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Betai D, Ahmed AS, Saxena P, Rashid H, Patel H, Shahzadi A, Mowo-Wale AG, Nazir Z. Gender Disparities in Cardiovascular Disease and Their Management: A Review. Cureus 2024; 16:e59663. [PMID: 38836150 PMCID: PMC11148660 DOI: 10.7759/cureus.59663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
Worldwide, cardiovascular diseases (CVDs) are still the primary cause of death, and there are notable differences between sexes when it comes to symptoms/course and treatment. Due to evolving healthcare technologies, significant progress has been made in understanding CVDs. Hence, it is evident that gender disparities exist in the clinical presentation, prevalence, management, outcomes, and risk factors, including biological, behavioral, and sociocultural factors. This narrative review is designed to provide a generalized idea of gender disparities in CVDs. It aims to provide insights to prove the role of hormonal influences, genetic predispositions, and the difference in physiological outcomes owing to different genders. This review explores subtle distinctions in CVD across genders, including changes in structure, biology, and hormones that affect how illness presents and progresses. Lifestyle variables also influence sociocultural factors and gender disparities in risk profiles. Traditional risk factors, diabetes mellitus (DM), cholesterol levels, and smoking may have different weights and relevance in men and women. Moreover, age and other conventional risk variables have distinct effects on gender. Treatment efficacy may be impacted by the expression of gender-specific factors, emphasizing the necessity for customized strategies. Development of CVDs can be delayed or prevented, and its consequences can be lessened with the early identification and effective management of gender-specific factors. More investigation is necessary to clarify complex interactions between structural, biochemical, and hormonal aspects across genders in order to maximize treatment results and reduce the burden of CVDs.
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Affiliation(s)
- Dhruva Betai
- General Practice, Pandit Deendayal Upadhyay Medical College, Rajkot, IND
| | - Aamina S Ahmed
- Internal Medicine, St. George's University School of Medicine, New York, USA
| | - Prerna Saxena
- Medicine and Surgery, K. S. Hegde Medical Academy, Mangalore, IND
| | - Hurria Rashid
- Basic Sciences, Fatima Jinnah Medical University, Lahore, PAK
| | - Happy Patel
- Internal Medicine, Angeles University Foundation, Angeles City, PHL
| | - Atika Shahzadi
- Medicine, Aziz Bhatti Shaheed Teaching Hospital, Gujrat, PAK
| | | | - Zahra Nazir
- Internal Medicine, Combined Military Hospital Quetta, Quetta, PAK
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2
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Phillips LM, Mieres JH. President's message: The evolving dilemma of cardiac imaging in women. J Nucl Cardiol 2024; 32:101801. [PMID: 38219972 DOI: 10.1016/j.nuclcard.2024.101801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Affiliation(s)
| | - Jennifer H Mieres
- Northwell Health/Zucker School of Medicine at Hofstra, New Hyde Park, NY, USA
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3
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Krljanac G, Apostolović S, Polovina M, Maksimović R, Nedeljković Arsenović O, Đorđevic N, Stanković S, Savić L, Ušćumlić A, Stanković S, Ašanin M. Differences in left ventricular myocardial function and infarct size in female patients with ST elevation myocardial infarction and spontaneous coronary artery dissection. Front Cardiovasc Med 2024; 10:1280605. [PMID: 38259320 PMCID: PMC10800883 DOI: 10.3389/fcvm.2023.1280605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Differences in pathophysiology, clinical presentation, and natural course of ST-elevation myocardial infarction in female patients due to either spontaneous dissection (SCAD-STEMI) or atherothrombotic occlusion (type 1 STEMI) have been discussed. Current knowledge on differences in left ventricular myocardial function and infarct size is limited. The aim of this study was to assess baseline clinical characteristics, imaging findings, and therapeutic approach and to compare differences in echocardiographic findings at baseline and 3-month follow-up in patients with SCAD-STEMI and type 1 STEMI. Methods This was a prospective multicenter study of 32 female patients (18-55 years of age) presenting with either SCAD-STEMI due to left anterior descending coronary artery (LAD) dissection or type 1 STEMI due to atherothrombotic LAD occlusion. Results The two groups were similar in age, risk factors, comorbidities, and complications. SCAD-STEMI patients more often had Thrombolysis in Myocardial Infarction 3 flow, while type 1 STEMI patients were more often treated with percutaneous coronary intervention and dual antiplatelet therapy. Baseline mean left ventricular (LV) ejection fraction (LVEF) was similar in the two groups (48.0% vs. 48.6%, p = 0.881), but there was a significant difference at the 3-month follow-up, driven by an improvement in LVEF in SCAD-STEMI compared to type 1 STEMI patients (Δ LVEF 10.1 ± 5.3% vs. 1.8 ± 5.1%, p = 0.002). LV global longitudinal strain was slightly improved in both groups at follow-up; however, the improvement was not significantly different between groups (-4.6 ± 2.9% vs. -2.0 ± 2.8%, p = 0.055). Conclusions The results suggest that female patients with SCAD-STEMI are more likely to experience improvement in LV systolic function than type 1 STEMI patients.
