Lower diagnostic accuracy of thallium-201 SPECT myocardial perfusion imaging in women: an effect of smaller chamber size

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Approach to Imaging Ischemia in Women

Approach to imaging ischemia in women Coronary artery disease in women tends to have a worse short- and long-term prognosis relative to men and remains the leading cause of mortality worldwide. Both clinical symptoms and diagnostic approach remain challenging in women due to lesser likelihood of women presenting with classic anginal symptoms on one hand and underperformance of conventional exercise treadmill testing in women on the other. Moreover, a higher proportion of women with signs and symptoms suggestive of ischemia are more likely to have nonobstructive coronary artery disease (CAD) that requires additional imaging and therapeutic considerations. New imaging techniques such as coronary computed tomography (CT) angiography, CT myocardial perfusion imaging, CT functional flow reserve assessment, and cardiac magnetic resonance imaging carry substantially better sensitivity and specificity for the detection of ischemia and coronary artery disease in women. Familiarity with various clinical subtypes of ischemic heart disease in women and with the major advantages and disadvantages of advanced imaging tests to ensure the decision to select one modality over another is one of the keys to successful diagnosis of CAD in women. This review compares the 2 major types of ischemic heart disease in women - obstructive and nonobstructive, while focusing on sex-specific elements of its pathophysiology.

Sex-Specific Stress Perfusion Cardiac Magnetic Resonance Imaging in Suspected Ischemic Heart Disease: Insights From SPINS Retrospective Registry

BACKGROUND

Cardiovascular disease (CVD) remains the leading cause of mortality in women, but current noninvasive cardiac imaging techniques have sex-specific limitations.

OBJECTIVES

In this study, the authors sought to investigate the effect of sex on the prognostic utility and downstream invasive revascularization and costs of stress perfusion cardiac magnetic resonance (CMR) for suspected CVD.

METHODS

Sex-specific prognostic performance was evaluated in a 2,349-patient multicenter SPINS (Stress CMR Perfusion Imaging in the United States [SPINS] Study) registry. The primary outcome measure was a composite of cardiovascular death and nonfatal myocardial infarction; secondary outcomes were hospitalization for unstable angina or heart failure, and late unplanned coronary artery bypass grafting.

RESULTS

SPINS included 1,104 women (47% of cohort); women had higher prevalence of chest pain (62% vs 50%; P < 0.0001) but lower use of medical therapies. At the 5.4-year median follow-up, women with normal stress CMR had a low annualized rate of primary composite outcome similar to men (0.54%/y vs 0.75%/y, respectively; P = NS). In contrast, women with abnormal CMR were at higher risk for both primary (3.74%/y vs 0.54%/y; P < 0.0001) and secondary (9.8%/y vs 1.6%/y; P < 0.0001) outcomes compared with women with normal CMR. Abnormal stress CMR was an independent predictor for the primary (HR: 2.64 [95% CI: 1.20-5.90]; P = 0.02) and secondary (HR: 2.09 [95% CI: 1.43-3.08]; P < 0.0001) outcome measures. There was no effect modification for sex. Women had lower rates of invasive coronary angiography (ICA; 3.6% vs 7.3%; P = 0.0001) and downstream costs ($114 vs $171; P = 0.001) at 90 days following CMR. There was no effect of sex on diagnostic image quality.

CONCLUSIONS

Stress CMR demonstrated excellent prognostic performance with lower rates of ICA referral in women. Stress CMR should be considered as a first-line noninvasive imaging tool for the evaluation of women. (Stress CMR Perfusion Imaging in the United States [SPINS] Study [SPINS]; NCT03192891).

Sex-specific associations of myocardial perfusion imaging with outcomes in patients with suspected chronic coronary syndrome

BACKGROUND

Myocardial perfusion scintigraphy (MPS) is an established diagnostic technique for inducible ischemia in patients with suspected chronic coronary syndrome (CCS). Some MPS findings, most notably an ischemia extent>10% of the left ventricle (LV), hold prognostic significance and support maximization of anti-ischemic treatment. We aimed to assess sex-specific associations of MPS findings with cardiovascular (CV) events in a population at high risk of CCS.

METHODS

In a prospective cohort study, 1,229 consecutive patients (age 70 ± 9.5 years, 73.5% males) without known CCS were referred to stress-rest MPS. All patients were followed for a median of 4.6 years for CV events.

RESULTS

Men and women had comparable risk profiles and incidence rates of CV events (6.6% vs. 4.6% respectively, P = 0.186). A summed stress score (SSS) > 7 was associated with the primary endpoint, including CV death and/or nonfatal myocardial infarction (MI) (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], 1.79-5.46; P = 0.001), all-cause mortality (HR, 3.01; 95% CI, 1.31-6.93; P = 0.01), and incidence of late revascularization (HR, 1.84; 95% CI, 1.22-2.78; P = 0.004) in men but not women. A summed difference score (SDS) > 6 was related to a higher rate of the primary endpoint only in men (adjusted HR, 1.97; 95% CI, 1.18-3.30; P = 0.009).

CONCLUSIONS

Among patients undergoing a diagnostic workup for suspected CCS, stress perfusion and reversible ischemia abnormalities may independently predict worse survival and more CV events in men. However, the obtained results indicated the need for sex-specific cutoffs to refine risk stratification and assist in clinical decisions on anti-ischemic therapy beyond coronary artery anatomy.

Cardiovascular Imaging for Ischemic Heart Disease in Women: Time for a Paradigm Shift

Heart disease is the leading cause of death among men and women. Women have a unique phenotype of ischemic heart disease with less calcified lesions, more nonobstructive plaques, and a higher prevalence of microvascular disease compared with men, which may explain in part why current risk models to detect obstructive coronary artery disease (CAD) may not work as well in women. This paper summarizes the sex differences in the functional and anatomical assessment of CAD in women presenting with stable chest pain and provides an approach for using multimodality imaging for the evaluation of suspected ischemic heart disease in women in accordance to the recently published American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain. A paradigm shift in the approach to imaging ischemic heart disease women is needed including updated risk models, a more profound understanding of CAD in women where nonobstructive disease is more prevalent, and algorithms focused on the evaluation of ischemia with nonobstructive CAD and myocardial infarction with nonobstructive CAD.

