
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32
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Gebhard C, Fiechter M, Herzog BA, Lohmann C, Bengs S, Treyer V, Messerli M, Benz DC, Giannopoulos AA, Gräni C, Pazhenkottil AP, Buechel RR, Kaufmann PA. Sex differences in the long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography. Eur J Nucl Med Mol Imaging 2018; 45:1964-1974. [PMID: 29779046 DOI: 10.1007/s00259-018-4046-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/02/2018] [Indexed: 01/02/2023]
Abstract
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; pinteraction < 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.
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Affiliation(s)
- Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.
| | - Michael Fiechter
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Bernhard A Herzog
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christine Lohmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Aggarwal NR, Bond RM, Mieres JH. The role of imaging in women with ischemic heart disease. Clin Cardiol 2018; 41:194-202. [PMID: 29505091 DOI: 10.1002/clc.22913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Rachel M Bond
- Zucker School of Medicine at Hofstra Northwell, New York
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34
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Aggeli C, Polytarchou K, Felekos I, Zisimos K, Venieri E, Verveniotis A, Varvarousis D, Toutouzas K, Tsiamis E, Tousoulis D. Effect of gender on the prognostic value of dobutamine stress myocardial contrast echocardiography. Hellenic J Cardiol 2017; 58:419-424. [DOI: 10.1016/j.hjc.2017.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/04/2017] [Accepted: 04/12/2017] [Indexed: 12/18/2022] Open
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35
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Comparative Effectiveness Trials of Imaging-Guided Strategies in Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2017; 10:321-334. [PMID: 28279380 DOI: 10.1016/j.jcmg.2016.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
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.
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36
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Taqueti VR, Dorbala S, Wolinsky D, Abbott B, Heller GV, Bateman TM, Mieres JH, Phillips LM, Wenger NK, Shaw LJ. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations. J Nucl Cardiol 2017; 24:1402-1426. [PMID: 28585034 PMCID: PMC5942593 DOI: 10.1007/s12350-017-0926-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Viviany R Taqueti
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Wolinsky
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Brian Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Cardiovascular Institute, The Miriam and Newport Hospitals, Providence, RI, USA
| | - Gary V Heller
- Gagnon Cardiovascular Center, Morristown Medical Center, Morristown, NJ, USA
| | - Timothy M Bateman
- Saint Luke's Health System, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, USA
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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Paul TK, Sivanesan K, Schulman-Marcus J. Sex differences in nonobstructive coronary artery disease: Recent insights and substantial knowledge gaps. Trends Cardiovasc Med 2017; 27:173-179. [DOI: 10.1016/j.tcm.2016.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
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38
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Standbridge K, Reyes E. The role of pharmacological stress testing in women. J Nucl Cardiol 2016; 23:997-1007. [PMID: 27515346 DOI: 10.1007/s12350-016-0602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Katherine Standbridge
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom.
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