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Affiliation(s)
- Gordana Krljanac
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Svetlana Apostolović
- Coronary Care Unit, Cardiology Clinic, University Clinical Center of Nis, Nis, Serbia
- Faculty of Medicine, University of Nis, Nis, Serbia
| | - Marija Polovina
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ružica Maksimović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, Serbia
| | - Olga Nedeljković Arsenović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nemanja Đorđevic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Stefan Stanković
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Lidija Savić
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Ušćumlić
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Stanković
- Center for Medical Biochemistry, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Milika Ašanin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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4
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Gaine SP, Sharma G, Tower-Rader A, Botros M, Kovell L, Parakh A, Wood MJ, Harrington CM. Multimodality Imaging in the Detection of Ischemic Heart Disease in Women. J Cardiovasc Dev Dis 2022; 9:350. [PMID: 36286302 PMCID: PMC9604786 DOI: 10.3390/jcdd9100350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Women with coronary artery disease tend to have a worse short and long-term prognosis relative to men and the incidence of atherosclerotic cardiovascular disease is increasing. Women are less likely to present with classic anginal symptoms when compared with men and more likely to be misdiagnosed. Several non-invasive imaging modalities are available for diagnosing ischemic heart disease in women and many of these modalities can also assist with prognostication and help to guide management. Selection of the optimal imaging modality to evaluate women with possible ischemic heart disease is a scenario which clinicians often encounter. Earlier modalities such as exercise treadmill testing demonstrate significant performance variation in men and women, while newer modalities such as coronary CT angiography, myocardial perfusion imaging and cardiac magnetic resonance imaging are highly specific and sensitive for the detection of ischemia and coronary artery disease with greater parity between sexes. Individual factors, availability, diagnostic performance, and female-specific considerations such as pregnancy status may influence the decision to select one modality over another. Emerging techniques such as strain rate imaging, CT-myocardial perfusion imaging and cardiac magnetic resonance imaging present additional options for diagnosing ischemia and coronary microvascular dysfunction.
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Affiliation(s)
- Sean Paul Gaine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Garima Sharma
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Albree Tower-Rader
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02214, USA
| | - Mina Botros
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Lara Kovell
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Anushri Parakh
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Malissa J. Wood
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02214, USA
| | - Colleen M. Harrington
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
- Corrigan Women’s Heart Health Program, Massachusetts General Hospital, Boston, MA 02214, USA
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5
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Mansour M, Radaideh Q, Alaiwah MN, Alnimer Y, Devabhaktuni SR, Dhar G, Vallurupalli S, Michos ED, Newby DE, Williams MC, Fudim M, Al'Aref SJ. Major adverse cardiac events in symptomatic women with non-obstructive CAD on coronary CTA: pooled analysis from PROMISE and SCOT-HEART. Int J Cardiovasc Imaging 2022; 38:683-693. [PMID: 34628593 PMCID: PMC8930619 DOI: 10.1007/s10554-021-02429-3] [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: 07/05/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
The presence of non-obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA) has been associated with the occurrence of major adverse cardiac events (MACE). However, factors associated with the development of MACE in symptomatic women with non-obstructive CAD on coronary CTA have not been fully elucidated. We sought to examine the influence of risk factors and coronary artery calcification on MACE in symptomatic women with non-obstructive CAD on coronary CTA. Women from PROMISE and SCOT-HEART trials with none or non-obstructive CAD on coronary CTA comprised the study cohort. Baseline characteristics and clinical presentation were assessed. Survival analysis using Kaplan-Meier curves was done to compare outcomes stratified by the atherosclerotic cardiovascular disease (ASCVD) risk score and the Agatston score. The primary endpoint was a composite of all-cause mortality, myocardial infarction, and revascularization. 2597 women had non-obstructive CAD or normal coronary CTA, with a median follow-up of 32 months. Compared to women without MACE, women with MACE had lower high-density lipoprotein cholesterol (HDL-C) levels and higher mean ASCVD risk scores. Further, women with non-obstructive CAD and ASCVD ≥ 7.5% had higher risk of MACE than those with ASCVD < 7.5% [3.2% vs. 1.1%, adjusted HR (aHR) of 3.1 (95% CI 1.32, 7.23), P-value 0.009]. The Agatston calcium score, on the other hand, was not independently associated with MACE among this population of symptomatic women. Symptomatic women with non-obstructive CAD on coronary CTA are at higher risk for MACE, with the ASCVD risk score being independently associated with the occurrence of adverse events.
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Affiliation(s)
- Munthir Mansour
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Qais Radaideh
- Division of Internal Medicine, Department of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Malek N Alaiwah
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Yanal Alnimer
- Department of Medicine, Tappahannock Hospital, Virginia Commonwealth University, Richmond, VA, USA
| | - Subodh R Devabhaktuni
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Gaurav Dhar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Srikanth Vallurupalli
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Subhi J Al'Aref
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
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Mannarino T, Assante R, Ricciardi C, Zampella E, Nappi C, Gaudieri V, Mainolfi CG, Di Vaia E, Petretta M, Cesarelli M, Cuocolo A, Acampa W. Head-to-head comparison of diagnostic accuracy of stress-only myocardial perfusion imaging with conventional and cadmium-zinc telluride single-photon emission computed tomography in women with suspected coronary artery disease. J Nucl Cardiol 2021; 28:888-897. [PMID: 31222530 DOI: 10.1007/s12350-019-01789-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Breast attenuation may impact the diagnostic accuracy of stress myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT). We compared the performance of conventional (C)-SPECT and cadmium-zinc-telluride (CZT)-SPECT systems in women with low-intermediate likelihood of coronary artery disease (CAD). METHODS AND RESULTS A total of 109 consecutive women underwent stress-optional rest MPI by both C-SPECT and CZT-SPECT. In the overall study population, a weak albeit significant correlation between total perfusion defect (TPD) measured by C-SPECT and CZT-SPECT was observed (r = 0.38, P < .001) and at Bland-Altman analysis the mean difference in TPD (C-SPECT minus CZT-SPECT) was 2.40% (P < .001). Overall concordance of semi-quantitative diagnostic performance between C-SPECT and CZT-SPECT was observed in 52 (48%) women with a κ value of 0.09. Normalcy rate was significantly higher using CZT-SPECT compared to C-SPECT (P < .001). Machine learning analysis performed through the implementation of J48 algorithm proved that CZT-SPECT has higher sensitivity, specificity, and accuracy than C-SPECT. CONCLUSIONS In women with low-intermediate likelihood of CAD, there is a poor concordance of diagnostic performance between C-SPECT and CZT-SPECT, and CZT-SPECT allows better normalcy rate detection compared to C-SPECT.
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Affiliation(s)
- Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Carlo Ricciardi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Ciro Gabriele Mainolfi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Eugenio Di Vaia
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Mario Cesarelli
- Department of Electrical Engineering and Information Technology, University Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy.