Underrepresentation of women in cardiac imaging trials: A review

Inclusion and equal representation of women in cardiovascular imaging trials are essential to provide insight into the factors impacting women's heart health and outcomes. Despite heart disease being the leading cause of mortality for women in the United States, women have been underrepresented in cardiovascular clinical trials, including imaging trials. Research demonstrates that women have key sex-specific differences in the pathophysiology of cardiovascular disease, the evolution of disease state, and disease manifestation (Solimene, 2010; Nevsky et al., 2011 [1,2]). This understanding and acknowledgment come decades after clinical providers have extrapolated data from cardiovascular disease clinical trials conducted primarily on Caucasian men, assuming the data were generalizable to sex, race, and ethnicity. The current cardiology society guidelines, which recommend optimal medical therapies for various cardiovascular diseases, are based on trials predominantly focused on men rather than women. Sex-based research, governmental and institutional task forces, and policies on gender equity have made inroads into the disproportionate number of women's enrollment in clinical research. The National Institutes of Health in the 1990s set forth requirements on incorporating women and minorities in research, including clinical trials (Mastroianni et al., 1994; Mieres et al., 2014 [3,4]). Continued progress is imperative to improve the gap in the number of women enrolled in clinical research trials.

Diagnostic Performance of PET Versus SPECT Myocardial Perfusion Imaging in Patients with Smaller Left Ventricles: A Substudy of the 18F-Flurpiridaz Phase III Clinical Trial

The performance of SPECT myocardial perfusion imaging (MPI) may deteriorate in smaller hearts, primarily because of the lower resolution of conventional Anger cameras. ¹⁸F-flurpiridaz is a novel PET MPI agent with superior image and defect resolution. We sought to determine the diagnostic performance of ^99mTc-labeled SPECT MPI compared with ¹⁸F-flurpiridaz PET MPI according to left ventricle (LV) size. Methods: We conducted a substudy of the phase III clinical trial of flurpiridaz (n = 750) and stratified diagnostic performance according to the median PET LV end-diastolic volume (LVEDV), with smaller LVs defined as having an LVEDV of less than 113 mL (n = 369) and larger LVs defined as having an LVEDV of at least 113 mL (n = 381). Images were interpreted by the majority rule of 3 independent masked readers. The reference standard was quantitative invasive angiography, with at least 50% stenosis in at least 1 coronary artery considered significant. Results: SPECT performance decreased significantly from an area under the curve (AUC) of 0.75 in larger LVs to 0.67 in smaller LVs (P = 0.03), whereas PET performance was similar in larger and smaller LVs (AUC, 0.79 vs. 0.77, P = 0.49). Accordingly, in smaller LVs, PET had a higher AUC (0.77) than the SPECT AUC (0.67) (P < 0.0001), a phenomenon driven by female patients (P < 0.0001). In smaller LVs, there was a degradation of SPECT sensitivity that was highly significant (P < 0.001), whereas there was no significant change in PET sensitivity according to LV size (P = 0.07). Overall, PET had significantly higher sensitivity than SPECT in both smaller LVs (67% vs. 43%, P < 0.001) and larger LVs (76% vs. 61%, P < 0.001). The specificities of PET and SPECT were similar in larger LVs (76% vs. 83%, P = 0.11). Although SPECT specificity improved in smaller compared with larger LVs (90% vs. 83%, P = 0.03), the PET specificity did not change with LV size (76% vs. 76%, P = 0.9). Conclusion: The diagnostic performance of ¹⁸F-flurpiridaz PET MPI is not affected by LV size and is superior to SPECT MPI in patients with smaller LVs, highlighting the importance of appropriate test selection in these patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Coronary artery disease in post-menopausal women: are there appropriate means of assessment?

The recognition of sex differences in cardiovascular disease, particularly the manifestations of coronary artery disease (CAD) in post-menopausal women, has introduced new challenges in not only understanding disease mechanisms but also identifying appropriate clinical means of assessing the efficacy of management strategies. For example, the majority of treatment algorithms for CAD are derived from the study of males, focus on epicardial stenoses, and inadequately account for the small intramyocardial vessel disease in women. However, newer investigational modalities, including stress perfusion cardiac magnetic resonance imaging and positron emission tomography are providing enhanced diagnostic accuracy and prognostication for women with microvascular disease. Moreover, these investigations may soon be complemented by simpler screening tools such as retinal vasculature imaging, as well as novel biomarkers (e.g. heat shock protein 27). Hence, it is vital that robust, sex-specific cardiovascular imaging modalities and biomarkers continue to be developed and are incorporated into practice guidelines that are used to manage women with CAD, as well as gauge the efficacy of any new treatment modalities. This review provides an overview of some of the sex differences in CAD and highlights emerging advances in the investigation of CAD in post-menopausal women.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Gender Differences in Radiation Dose From Nuclear Cardiology Studies Across the World: Findings From the INCAPS Registry

OBJECTIVES

The aim of this study was to investigate gender-based differences in nuclear cardiology practice globally, with a particular focus on laboratory volume, radiation dose, protocols, and best practices.

BACKGROUND

It is unclear whether gender-based differences exist in radiation exposure for nuclear cardiology procedures.

METHODS

In a large, multicenter, observational, cross-sectional study encompassing 7,911 patients in 65 countries, radiation effective dose was estimated for each examination. Patient-level best practices relating to radiation exposure were compared between genders. Analysis of covariance was used to determine any difference in radiation exposure according to gender, region, and the interaction between gender and region. Linear, logistic, and hierarchical regression models were developed to evaluate gender-based differences in radiation exposure and laboratory adherence to best practices. The study also included the United Nations Gender Inequality Index and Human Development Index as covariates in multivariable models.

RESULTS

The proportion of myocardial perfusion imaging studies performed in women varied among countries; however, there was no significant correlation with the Gender Inequality Index. Globally, mean effective dose for nuclear cardiology procedures was only slightly lower in women (9.6 ± 4.5 mSv) than in men (10.3 ± 4.5 mSv; p < 0.001), with a difference of only 0.3 mSv in a multivariable model adjusting for patients' age and weight. Stress-only imaging was performed more frequently in women (12.5% vs. 8.4%; p < 0.001); however, camera-based dose reduction strategies were used less frequently in women (58.6% vs. 65.5%; p < 0.001).