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7
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Ker WDS, Neves DGD, Magalhães TA, Santos AASMDD, Mesquita CT, Nacif MS. Myocardial Perfusion by Coronary Computed Tomography in the Evaluation of Myocardial Ischemia: Simultaneous Stress Protocol with SPECT. Arq Bras Cardiol 2019; 113:1092-1101. [PMID: 31596324 PMCID: PMC7021272 DOI: 10.5935/abc.20190201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 02/13/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Functional assessment to rule out myocardial ischemia using coronary computed tomography angiography (CCTA) is extremely important and data on the Brazilian population are still limited. OBJECTIVE To assess the diagnostic performance of myocardial perfusion by CCTA in the detection of severe obstructive coronary artery disease (CAD) compared with single-photon emission computerized tomography (SPECT). To analyze the importance of anatomical knowledge to understand the presence of myocardial perfusion defects on SPECT imaging that is not identified on computed tomography (CT) scan. METHOD A total of 35 patients were evaluated by a simultaneous pharmacologic stress protocol. Fisher's exact test was used to compare proportions. The patients were grouped according to the presence or absence of significant CAD. The area under the ROC curve was used to identify the diagnostic performance of CCTA and SPECT in perfusion assessment. P < 0.05 values were considered statistically significant. RESULTS For detection of obstructive CAD, CT myocardial perfusion analysis yielded an area under the ROC curve of 0.84 [a 95% confidence interval (CI95%): 0.67-0.94, p < 0.001]. SPECT myocardial perfusion imaging, on the other hand, showed an AUC of 0.58 (95% CI 0.40 - 0.74, p < 0.001). In this study, false-positive results with SPECT are described. CONCLUSION Myocardial perfusion analysis by CTA displays satisfactory results compared to SPECT in the detection of obstructive CAD. CCTA can rule out false-positive results of SPECT.
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Affiliation(s)
- Wilter Dos Santos Ker
- Hospital Universitário Antonio Pedro, Niterói, RJ - Brazil.,Universidade Federal Fluminense, Niterói, RJ - Brazil
| | | | - Tiago Augusto Magalhães
- Complexo Hospital de Clínicas da Universidade Federal do Paraná (CHC-UFPR), Curitiba, PR - Brazil
| | | | | | - Marcelo Souto Nacif
- Hospital Universitário Antonio Pedro, Niterói, RJ - Brazil.,Universidade Federal Fluminense, Niterói, RJ - Brazil.,Complexo Hospital de Clínicas da Universidade Federal do Paraná (CHC-UFPR), Curitiba, PR - Brazil
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8
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Abstract
Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.
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9
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Safdar B, Ona Ayala KE, Ali SS, Seifer BJ, Hong M, Greenberg MR, Choo EK, McGregor AJ. Inclusion of Sex and Gender in Emergency Medicine Research-A 2018 Update. Acad Emerg Med 2019; 26:293-302. [PMID: 30637897 DOI: 10.1111/acem.13688] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/23/2018] [Accepted: 01/01/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The objectives were to 1) evaluate the inclusion of sex and gender in publications by emergency medicine (EM) researchers following the 2014 federal mandate and an Academic Emergency Medicine consensus conference on sex- and gender-based research and 2) assess trends compared with 2011 status report that showed 29% studies used sex and gender in the study design and 2% reported it as a primary outcome. METHODS Using MEDLINE, the term "emergency" was used to identify all English-language studies of adult humans published between 2014 and 2017 as EM affiliated (i.e., the first, second, or last author belonged to an EM section, division, center, or institution functioning as emergency department). Four trained abstractors reviewed the data using a standardized data abstraction form. RESULTS The search revealed 6,442 articles using the selected "emergency" terms, and 2,628 original studies coded as EM-affiliated publications were reviewed, 2,340 met inclusion criteria, and 2,336 were analyzed. This compared to 750 articles reviewed in 2011 using similar search strategy. The adjusted inter-rater reliability for data abstraction was 97% (95% confidence interval [CI] = 95.4%-98.6%]. The leading study areas contributing the most articles were cardiovascular (17.5%), administration/crowding (15.8%), infectious diseases (9.2%), trauma/injury (9.2%), emergency medical services (6.1%), and pulmonary (6.1%). Eighty-six percent (n = 1,921) reported the sex/gender composition of the sample and 0.4% (n = 8) reported transgender identity. Thirty-four percent used sex/gender in the study design, with 27% (n = 609) reporting it as a control variable, 24% (n = 543) as an independent variable, and 2% using sex/gender as primary outcome. Studies funded by federal sources were significantly more likely to include sex/gender in the study design than other sources of funding (odds ratio = 1.77; 95% CI = 1.4-2.2). CONCLUSIONS Compared to 2011, we noted an increase in the number of EM scholarship and use of sex and gender in study design, yet the proportion evaluating it as a primary outcome remained unchanged.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine Yale School of Medicine New Haven CT
| | | | - Syed Shayan Ali
- Department of Emergency Medicine Yale School of Medicine New Haven CT
| | - Benjamin J. Seifer
- Department of Emergency and Hospital Medicine University of South Florida MCOM LV Campus Allentown PA
| | - Michelle Hong
- Department of Emergency and Hospital Medicine University of South Florida MCOM LV Campus Allentown PA
| | - Marna Rayl Greenberg
- Department of Emergency and Hospital Medicine University of South Florida MCOM LV Campus Allentown PA
| | | | - Alyson J. McGregor
- Department of Emergency Medicine Alpert Medical School of Brown University Providence RI
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10
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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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11
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Murthy VL, Bateman TM, Beanlands RS, Berman DS, Borges-Neto S, Chareonthaitawee P, Cerqueira MD, deKemp RA, DePuey EG, Dilsizian V, Dorbala S, Ficaro EP, Garcia EV, Gewirtz H, Heller GV, Lewin HC, Malhotra S, Mann A, Ruddy TD, Schindler TH, Schwartz RG, Slomka PJ, Soman P, Di Carli MF, Einstein A, Russell R, Corbett JR. Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC. J Nucl Cardiol 2018; 25:269-297. [PMID: 29243073 DOI: 10.1007/s12350-017-1110-x] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Venkatesh L Murthy
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | | | - Rob S Beanlands
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Salvador Borges-Neto
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Duke University School of Medicine, Duke University Health System, Durham, NC, USA
| | | | | | - Robert A deKemp
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - E Gordon DePuey
- Division of Nuclear Medicine, Department of Radiology, Mt. Sinai St. Luke's and Mt. Sinai West Hospitals, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward P Ficaro
- Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Henry Gewirtz
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gary V Heller
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | | | - Saurabh Malhotra
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | - Terrence D Ruddy
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Thomas H Schindler
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, and Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Prem Soman
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Raymond Russell
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James R Corbett
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, and Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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12
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Murthy VL, Bateman TM, Beanlands RS, Berman DS, Borges-Neto S, Chareonthaitawee P, Cerqueira MD, deKemp RA, DePuey EG, Dilsizian V, Dorbala S, Ficaro EP, Garcia EV, Gewirtz H, Heller GV, Lewin HC, Malhotra S, Mann A, Ruddy TD, Schindler TH, Schwartz RG, Slomka PJ, Soman P, Di Carli MF. Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC. J Nucl Med 2017; 59:273-293. [PMID: 29242396 DOI: 10.2967/jnumed.117.201368] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/11/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Venkatesh L Murthy
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Rob S Beanlands
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Salvador Borges-Neto
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Duke University School of Medicine, Duke University Health System, Durham, North Carolina
| | | | | | - Robert A deKemp
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - E Gordon DePuey
- Division of Nuclear Medicine, Department of Radiology, Mt. Sinai St. Luke's and Mt. Sinai West Hospitals, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward P Ficaro
- Division of Nuclear Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Henry Gewirtz
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gary V Heller
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | | | - Saurabh Malhotra
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - April Mann
- Hartford Hospital, Hartford, Connecticut
| | - Terrence D Ruddy
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thomas H Schindler
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, and Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York; and
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Prem Soman
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, Massachusetts
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13
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Leclercq F. [Cardiovascular disease in women in 2017]. REVUE DE L'INFIRMIÈRE 2017; 66:16-19. [PMID: 28865690 DOI: 10.1016/j.revinf.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
From an anatomical, physiological and clinical point of view, cardiovascular diseases in women are specific. Long considered as being less exposed to these risks, women are nevertheless victims of coronary disease, which remains, in developed countries, the leading cause of death in women. The situation is all the more concerning given that the number of young women presenting risk factors is constantly rising. Encouraging female patients to become players in their health care with regard to this pathology is especially important given that effective treatments exist which can improve the prognosis.
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Affiliation(s)
- Florence Leclercq
- Département de cardiologie, CHU de Montpellier, 371 avenue du Doyen Gaston-Giraud, 34090 Montpellier, France.
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14
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Lau ES, Sarma A. Utility of Imaging in Risk Stratification of Chest Pain in Women. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:72. [PMID: 28782082 DOI: 10.1007/s11936-017-0568-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OPINION STATEMENT Recent decades have seen a growing recognition that the understanding of sex differences in cardiovascular disease (CVD) is vital to optimal diagnosis and management, particularly of women (Mosca et al. Circulation 124:2145-54, 2011). There is simultaneously an increasing appreciation of the multifactorial nature of ischemic heart disease (IHD) in many patients, in whom disease may extend beyond the epicardial coronaries. While obstructive coronary artery disease (CAD) remains underdiagnosed in women and still represents a major burden of disease, women also present with nonobstructive CAD more commonly than men (Patel et al. N Engl J Med 362:886-95, 2010). Indeed, microvascular dysfunction, coronary artery vasospasm, and coronary dissections contribute to a larger proportion of IHD in women than men (Bairey Merz et al. J Am Coll Cardiol 47:S21-9, 2006). Here, we review the symptom presentation of women with IHD and the noninvasive modalities used to risk stratify women with suspected IHD.
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Affiliation(s)
- Emily S Lau
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Amy Sarma
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
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15
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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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16
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Abstract
OPINION STATEMENT Despite continued advances in the field, cardiovascular disease remains the leading cause of death in women in the USA with an annual mortality rate that has remained higher for women as compared to men. The factors leading to this sex difference remain incompletely understood. Likely contributors include atypical symptoms at presentation and lack of recognition of cardiovascular risk by women and their providers alike. In addition, women have a higher burden of comorbidities at the time of disease diagnosis and can have differential pathophysiological mechanisms of their acute events. Women also can develop unique cardiovascular risk factors such as preeclampsia and hypertensive disorders of pregnancy. As a result, when women present with symptoms, even atypical, healthcare providers should increase their index level of suspicion for cardiovascular disease. Even after diagnosis, women are less likely to receive guideline-directed medical therapies and be referred for coronary angiography or cardiac rehabilitation. Thus, greater awareness of and research into the aspects of coronary disease that remain unique to women is critical, as women presenting with coronary disease continue to receive disparate care as compared to men. Improvements in awareness and care and new research avenues may reduce the incidence and complications of cardiovascular disease among women.