CONCLUSIONS

Despite significant worldwide variation in best practice use and radiation doses from nuclear cardiology procedures, only small differences were observed between genders worldwide. Regional variations noted in myocardial perfusion imaging use and radiation dose offer potential opportunities to address gender-related differences in delivery of nuclear cardiology care.

The effect of patient anxiety and depression on motion during myocardial perfusion SPECT imaging

Background

Patient motion during myocardial perfusion SPECT imaging (MPI) may be triggered by a patient’s physical and/or psychological discomfort. The aim of this study was to investigate the impact of state anxiety (patient’s reaction to exam-related stress), trait anxiety (patient’s personality characteristic) and depression on patient motion during MPI.

Methods

All patients that underwent MPI in our department in a six-month period were prospectively enrolled. One hundred eighty-three patients (45 females; 138 males) filled in the State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI), along with a short questionnaire regarding their age, height and weight, level of education in years, occupation, and marital status. Cardiovascular and other co-morbidity factors were also evaluated. Through inspection of raw data on cinematic display, the presence or absence of patient motion was registered and classified into mild, moderate and severe, for both phases involved in image acquisition.

Results

The correlation of patient motion in the stress and delay phases of MPI and each of the other variables was investigated and the corresponding Pearson’s coefficients of association were calculated. The anxiety-motion (r = 0.43, P < 0.0001) and depression-motion (r = 0.32, P < 0.0001) correlation results were moderately strong and statistically significant for the female but not the male patients. All the other variables did not demonstrate any association with motion in MPI, except a weak correlation between age and motion in females (r = 0.23, P < 0.001).

Conclusions

The relationship between anxiety-motion and depression-motion identified in female patients represents the first supporting evidence of psychological discomfort as predisposing factor for patient motion during MPI.

Comparison of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) Trial

BACKGROUND

Coronary artery disease is the leading cause of death in women, and underdiagnosis contributes to the high mortality. This study compared the sex-specific diagnostic performance of cardiovascular magnetic resonance (CMR) and single-photon emission computed tomography (SPECT).

METHODS AND RESULTS

A total of 235 women and 393 men with suspected angina underwent CMR, SPECT, and x-ray angiography as part of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) study. CMR comprised adenosine stress/rest perfusion, cine imaging, late gadolinium enhancement, and magnetic resonance coronary angiography. Gated adenosine stress/rest SPECT was performed with (99m)Tc-tetrofosmin. For CMR, the sensitivity in women and men was similar (88.7% versus 85.6%; P=0.57), as was the specificity (83.5% versus 82.8%; P=0.86). For SPECT, the sensitivity was significantly worse in women than in men (50.9% versus 70.8%; P=0.007), but the specificities were similar (84.1% versus 81.3%; P=0.48). The sensitivity in both the female and male groups was significantly higher with CMR than SPECT (P<0.0001 for both), but the specificity was similar (P=0.77 and P=1.00, respectively). For perfusion-only components, CMR outperformed SPECT in women (area under the curve, 0.90 versus 0.67; P<0.0001) and in men (area under the curve, 0.89 versus 0.74; P<0.0001). Diagnostic accuracy was similar in both sexes with perfusion CMR (P=1.00) but was significantly worse in women with SPECT (P<0.0001).

CONCLUSIONS

In both sexes, CMR has greater sensitivity than SPECT. Unlike SPECT, there are no significant sex differences in the diagnostic performance of CMR. These findings, plus an absence of ionizing radiation exposure, mean that CMR should be more widely adopted in women with suspected coronary artery disease.

CLINICAL TRIAL REGISTRATION URL

http://www.controlled-trials.com. Unique identifier: ISRCTN77246133.

Diagnosing and characterizing coronary artery disease in women: developments in noninvasive and invasive imaging techniques

Cardiovascular disease is the leading cause of death in men and women in the USA; yet, coronary artery disease (CAD) continues to be underrecognized and underdiagnosed in women. Noninvasive and invasive imaging techniques are constantly being developed in order to more accurately assess CAD. At the same time, the impact of gender on the interpretation and accuracy of these studies is still being elucidated. Furthermore, new imaging techniques have improved our understanding of CAD pathophysiology and progression and have begun to reveal gender differences in the development of CAD. This article will review current imaging techniques and their application to diagnosing and understanding CAD in women.

Sex preferences in cardiovascular testing: the contribution of the patient-physician discussion

OBJECTIVES

Prior studies suggest that a decreased cardiac catheterization rate for women with acute coronary syndrome (ACS) is partially attributed to gender differences in patient preferences for testing. The hypothesis was that these preferences are influenced by physician recommendations for cardiovascular testing.

METHODS

This was a cohort study of patients who presented to an emergency department (ED) with chest pain. At the time of ED disposition, patients were surveyed to assess whether or not the doctor discussed the possibility of coronary artery disease (CAD), the physician's recommendations for diagnostic testing, and the patient's preferences for further testing. The survey was repeated at the time of discharge from the hospital if the patient was admitted and again at 30 days for all patients. The main outcome was patient-reported physician recommendation for testing, and the secondary outcome was patient preference for cardiovascular testing.

RESULTS

There were 206 patients enrolled (118 women, 88 men). Women were less likely than men to receive cardiac catheterization as inpatients (9.8% vs. 20.0%, p = 0.04). In the ED, women were less likely to be recommended for stress testing (8.5% vs. 19.3%, p = 0.02) or cardiac catheterization (4.2% vs. 13.6%, p = 0.02) or to see a cardiologist (8.5% vs. 22.7%, p < 0.01). As inpatients, women were more likely to be told that no further testing was needed (70.5% vs. 50.0%, p = 0.03). While there was higher incidence of prior CAD and myocardial infarction among the men in the study, analysis after removal of these patients did not alter results. Physicians were less likely to counsel women about diagnostic testing options in the ED (10.1% vs. 22.7%, p = 0.03), as inpatients (11.5% vs. 40.0%, p < 0.01), and as outpatients (26.1% vs. 48.6%, p = 0.04). No patients in the study refused their doctors' recommendations. Women were less likely to prefer catheterization in the ED (5.1% vs. 15.9%, p = 0.01) and were more likely to prefer no further testing as inpatients (60.7% vs. 40.0%, p = 0.02).

CONCLUSIONS

Women who presented to the ED with symptoms concerning for ACS reported lower rates of physician recommendation for cardiovascular testing, as well as lower rates of counseling regarding cardiac etiologies of their chest pain. These findings suggest sex differences in preference for cardiovascular testing may be partially explained by the discussions between women and their doctors.