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17
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Tailor TD, Kicska GA, Jacobs JE, Pampaloni MH, Litmanovich DE, Reddy GP. Imaging of Heart Disease in Women. Radiology 2017; 282:34-53. [DOI: 10.1148/radiol.2016151643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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18
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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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19
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McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, Fletcher GF, Gulati M, Mehta LS, Pettey C, Reckelhoff JF. Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association. Circulation 2016; 133:1302-31. [PMID: 26927362 PMCID: PMC5154387 DOI: 10.1161/cir.0000000000000381] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Mieres JH, Gulati M, Bairey Merz N, Berman DS, Gerber TC, Hayes SN, Kramer CM, Min JK, Newby LK, Nixon JVI, Srichai MB, Pellikka PA, Redberg RF, Wenger NK, Shaw LJ. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350-79. [PMID: 25047587 DOI: 10.1161/cir.0000000000000061] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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21
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Santos MTH, Parker MW, Heller GV. Evaluating gender differences in prognosis following SPECT myocardial perfusion imaging among patients with diabetes and known or suspected coronary disease in the modern era. J Nucl Cardiol 2013; 20:1021-9. [PMID: 23963598 DOI: 10.1007/s12350-013-9771-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 08/02/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous data suggested that diabetic women were at greater risk for future cardiac events than diabetic men. Increasing awareness of coronary artery disease (CAD) in women and advances in the management of CAD may have changed this paradigm. OBJECTIVE To investigate gender differences in prognosis among patients with diabetes who were clinically referred for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). METHODS Patients with diabetes undergoing SPECT-MPI from 1996 to 2006 were followed for 5 years or until cardiac death or non-fatal myocardial infarction. Clinical characteristics and nuclear parameters were compared with χ (2) and t tests. Multivariable Cox regression controlled for baseline differences and tested the impact of gender on survival. RESULTS A total of 4,628 SPECT-MPI patients with diabetes (50% women, mean age 63 ± 12 years) were analyzed. There were 380 events, with rates higher in men (10% vs 7%, P < .001). Patients of either gender with abnormal scans had higher event rates than patients with normal scans. There were fewer cardiac events in diabetic females with no known CAD and normal scans compared to similar males (P = .044). However, diabetic males and females with known CAD had similar event rates for all degrees of perfusion abnormalities. Only age, history of heart failure, nuclear perfusion defect, and LVEF predicted survival; gender did not. LVEF ≤ 50% had the strongest association with cardiac events (hazard ratio = 2.518, 95% confidence interval, 1.922-3.298). CONCLUSION Cardiovascular outcomes among patients with diabetes, regardless of a history of CAD, were similar in women and men. The size and severity of stress-induced perfusion abnormalities predicted outcomes equally in both genders.
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Affiliation(s)
- Maria Theresa H Santos
- Division of Cardiology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA,
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22
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Shaw LJ, Tandon S, Rosen S, Mieres JH. Evaluation of suspected ischemic heart disease in symptomatic women. Can J Cardiol 2013; 30:729-37. [PMID: 24582723 DOI: 10.1016/j.cjca.2013.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/20/2013] [Accepted: 09/22/2013] [Indexed: 01/22/2023] Open
Abstract
There is a wealth of evidence about the role of a variety of diagnostic testing modalities to define coronary artery disease (CAD) risk in women presenting for evaluation of suspected myocardial ischemia. The exercise electrocardiogram (ECG) is the core index procedure, which can define risk in women capable of performing maximal exercise. Stress imaging, using echocardiography or myocardial perfusion single-photon emission computed tomography/positron emission tomography, is useful for symptomatic women with an abnormal resting ECG or for those who are functionally disabled. For women with low-risk stress imaging findings, there is a very low risk of CAD events, usually < 1%. There is a gradient relationship between the extent and severity of inducible abnormalities and CAD event risk. Women at high risk are those defined as having moderate to severely abnormal wall motion or abnormal perfusion imaging findings. In addition to stress imaging, the evidence of the relationship between CAD extent and severity and prognosis has been clearly defined with coronary computed tomographic angiography. In women, prognosis for those with mild but nonobstructive CAD is higher when compared with those without any CAD. The current evidence base clearly supports that women presenting with chest pain can benefit from one of the commonly applied diagnostic testing modalities.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia, USA.
| | | | - Stacey Rosen
- North Shore Long Island Jewish Hospital, Manhasset, New York, USA
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23
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Vaccarino V, Badimon L, Corti R, de Wit C, Dorobantu M, Manfrini O, Koller A, Pries A, Cenko E, Bugiardini R. Presentation, management, and outcomes of ischaemic heart disease in women. Nat Rev Cardiol 2013; 10:508-18. [PMID: 23817188 PMCID: PMC10878732 DOI: 10.1038/nrcardio.2013.93] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.
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Affiliation(s)
- Viola Vaccarino
- Emory University Rollins School of Public Health and School of Medicine, USA
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24
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Matheus ASDM, Gomes MB. Early aggressive macrovascular disease and type 1 diabetes mellitus without chronic complications: a case report. BMC Res Notes 2013; 6:222. [PMID: 23742649 PMCID: PMC3681711 DOI: 10.1186/1756-0500-6-222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 04/24/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Type 1 diabetes (T1DM) is considered to be one of the most significant risk factors for the development of coronary artery disease (CAD). However, the specific risk predictor models for T1DM are subject to many limitations. CASE PRESENTATION We report the case of a 42-year-old Caucasian woman presenting with T1DM for 26 years. During her chronic hyperglycemic evolution (mean of HbA1c > 3 percentage points above the superior limit) without microvascular complications, this patient presented with early and aggressive coronary artery disease, despite the lack of classical risk factors for CAD CONCLUSIONS: The rapidly progressive macrovascular disease observed in this case demonstrates the different degrees of aggressiveness and unpredictable clinical evolution observed in some cases. It also confirms the need for a multi-factorial, early and optimized clinical management regime.