MR myocardial perfusion imaging

Contrast material-enhanced myocardial perfusion imaging by using cardiac magnetic resonance (MR) imaging has, during the past decade, evolved into an accurate technique for diagnosing coronary artery disease, with excellent prognostic value. Advantages such as high spatial resolution; absence of ionizing radiation; and the ease of routine integration with an assessment of viability, wall motion, and cardiac anatomy are readily recognized. The need for training and technical expertise and the regulatory hurdles, which might prevent vendors from marketing cardiac MR perfusion imaging, may have hampered its progress. The current review considers both the technical developments and the clinical experience with cardiac MR perfusion imaging, which hopefully demonstrates that it has long passed the stage of a research technique. In fact, cardiac MR perfusion imaging is moving beyond traditional indications such as diagnosis of coronary disease to novel applications such as in congenital heart disease, where the imperatives of avoidance of ionizing radiation and achievement of high spatial resolution are of high priority. More wide use of cardiac MR perfusion imaging, and novel applications thereof, are aided by the progress in parallel imaging, high-field-strength cardiac MR imaging, and other technical advances discussed in this review.

Cardiovascular disease in women

Gender-specific data focused on cardiovascular disease (CVD) are becoming increasingly available. This is of great importance, given that CVD has become the number 1 killer of women, and unlike for men, mortality rates do not seem to be declining. Many factors are cited as the causes of sex-based differences, including delays in recognizing symptoms, underutilization of diagnostic tests and treatments, as well as anatomic, physiological, and genetic factors. Evidence of fundamental biological differences in vascular function and the underlying pathologic processes is only beginning to elucidated, motivated by growing evidence of differences in clinical presentations and outcomes between men and women. The good news is that we are starting to see improvements in outcomes for women, such as after coronary revascularization; decrease in complication rates with the advent of new techniques, such as radial access for cardiac catheterizations; as well as increased participation of women in clinical trials. The underlying mechanisms of ischemic heart disease remain to be elucidated, and will help guide therapy and ultimately may explain the higher prevalence of : subendocardial myocardial infarctions, spontaneous arterial dissections, plaque erosion, increased vasospastic disorders, such as coronary microvascular disease, and pulmonary hypertension in women compared with men. We have made great progress in understanding gender-related differences in CVDs, but much remains to be done to optimize the prevention of CVD for both men and women.

Methods used for the assessment of LV systolic function: common currency or tower of Babel?

The last decade has produced a proliferation of techniques for the assessment of left ventricular systolic function, and there now seems to be more choice than seems rational for the questions that we need answers to. In some instances, simple estimation is all that is required-the risk stratification process is inexact, as emphasised by the variety of modalities used to characterise ejection fraction (EF) in studies that validated the efficacy of treatments selected on the basis of EF. Nonetheless, while technical advances often cause disruption and confusion, it would be wrong to dismiss them as lacking benefit. The purpose of this review is to try to provide rational grounds for selecting both test modality and physiological parameter in various specific clinical situations.

Gender differences in the diagnostic accuracy of SPECT myocardial perfusion imaging: a bivariate meta-analysis

BACKGROUND

It remains controversial whether the diagnostic accuracy of single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) is different in men as compared to women. We performed a meta-analysis to investigate gender differences of SPECT MPI for the diagnosis of CAD (≥50% stenosis).

METHOD

Two investigators independently performed a systematic review of the MEDLINE and EMBASE databases from inception through January 2012 for English-language studies determining the diagnostic accuracy of SPECT MPI. We included prospective studies that compared SPECT MPI with conventional coronary angiography which provided sufficient data to calculate gender-specific true and false positives and negatives. Data from studies evaluating <20 patients of one gender were excluded. Bivariate meta-analysis was used to create summary receiver operating curves.

RESULTS

Twenty-six studies met inclusion criteria, representing 1,148 women and 1,142 men. Bivariate meta-analysis yielded a mean sensitivity and specificity of 84.2% (95% confidence interval [CI] 78.7%-88.6%) and 78.7% (CI 70.0%-85.3%) for SPECT MPI in women and 89.1% (CI 84.0%-92.7%) and 71.2% (CI 60.8%-79.8%) for SPECT MPI in men. There was no significant difference in the sensitivity (P = .15) or specificity (P = .23) between male and female subjects.

CONCLUSION

In a bivariate meta-analysis of the available literature, the diagnostic accuracy of SPECT MPI is similar for both men and women.

Superior diagnostic performance of perfusion-cardiovascular magnetic resonance versus SPECT to detect coronary artery disease: The secondary endpoints of the multicenter multivendor MR-IMPACT II (Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary Artery Disease Trial)

BACKGROUND

Perfusion-cardiovascular magnetic resonance (CMR) is generally accepted as an alternative to SPECT to assess myocardial ischemia non-invasively. However its performance vs gated-SPECT and in sub-populations is not fully established. The goal was to compare in a multicenter setting the diagnostic performance of perfusion-CMR and gated-SPECT for the detection of CAD in various populations using conventional x-ray coronary angiography (CXA) as the standard of reference.

METHODS

In 33 centers (in US and Europe) 533 patients, eligible for CXA or SPECT, were enrolled in this multivendor trial. SPECT and CXA were performed within 4 weeks before or after CMR in all patients. Prevalence of CAD in the sample was 49% and 515 patients received MR contrast medium. Drop-out rates for CMR and SPECT were 5.6% and 3.7%, respectively (ns). The study was powered for the primary endpoint of non-inferiority of CMR vs SPECT for both, sensitivity and specificity for the detection of CAD (using a single-threshold reading), the results for the primary endpoint were reported elsewhere. In this article secondary endpoints are presented, i.e. the diagnostic performance of CMR versus SPECT in subpopulations such as multi-vessel disease (MVD), in men, in women, and in patients without prior myocardial infarction (MI). For diagnostic performance assessment the area under the receiver-operator-characteristics-curve (AUC) was calculated. Readers were blinded versus clinical data, CXA, and imaging results.

RESULTS

The diagnostic performance (= area under ROC = AUC) of CMR was superior to SPECT (p = 0.0004, n = 425) and to gated-SPECT (p = 0.018, n = 253). CMR performed better than SPECT in MVD (p = 0.003 vs all SPECT, p = 0.04 vs gated-SPECT), in men (p = 0.004, n = 313) and in women (p = 0.03, n = 112) as well as in the non-infarct patients (p = 0.005, n = 186 in 1-3 vessel disease and p = 0.015, n = 140 in MVD).

CONCLUSION

In this large multicenter, multivendor study the diagnostic performance of perfusion-CMR to detect CAD was superior to perfusion SPECT in the entire population and in sub-groups. Perfusion-CMR can be recommended as an alternative for SPECT imaging.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT00977093.

Imaging Tests, Provocative Tests, Including Exercise Testing in Women with Suspected Coronary Artery Disease

Evolving knowledge regarding sex differences in coronary heart disease has demonstrated that the prevalence, symptomatology, and pathophysiology of coronary atherosclerosis vary between genders. Women experience higher mortality rates and more adverse outcomes after acute myocardial infarction than men, despite a lower prevalence of obstructive coronary artery disease. Based on recent insights into the complex pathophysiology of coronary heart disease which includes a spectrum of obstructive coronary artery disease and dysfunction of the coronary microvasculature and endothelium, the term ischemic heart disease is a more accurate term for discussion of coronary atherosclerosis specific to women. In women, with clinical features and risk factors for ischemic heart disease, the detection and evaluation of ischemic heart disease is challenging due to the diverse pathogenic mechanisms of ischemic heart diseases in women. In this article, we discuss noninvasive imaging tests, provocative tests, including exercise testing in women with suspected ischemic heart disease.

Noninvasive diagnostic techniques for coronary disease in women

Significant advances in medical treatment, medical technology, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, coronary artery disease (CAD) is the leading cause of cardiovascular death of women in the Western world. In the past 2 decades, the focused research on women at risk for CAD has helped to clarify our understanding of some of the sex-specific factors that are important in the detection of CAD. In women, the detection and evaluation of physiologically significant CAD can be challenging. Many of the traditional tests that are designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients, who have a greater burden of symptoms, higher atherosclerotic burden, and lower prevalence of obstructive coronary disease. In this article, we review the available evidence on the role of contemporary noninvasive diagnostic techniques in the evaluation of women with symptoms of CAD. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Assessment of myocardial ischemia with cardiovascular magnetic resonance

Assessment of myocardial ischemia in symptomatic patients remains a common and challenging clinical situation faced by physicians. Risk stratification by presence of ischemia provides important utility for both prognostic assessment and management. Unfortunately, current noninvasive modalities possess numerous limitations and have limited prognostic capacity. More recently, ischemia assessment by cardiovascular magnetic resonance (CMR) has been shown to be a safe, available, and potentially cost-effective alternative with both high diagnostic and prognostic accuracy. Cardiovascular magnetic resonance has numerous advantages over other noninvasive methods, including high temporal and spatial resolution, relatively few contraindications, and absence of ionizing radiation. Furthermore, studies assessing the clinical utility and cost effectiveness of CMR in the short-term setting for patients without evidence of an acute myocardial infarction have also demonstrated favorable results. This review will cover techniques of ischemia assessment with CMR by both stress-induced wall motion abnormalities as well as myocardial perfusion imaging. The diagnostic and prognostic performance studies will also be reviewed, and the use of CMR for ischemia assessment will be compared with other commonly used noninvasive modalities.

The accuracy of the electrocardiogram during exercise stress test based on heart size

BACKGROUND

Multiple studies have shown that the exercise electrocardiogram (ECG) is less accurate for predicting ischemia, especially in women, and there is additional evidence to suggest that heart size may affect its diagnostic accuracy.

HYPOTHESIS

The purpose of this investigation was to assess the diagnostic accuracy of the exercise ECG based on heart size.

METHODS

We evaluated 1,011 consecutive patients who were referred for an exercise nuclear stress test. Patients were divided into two groups: small heart size defined as left ventricular end diastolic volume (LVEDV) <65 mL (Group A) and normal heart size defined as LVEDV ≥65 mL (Group B) and associations between ECG outcome (false positive vs. no false positive) and heart size (small vs. normal) were analyzed using the Chi square test for independence, with a Yates continuity correction. LVEDV calculations were performed via a computer-processing algorithm. SPECT myocardial perfusion imaging was used as the gold standard for the presence of coronary artery disease (CAD).

RESULTS

Small heart size was found in 142 patients, 123 female and 19 male patients. There was a significant association between ECG outcome and heart size (χ(2) = 4.7, p = 0.03), where smaller hearts were associated with a significantly greater number of false positives.

CONCLUSIONS

This study suggests a possible explanation for the poor diagnostic accuracy of exercise stress testing, especially in women, as the overwhelming majority of patients with small heart size were women.

Gender-based prognostic value of pharmacological cardiac magnetic resonance stress testing: head-to-head comparison of adenosine perfusion and dobutamine wall motion imaging

This study evaluated the gender related long-term prognostic value of adenosine perfusion and dobutamine wall motion imaging as assessed during a combined single-session stress cardiac magnetic resonance (CMR) examination. In 717 patients a combined CMR stress examination was performed. Inducible perfusion deficits and wall motion abnormalities were identified visually. Clinical parameters were assessed at the time of the CMR examination. All patients were contacted to determine the occurrence of hard cardiac events (cardiac death, myocardial infarction) during a median follow-up period of 5.3 years. A complete combined CMR examination and follow-up data were available in 679 patients (471 men). A total of 77 hard cardiac events (63 in men) occurred during follow-up. Multivariate analysis revealed the presence of inducible perfusion deficits or wall motion abnormalities as independent predictors of hard cardiac events for both gender with an incremental value over conventional cardiovascular risk factors. In case of a negative stress test result, event-free survival was 100% in women for 4 years and >99% in men for 2 years after the CMR examination. CMR perfusion and wall motion testing are equally suited for cardiac risk stratification in men and women. Stress CMR negative women exhibited very low event rates up to 4 years following the examination, while in men annual event rates increased after the second year. Consequently, the generally proposed 2-year warranty period of non-invasive stress testing may be prolonged to a 4 year level in CMR stress testing negative women.

Noninvasive assessment of coronary artery disease in women: What's next?