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25
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McPherson JA, Davis K, Yau M, Beineke P, Rosenberg S, Monane M, Fredi JL. The clinical utility of gene expression testing on the diagnostic evaluation of patients presenting to the cardiologist with symptoms of suspected obstructive coronary artery disease: results from the IMPACT (Investigation of a Molecular Personalized Coronary Gene Expression Test on Cardiology Practice Pattern) trial. Crit Pathw Cardiol 2013; 12:37-42. [PMID: 23680805 DOI: 10.1097/hpc.0b013e3182822bd0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Accurate, noninvasive evaluation for obstructive coronary artery disease (CAD) remains challenging and inefficient. In this study, 171 patients presenting with stable chest pain and related symptoms without a history of CAD were referred to 6 cardiologists for evaluation. In the prospective cohort of 88 patients, the cardiologist's diagnostic strategy was evaluated before and after gene expression score (GES) testing. The GES is a validated, quantitative blood-based diagnostic test measuring peripheral blood cell expression levels of 23 genes to determine the likelihood of obstructive CAD (at least 1 vessel with ≥ 50% angiographic coronary artery stenosis). The objective of the study was to measure the effect of the GES on diagnostic testing using a pre/post study design. There were 83 prospective patients evaluable for study analysis, which included 57 (69%) women, mean age 53 ± 11 years, and mean GES 12.5 ± 9. Presenting symptoms were classified as typical angina, atypical angina, and noncardiac chest pain in 33%, 60%, and 7% of patients (n = 27, 50, and 6), respectively. After GES, changes in diagnostic testing occurred in 58% of patients (n = 48, P < 0.001). Of note, 91% (29/32) of patients with decreased testing had low GES (≤ 15), whereas 100% (16/16) of patients with increased testing had elevated GES (P < 0.001). A historical cohort of 83 patients, matched to the prospective cohort by clinical factors, had higher diagnostic test use compared with the post-GES prospective cohort (P < 0.001). In summary, the GES showed clinical utility in the evaluation of patients with suspected obstructive CAD presenting to the cardiologist's office.
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Affiliation(s)
- John A McPherson
- Vanderbilt University, MCE, South Tower, Nashville, TN 37232, USA.
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26
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Gender differences in the evaluation of coronary artery disease with a cadmium-zinc telluride camera. Eur J Nucl Med Mol Imaging 2013; 40:1542-8. [PMID: 23703458 DOI: 10.1007/s00259-013-2449-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Coronary artery disease remains one of the most significant causes of morbidity and mortality among women. The published literature shows the importance of standard single photon emission computed tomography in the evaluation of women with known or suspected ischaemic heart disease, in terms of target intervention and clinical treatment. The purpose of the present study was to ascertain the diagnostic accuracy of cadmium-zinc-telluride (CZT) myocardial perfusion imaging according to gender, within a prospective database of patients with known or suspected coronary artery disease, using coronary angiography as the reference standard. METHODS Included in the study were 309 consecutive patients, of whom 248 were men (80 %), with known or suspected coronary artery disease and who had been referred to our laboratory for stress-rest myocardial perfusion imaging. All patients underwent coronary angiography within 30 days. All patients underwent a single-day stress-rest low-dose ultrafast protocol. Fifteen minutes after the end of the stress (dose range 185 to 222 MBq of (99m)Tc-tetrofosmin), all patients underwent the first scan with an acquisition time of 7 min. The rest scan (dose range 370 to 444 MBq of (99m)Tc-tetrofosmin) was acquired from 30 min to 45 min after injection, with an acquisition time of 6 min. Images were visually inspected, and summed stress scores (SSS) and summed rest scores (SRS) were obtained. RESULTS Image quality was graded "good" or better in more than 90 % of patients. On coronary angiography, left main trunk stenosis, left anterior descending artery stenosis, left circumflex artery stenosis and right coronary artery stenosis were seen in 3, 155 , 142 and 131 patients, respectively. In women, the mean SSS and SRS were 8 ± 5 and 3 ± 1, respectively. Semiquantitative regional and global SSS were good discriminants of coronary artery disease, and the overall area under the receiver operator characteristic (ROC) curve was 0.822 (95 % CI 0.685 - 0.959). The value was comparable to that obtained in men (overall ROC area 0.884, 95 % CI 0.836 - 0.933). CONCLUSION A low-dose protocol with a CZT camera can be routinely used in women with known or suspected coronary artery disease without loss of accuracy and with lower radiation exposure of the patients.
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27
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Abstract
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.
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28
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Iskandar A, Limone B, Parker MW, Perugini A, Kim H, Jones C, Calamari B, Coleman CI, Heller GV. Gender differences in the diagnostic accuracy of SPECT myocardial perfusion imaging: a bivariate meta-analysis. J Nucl Cardiol 2013; 20:53-63. [PMID: 23149886 DOI: 10.1007/s12350-012-9646-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 10/19/2012] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Aline Iskandar
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA.
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Edwards ML. The enigma of heart disease in women: New insights may precipitate diagnosis and improve patient outcomes. ACTA ACUST UNITED AC 2012; 24:574-8. [DOI: 10.1111/j.1745-7599.2012.00773.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Vavas E, Hong SN, Henry S, Rosen SE, Mieres JH. Imaging Tests, Provocative Tests, Including Exercise Testing in Women with Suspected Coronary Artery Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2012; 6:469-478. [PMID: 23002416 PMCID: PMC3433655 DOI: 10.1007/s12170-012-0251-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Eleni Vavas
- Department of Cardiology, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Manhasset, NY 11030 USA
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Vavas E, Hong SN, Rosen SE, Mieres JH. Noninvasive diagnostic techniques for coronary disease in women. Clin Cardiol 2012; 35:149-55. [PMID: 22389118 DOI: 10.1002/clc.21953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Eleni Vavas
- Department of Cardiology, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA.
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Fathala A, Al Amer A, Shukri M, Abouzied MM, Alsugair A. The relationship between coronary artery calcification and myocardial perfusion in asymptomatic women. Ann Saudi Med 2012; 32:378-83. [PMID: 22705608 PMCID: PMC6081006 DOI: 10.5144/0256-4947.2012.378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES No data are available in Saudi Arabia on the relationship between coronary artery calcification (CAC) and myocardial perfusion scintigraphy (MPS) in asymptomatic women, for determining subclinical coronary artery disease (CAD). The main objective of this study was to investigate the relationship between the presence of CAC and stress-induced myocardial ischemia by MPS in asymptomatic women. DESIGN AND SETTING Single-center retrospective study over a 2-year period. METHODS One hundred and one women (mean [SD] age, 56 [11] years) without known CAD underwent both MPS and CAC scanning within 3 months. The frequency of ischemia by MPS was compared with the presence or absence of CAC and the number of CAD risk factors. RESULTS The prevalence of ischemic MPS was 22% (22/101). Among the 22 patients with ischemic MPS, the CAC score was 0 in 5 patients of 22 (23%), 1 to 200 in 4 patients of 22 (18%), and more than 200 in 13 patients of 22 (59%) (P=.0001). In contrast, among the 79 patients with normal MPS, the CAC score was 0 in 44 of 79 (56%) patients, 1 to 200 in 25 of 79 (32%), and more than 200 in 10 of 79 (13%). The presence or absence of CAC was the single most important predictor of the MPS result (P=.0001). CONCLUSIONS Moderate to severe CAC is associated with ischemic MPS in more than 50% of asymptomatic women with 2 or more CAD risk factors. Abnormal MPS is rarely associated with a 0 CAC score. Normal MPS does not exclude subclinical CAD. Therefore, CAC screening is an appropriate initial screening test for CAD in asymptomatic women.