Significant progress in research has been made in the areas of sex-specific aspects of cardiovascular disease. Despite these advances, coronary artery disease (CAD) is the leading cause of death of women in the Western world. Over the past decade, the focused research on women at risk for ischemic heart disease has helped to clarify our understanding of some of the sex-specific factors, which are important in detecting CAD. In women, the detection and evaluation of physiologically significant CAD is challenging, especially given that traditional tests designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients who have a lower prevalence of obstructive coronary disease, greater burden of symptoms, and a high atherosclerotic burden. In this article, we review the available evidence on the role of contemporary cardiovascular imaging techniques in evaluating ischemic heart disease in women.

Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain

Excluding obstructive coronary artery disease (CAD) as the etiology of acute chest pain in patients without diagnostic electrocardiographic changes or elevated serum cardiac biomarkers is challenging. Stress testing is a valuable risk-stratifying technique reserved for the subset of these patients with low-risk chest pain who have an intermediate clinical probability of obstructive CAD. Given the risks of radiation inherent to nuclear and computed tomography imaging, both adenosine stress cardiovascular magnetic resonance (AS-CMR) imaging and dobutamine stress echocardiography (DSE) are attractive alternative stress modalities. An essential characteristic of stress modalities is their negative prognostic value; as one must exclude clinically-relevant CAD such that patients can be discharged safely. Therefore, the aim of this study was to validate a favorable negative prognostic value for both AS-CMR and DSE in patients presenting with low-risk acute chest pain. This retrospective study included 255 patients with low-risk acute chest pain and no prior history of CAD presenting to the emergency department at our institution, with 89 patients evaluated by AS-CMR and 166 by DSE. Median follow-up was 292 days, and consisted of medical record review. The primary end-point was the composite of cardiac death, nonfatal acute myocardial infarction, obstructive CAD on invasive coronary angiography (ICA) or recurrent chest pain requiring hospital admission. Test characteristics such as sensitivity and specificity could not be evaluated as patients were not routinely evaluated with ICA. All patients completed the stress protocol without adverse events during testing. 82/89 patients (92.1%) and 164/166 patients (98.8%) had negative AS-CMR and DSE studies, respectively. Both AS-CMR and DSE had excellent negative prognostic values for the primary endpoint, 100 and 99%, respectively. Both AS-CMR and DSE are effective stress modalities for excluding clinically significant coronary artery disease in patients presenting acute low-risk chest pain. Patients without findings to suggest ischemia have an excellent intermediate-term prognosis.

Quantification of myocardial perfusion SPECT studies in Chinese population with Western normal databases

BACKGROUND

The purpose of this study is to assess diagnostic performance of the current quantification packages using Western normal databases in detecting coronary artery disease in Chinese population.

METHODS

Seventy-five patients who underwent rest/stress myocardial perfusion SPECT and coronary angiography (CAG) were enrolled. Emory Cardiac Toolbox (ECTb) and Quantitative Perfusion SPECT (QPS) with its standard (QPS-standard) and simplified (QPS-simplified) methods were used to quantify these studies. A preliminary Chinese normal database was created from 80 normal subjects (QPS-simplified-Chinese). Receiver operator characteristic (ROC) was used to assess the accuracy of the four normal databases in detecting >or=50% or >or=70% stenosis given by CAG.

RESULTS

The enrolled cohorts had lower body mass index (BMI) and smaller heart size than Western population. The areas under ROC curve of ECTb, QPS-standard, and QPS-simplified were significantly lower than QPS-simplified-Chinese in detecting >or=50% stenosis, but not in detecting >or=70% stenosis. Diagnostic accuracy was much lower in the RCA and LCX territory.

CONCLUSION

Chinese normal database is needed for accurately applying these quantification methods to Chinese population, especially for detecting moderate defects in regions with relatively greater attenuation impact. An alternative approach could be modification of the existing Western normal databases for low-BMI and/or small-heart subjects.

Comparison of exercise electrocardiography, technetium-99m sestamibi single photon emission computed tomography, and dobutamine and dipyridamole echocardiography for detection of coronary artery disease in hypertensive women

To assess the performance of currently used stress tests for the detection of coronary artery disease (CAD) in a series of female hypertensive patients. We performed exercise electrocardiography (ECG), technetium-99m sestamibi (MIBI) single photon emission computed tomography, dobutamine and dipyridamole echocardiography, and coronary angiography in 76 hypertensive women. Of the 76 study patients, 31 (41%) had significant CAD. The sensitivity of exercise ECG (81%), MIBI scanning (90%), and dobutamine echocardiography (87%) was greater than that of dipyridamole echocardiography (61%). This finding resulted from the lower sensitivity of dipyridamole echocardiography in the detection of single-vessel CAD (47% vs 76%, 88%, and 82% for the other 3 methods). In contrast, the sensitivity of the 4 tests was similar in the detection of multivessel CAD. The specificity of exercise ECG (56%) and MIBI scanning (53%) was less than that of dobutamine (82%, both p <0.01) and dipyridamole (91%, both p <0.001) echocardiography. This finding related to the lower specificity of exercise ECG in patients with either left ventricular hypertrophy or ST-T abnormalities at rest compared to the specificity in patients without these disorders (33% vs 89%, p <0.01). A lower MIBI scan specificity was found only in patients with left ventricular hypertrophy (31% vs 66%, p <0.05). The overall accuracy of dobutamine echocardiography reached 84% compared to exercise ECG (66%, p <0.01), MIBI scan (68%, p <0.05), and dipyridamole echocardiography (79%, p <0.05). In conclusion, dobutamine echocardiography yielded satisfactory diagnostic accuracy for identifying CAD in hypertensive women. Although dipyridamole echocardiography had the greatest specificity, it might be limited in detecting mild CAD. Both exercise ECG and MIBI scanning had fare sensitivity; however, our findings limit the usefulness of these 2 tests in unselected patients.

Gender differences in systolic tissue velocity: role of left ventricular length

AIMS

Previous research has described differences in left ventricular (LV) systolic tissue velocity between genders. This study aimed to determine the association between LV tissue velocity and LV size in healthy controls and in those with type 2 diabetes (T2DM).

METHODS AND RESULTS

LV tissue velocities were measured in 71 controls and 222 patients with T2DM by pulsed-wave Doppler and colour-coded tissue Doppler (TDI) during systole (S' and S(m)) and diastole (early, E' and E(m), and late, A' and A(m)) at the basal septum and lateral wall. Both systolic tissue velocities were higher in males than in females within controls (S': 7.3 +/- 1.2 vs. 6.6 +/- 1.0 cm/s; P = 0.017, S(m): 6.2 +/- 1.0 vs. 5.5 +/- 0.7 cm/s; P = 0.002) but only by colour-coded TDI in patients with T2DM (S(m): 5.7 +/- 1.7 vs. 4.9 +/- 1.7 cm/s; P = 0.025). Correction for LV length negated the difference between genders in the controls and patients with T2DM (P > 0.05 for all). In controls, LV length was the strongest predictor of S' (beta = 0.393, P = 0.002), whereas height was the strongest predictor of S(m) (beta = 0.394, P = 0.003).

CONCLUSION

In controls, systolic tissue velocities are significantly higher in males compared with females, which may be explained by the increased chamber size of men.

Value of cardiovascular magnetic resonance stress perfusion testing for the detection of coronary artery disease in women

OBJECTIVES

We wanted to assess the value of cardiovascular magnetic resonance (CMR) stress testing for evaluation of women with suspected coronary artery disease (CAD).

BACKGROUND

A combined perfusion and infarction CMR examination can accurately diagnose CAD in the clinical setting in a mixed gender population.

METHODS

We prospectively enrolled 147 consecutive women with chest pain or other symptoms suggestive of CAD at 2 centers (Duke University Medical Center, Robert-Bosch-Krankenhaus). Each patient underwent a comprehensive clinical evaluation, a CMR stress test consisting of cine rest function, adenosine-stress and rest perfusion, and delayed-enhancement CMR infarction imaging, and X-ray coronary angiography within 24 h. The components of the CMR test were analyzed visually both in isolation and combined using a pre-specified algorithm. Coronary artery disease was defined as stenosis > or =70% on quantitative analysis of coronary angiography.

RESULTS

Cardiovascular magnetic resonance imaging was completed in 136 females (63.0 +/- 11.1 years), 37 (27%) women had CAD on coronary angiography. The combined CMR stress test had a sensitivity, specificity, and accuracy of 84%, 88%, and 87%, respectively, for the diagnosis of CAD. Diagnostic accuracy was high at both sites (Duke University Medical Center 82%, Robert-Bosch-Krankenhaus 90%; p = 0.18). The accuracy for the detection of CAD was reduced when intermediate grade stenoses were included (82% vs. 87%; p = 0.01 compared the cutoff of stenosis > or =50% vs. > or =70%). The sensitivity was lower in women with single-vessel disease (71% vs. 100%; p = 0.06 compared with multivessel disease) and small left ventricular mass (69% vs. 95%; p = 0.04 for left ventricular mass < or =97 g vs. >97 g). The latter difference was even more significant after accounting for end-diastolic volumes (70% vs. 100%; p = 0.02 for left ventricular mass indexed to end-diastolic volume < or =1.15 g/ml vs. >1.15 g/ml).

CONCLUSIONS

A multicomponent CMR stress test can accurately diagnose CAD in women. Detection of CAD in women with intermediate grade stenosis, single-vessel disease, and with small hearts is challenging.

Diagnostic strategies for heart disease in women: an update on imaging techniques for optimal management

Significant progress has been made toward increasing awareness of the risks of heart disease in women and in the area of sex-specific cardiovascular research. Yet, coronary artery disease remains the leading cause of death of women in the western world. Over the last decade, the increased research focus of women at risk for ischemic heart disease has helped in defining and delineating some of the sex-specific factors, which have adversely affected the accuracy of imaging techniques in women. A focused body of clinical research has been published over the last few years, and there now exists a growing body of evidence on the diagnostic and prognostic accuracy of contemporary cardiovascular imaging techniques in women. Recent publications specifically addressing this issue [namely the 2005 American Heart Association Statement on Cardiac Imaging in Women, and the 2006 Women's Ischemia Syndrome Evaluation (WISE) study] are now changing the existing paradigm of ischemic heart disease from one representing a "man's disease," to one including sex-specific algorithms. In this article we review the literature regarding the diagnostic and prognostic evaluation of coronary artery disease in women with respect to imaging.

Value of electrocardiographically gated single-photon emission computed tomographic myocardial perfusion scintigraphy in a cohort of symptomatic postmenopausal women

The aim of this study is to prospectively evaluate the clinical value of electrocardiographically gated single-photon emission computed tomographic myocardial perfusion scintigraphy (MPS) imaging in a cohort of postmenopausal women with symptoms suggestive of ischemic heart disease. Forty-six postmenopausal women with no history of coronary artery disease (CAD), but with typical or atypical angina and >or=1 risk factor for CAD, were enrolled and underwent both coronary angiography and technetium-99m sestamibi MPS with exercise (n = 36) or pharmacologic stress (n = 10). All women were followed up for 5.0 +/- 3 years for the occurrence of hospitalization for acute coronary syndrome, myocardial infarction, and/or new-onset or worsening angina. CAD prevalence (>or=50% diameter stenosis) was 62% (26 of 42 patients). Fifteen patients (36%) had 1-vessel disease, 7 (17%) had 2-vessel disease, and 4 (10%) had 3-vessel disease. Diagnostic sensitivity and specificity of the exercise electrocardiogram were 67% and 69%, respectively. By comparison, sensitivity of MPS was 88% and specificity was 87.5% (p <0.0001). Cox survival analysis showed 3- and 5-year cumulative event-free survival rates of 97% and 94% for patients with normal MPS results compared with 60% and 48% for those with abnormal MPS findings (p <0.001). In conclusion, results of this study indicate high diagnostic and prognostic accuracy for MPS in symptomatic postmenopausal women.

Dobutamine stress echocardiography for the detection of coronary artery disease in women

Dobutamine stress echocardiography (DSE) has good diagnostic accuracy for the diagnosis of coronary artery disease (CAD). However, in most published diagnostic studies, patients are predominantly men. In women, diagnostic accuracy may be lower because of a lower prevalence and extent of CAD, a higher incidence of dobutamine stress-induced hypotension (resulting in less stress or even nondiagnostic test results), smaller left ventricular chamber size, and the beneficial effects of estrogens on the induction of myocardial ischemia. To determine the diagnostic accuracy of DSE in women, 14 diagnostic studies published through 2006 were identified through a Medline search. For a total of 901 patients, the weighted mean sensitivity and specificity were 72% and 88%, respectively. In 7 studies directly comparing results in women and men, conflicting results were reported. However, pooled data showed nearly identical values for sensitivity and specificity in women and men. Additionally, in 6 studies directly comparing DSE results in women with those of stress nuclear scintigraphy, DSE was as sensitive and more specific to detect CAD (90% vs 70%, p <0.0001). The excellent specificity of DSE in women was also confirmed by excellent normalcy rates, ranging from 92% to 100% in women, with a <5% pretest probability of CAD. In conclusion, despite some theoretical limitations, DSE has reasonable sensitivity and excellent specificity for the detection of CAD in women. Considering the diagnostic problems of exercise electrocardiography and nuclear scintigraphy in women, stress echocardiography may be the stress modality of choice in women because of its superior diagnostic specificity.