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Affiliation(s)
- Ahmed Fathala
- Imaging Service, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Abstract
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.
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Affiliation(s)
- Lawrence M Phillips
- Department of Medicine, New York University School of Medicine-Langone Medical Center, New York, NY 10016, USA
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Affiliation(s)
- Priya Kohli
- Department of Medicine (Cardiology), Northwestern University, Evanston, IL, USA
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Doyle M, Weinberg N, Pohost GM, Bairey Merz CN, Shaw LJ, Sopko G, Fuisz A, Rogers WJ, Walsh EG, Johnson BD, Sharaf BL, Pepine CJ, Mankad S, Reis SE, Vido DA, Rayarao G, Bittner V, Tauxe L, Olson MB, Kelsey SF, Biederman RWW. Prognostic value of global MR myocardial perfusion imaging in women with suspected myocardial ischemia and no obstructive coronary disease: results from the NHLBI-sponsored WISE (Women's Ischemia Syndrome Evaluation) study. JACC Cardiovasc Imaging 2010; 3:1030-6. [PMID: 20947048 PMCID: PMC3278772 DOI: 10.1016/j.jcmg.2010.07.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the prognostic value of global magnetic resonance (MR) myocardial perfusion imaging (MPI) in women with suspected myocardial ischemia and no obstructive (stenosis <50%) coronary artery disease (CAD). BACKGROUND The prognostic value of global MR-MPI in women without obstructive CAD remains unknown. METHODS Women (n = 100, mean age 57 ± 11 years, age range 31 to 76 years), with symptoms of myocardial ischemia and with no obstructive CAD, as assessed by coronary angiography, underwent MR-MPI and standard functional assessment. During follow-up (34 ± 16 months), time to first adverse event (death, myocardial infarction, or hospitalization for worsening anginal symptoms) was analyzed using global MPI and left ventricular ejection fraction (EF) data. RESULTS Adverse events occurred in 23 (23%) women. Using univariable Cox proportional hazards regression modeling, variables found to be predictive of adverse events were global MR-MPI average uptake slope (p < 0.05), the ratio of MR-MPI peak signal amplitude to uptake slope (p < 0.05), and EF (p < 0.05). Two multivariable Cox models were formed, 1 using variables that were performance site dependent: ratio of MR-MPI peak amplitude to uptake slope together with EF (chi square: 13, p < 0.005); and a model using variables that were performance site independent: MR-MPI slope and EF (chi square: 12, p < 0.005). Each of the 2 multivariable models remained predictive of adverse events after adjustment for age, disease history, and Framingham risk score. For each of the Cox models, patients were categorized as high risk if they were in the upper quartile of the model and as not high risk otherwise. Kaplan-Meier analysis of time to event was performed for high risk versus not high risk for site-dependent (log rank: 15.2, p < 0.001) and site-independent (log rank: 13.0, p < 001) models. CONCLUSIONS Among women with suspected myocardial ischemia and no obstructive CAD, MR-MPI-determined global measurements of normalized uptake slope and peak signal uptake, together with global functional assessment of EF, appear to predict prognosis.
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Affiliation(s)
- Mark Doyle
- Division of Cardiology, CV MRI Center, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212-4772, USA.
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Kones R. Recent advances in the management of chronic stable angina I: approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities. Vasc Health Risk Manag 2010; 6:635-56. [PMID: 20730020 PMCID: PMC2922325 DOI: 10.2147/vhrm.s7564] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Indexed: 01/28/2023] Open
Abstract
The potential importance of both prevention and personal responsibility in controlling heart disease, the leading cause of death in the USA and elsewhere, has attracted renewed attention. Coronary artery disease is preventable, using relatively simple and inexpensive lifestyle changes. The inexorable rise in the prevalence of obesity, diabetes, dyslipidemia, and hypertension, often in the risk cluster known as the metabolic syndrome, drives the ever-increasing incidence of heart disease. Population-wide improvements in personal health habits appear to be a fundamental, evidence based public health measure, yet numerous barriers prevent implementation. A common symptom in patients with coronary artery disease, classical angina refers to the typical chest pressure or discomfort that results when myocardial oxygen demand rises and coronary blood flow is reduced by fixed, atherosclerotic, obstructive lesions. Different forms of angina and diagnosis, with a short description of the significance of pain and silent ischemia, are discussed in this review. The well accepted concept of myocardial oxygen imbalance in the genesis of angina is presented with new data about clinical pathology of stable angina and acute coronary syndromes. The roles of stress electrocardiography and stress myocardial perfusion scintigraphic imaging are reviewed, along with the information these tests provide about risk and prognosis. Finally, the current status of gender disparities in heart disease is summarized. Enhanced risk stratification and identification of patients in whom procedures will meaningfully change management is an ongoing quest. Current guidelines emphasize efficient triage of patients with suspected coronary artery disease. Many experts believe the predictive value of current decision protocols for coronary artery disease still needs improvement in order to optimize outcomes, yet avoid unnecessary coronary angiograms and radiation exposure. Coronary angiography remains the gold standard in the diagnosis of coronary artery obstructive disease. Part II of this two part series will address anti-ischemic therapies, new agents, cardiovascular risk reduction, options to treat refractory angina, and revascularization.