Electrocardiogram abnormalities predict angiographic coronary artery disease in women with chest pain: results from the NHLBI WISE Study

BACKGROUND AND HYPOTHESIS

Noninvasive risk stratification for coronary artery disease (CAD) isless accurate in women than in men. Based on recent reports that gender-specific exercise electrocardiogram (ECG) parameters predict CAD, we evaluated the independent predictive value of the resting ECG for angiographic CAD in women with chest pain.

METHODS

Women (n = 850, mean age 58 years) with chest pain in the NHLBI Women's Ischemia Syndrome Evaluation (WISE) underwent 12-lead ECG testing and quantitative coronary angiography.

RESULTS

Significant angiographic CAD (> or = 50% stenosis in > or = 1 coronary) was present in 39% of women. Q waves in < or = 2 contiguous ECG leads were present in 107 women (13%), including 49 of 657 (7%) without history of infarction. Among 585 women without prior infarction orrevascularization, 48% of those with Q waves in contiguous leads versus 26% of others, had significant CAD (p = 0.003; odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.3-4.8). Women with Q waves in < or = 2 inferior ECG leads were particularly likely to have CAD (63 vs. 26% of others, p < 0.001; OR = 4.6,95% CI = 2.0-10.8). Other ECG findings predictive of CAD were any ST-T abnormality (OR = 1.9,95% CI = 1.3-2.8) and T-wave inversion (OR = 2.4, 95% CI = 1.3-4.2). In risk-adjusted analysis, inferior Q waves and T-wave inversion independently predicted significant CAD. When considered together with radionuclide perfusion test results, T-wave inversion on resting ECG added significant independent predictive value (OR = 2.8, 95% CI = 1.1-7.2, p = 0.03).

CONCLUSIONS

Selected resting ECG parameters independently predict angiographic CAD in women with chest pain, including women who have also undergone radionuclide stress testing. Prospective studies should consider resting ECG parameters in diagnostic algorithms for CAD in women.

Dobutamine stress echocardiography in the diagnosis of coronary artery disease in women with chest pain: comparison with different noninvasive tests

BACKGROUND

Diagnosis of coronary artery disease(CAD) in women remains elusive. The classical diagnostic armamentarium has been found to be very limited. Dobutamine stress echocardiography has emerged as a powerful test in assessing CAD in the general population, but most studies failed to include women.

HYPOTHESIS

The accuracy of dobutamine stress echocardiography in the diagnosis of CAD in women with chest pain is high and superior to dipyridamole echocardiography, exercise electrocardiography, and sestamibi single-photon emission tomography (MIBI-SPECT) scintigraphy.

METHODS

We studied 99 consecutive women with chest pain and no previous history of CAD who underwent dobutamine echocardiography and coronary angiography. We also compared these results with those of dipyridamole echocardiography in 63 patients. exercise stress testing in 83 (48 conclusive), and MIBI-SPECT scintigraphy during dobutamine infusion in 54.

RESULTS

Significant CAD was found in 42 women. Sensitivity and specificity of dobutamine stress echocardiography were 69 and 89%, respectively. Dipyridamole echocardiography showed similar accuracy (sensitivity 72% and specificity 94%). Finally, sensitivity of exercise test and MIBI-SPECT was similar (76 and 88%, respectively) and specificity was lower (53 and 57%, respectively). After excluding patients known to have a high incidence of false positive results, MIBI-SPECT specificity rose up to 80%.

CONCLUSION

Dobutamine stress echocardiography and dipyridamole echocardiography bear a high diagnostic accuracy in women with chest pain. MIBI-SPECT is also a useful tool after excluding subgroups with a high incidence of false positive results.

The ratio of the apex/anterior wall: A marker of breast attenuation artifact in women

BACKGROUND

Breast attenuation artifact is well known for reducing the accuracy of myocardial perfusion imaging in women. We have noticed the particular pattern of relative preservation of apical activity in women with breast attenuation and decreased anterior wall counts. This study was undertaken to see if this finding could be used to improve the accuracy of perfusion imaging in women.

METHODS

We identified 295 women referred for exercise stress testing using (201)Tl single photon emission computed tomography (SPECT) of whom 193 had less than 5% probability of coronary disease and 102 had coronary artery disease documented by catheterization within 60 days of stress testing (mean of 1.8+/-0.8 vessels with=50% stenosis). Patients with documented myocardial infarction, pathologic Q waves, left bundle branch block, non-ischaemic cardiomyopathy or prior bypass grafting were excluded. Volume-weighted bullseye plots were generated and normalized to 100; next, regions of interest were drawn over the anterior wall and apex in all patients and the ratio of the mean counts of each region was calculated. The normals were further divided into those with breast attenuation (defined as mean anterior counts <70% maximum) and those without. Defect scores of all patients were calculated; a formula to adjust the score for patients with breast attenuation was developed. Accuracy was assessed by calculating the area under the receiver operating curve.

RESULTS

The normals, overall, had a mean ratio of 1.0+/-0.08 vs. 0.9+/-0.16 for those with coronary disease (P<0.0001). In normals with breast attenuation the ratio was 1.1+/-0.08 compared to 0.99+/-0.07 (P<0.0001) without. By adjusting the anterior wall defect score in patients with apex/anterior ratio >1 we were able to improve the accuracy from 0.808+/-0.028 to 0.826+/-0.027 (P<0.01).

CONCLUSIONS

A ratio of the apex to the anterior wall >1 is not physiological and suggests the presence of significant breast attenuation artifact. This finding can be used to produce a small but statistically significant improvement in the accuracy of quantitative thallium SPECT in women who have not undergone coronary bypass grafting.