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Affiliation(s)
- Richard Kones
- The Cardiometabolic Research Institute, Houston, Texas 77054, USA.
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Mastouri R, Sawada SG, Mahenthiran J. Current noninvasive imaging techniques for detection of coronary artery disease. Expert Rev Cardiovasc Ther 2010; 8:77-91. [PMID: 20030023 DOI: 10.1586/erc.09.164] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The development and widespread use of noninvasive imaging techniques have contributed to the improvement in evaluation of patients with known or suspected coronary artery disease. Stress echocardiography and single-photon computed tomography are well-established noninvasive techniques with a proven track record for the diagnosis of coronary atherosclerosis. These modalities are generally widely available and provide a relatively high sensitivity and specificity along with an incremental value over clinical risk factors for detection of coronary artery disease. PET has a high diagnostic performance but continues to have limited clinical use because of the high expense of the dedicated equipment and difficulties in obtaining adequate radionuclides. Cardiac MRI and multislice computed tomography constitute the most recent addition to the cardiac imaging armamentarium. Cardiac MRI offers a comprehensive cardiac evaluation, which includes wall-motion analysis, myocardial tissue morphology, rest and stress first-pass myocardial perfusion, as well as ventricular systolic function. Cardiac computed tomography allows coronary calcium scanning along with noninvasive anatomic assessment of the coronary tree. It can be combined with functional imaging to provide a complete evaluation of the presence and physiological significance of the atherosclerotic coronary disease. No single imaging modality has been proven to be superior overall. Available tests all have advantages and drawbacks, and none can be considered suitable for all patients. The choice of the imaging method should be tailored to each person based on the clinical judgment of the a priori risk of cardiac event, clinical history and local expertise.
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Affiliation(s)
- Ronald Mastouri
- Indiana University, Indianapolis, 1801 North Senate Boulevard, IN 46202, USA
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Leclercq F. La maladie coronaire de la femme est-elle particulière ? Presse Med 2010; 39:242-8. [DOI: 10.1016/j.lpm.2009.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 07/15/2009] [Indexed: 11/28/2022] Open
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Solutions for disparities for women with heart disease. J Cardiovasc Transl Res 2009; 2:518-25. [PMID: 20560011 DOI: 10.1007/s12265-009-9125-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 09/08/2009] [Indexed: 10/20/2022]
Abstract
Cardiovascular disease (CVD) mortality and morbidity is a major burden on the US and global population. Observed differences in prevalence, incidence, outcomes, and risk factors suggest a possible sex difference in etiology and pathophysiology of CVD. Disparate rates of referral and diagnosis may be attributable to differences in symptoms, presentation, and diagnostic accuracy. Many common procedural, pharmaceutical, and medical device therapies have been associated with worse outcomes in women compared to men. Awareness campaigns and efforts to improve female inclusion in clinical trials are contributing to improvements in CVD healthcare delivery for women, but much remains unknown about the biological basis for the differences described above, such as the role of estrogen, life-cycle changes (puberty, menstrual cycle, pregnancy, menopause), and possible chromosomal or genetic mechanisms. This is where translational research is uniquely poised to make immense contributions to resolving disparities in the quality of care and outcomes for women with CVD.
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Transitory Myocardial Ischemia in Patients with Vascular Lower Limb Amputation. Am J Phys Med Rehabil 2009; 88:114-8. [PMID: 19169177 DOI: 10.1097/phm.0b013e3181951c98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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America YGCJ, Bax JJ, Boersma E, Stokkel M, van der Wall EE. The additive prognostic value of perfusion and functional data assessed by quantitative gated SPECT in women. J Nucl Cardiol 2009; 16:10-9. [PMID: 19152124 DOI: 10.1007/s12350-008-9012-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 07/15/2008] [Accepted: 07/31/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to assess the prognostic value of technetium-99m tetrofosmin gated SPECT imaging in women using quantitative gated single photon emission computed tomography (SPECT) imaging. METHODS We followed 453 consecutive female patients. Average follow-up was 1.33 years (max. 2.55). Hard endpoints were cardiac death, acute myocardial infarction, or documented ventricular fibrillation. Event-free survival curves were obtained. Optimal cutoff values for left ventricular (LV) volumes, LV ejection fraction (LVEF), and perfusion data to predict outcome were determined by ROC curve analysis. RESULTS A total of 236 patients had an abnormal study, of whom 27 patients experienced hard events (16 deaths) and 47 patients soft events. For hard events summed stress score (SSS) and LVEF, and for any cardiac event SSS showed independent incremental prognostic value. The survival curves were maximally separated when using cutoff values for SSS of > or = 22 and LVEF < 52% (P < 0.001, HR 4.61 and P < 0.001 HR 5.24 for SSS and LVEF resp.), and SSS > or = 14 (P < 0.001 HR 3.76) for any cardiac event. CONCLUSION In women, perfusion and functional parameters derived from quantitative gated technetium-99m tetrofosmin SPECT imaging can adequately be used for cardiac risk assessment. Using quantitative gated SPECT, female patients with an LVEF < 52% or an SSS > or = 22 are at increased risk for subsequent hard events. Furthermore, patients with an SSS > or = 14 are at increased risk for any cardiac events.
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Affiliation(s)
- Yves G C J America
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Berger JS, Bairey-Merz CN, Redberg RF, Douglas PS. Improving the quality of care for women with cardiovascular disease: report of a DCRI Think Tank, March 8 to 9, 2007. Am Heart J 2008; 156:816-25, 825.e1. [PMID: 19061693 DOI: 10.1016/j.ahj.2008.06.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 06/13/2008] [Indexed: 12/25/2022]
Abstract
BACKGROUND Differences in pathophysiology, diagnosis, and treatment of women with cardiovascular disease compared with men has become a major focus during the past decade. Nevertheless, little attention has focused on improving the quality of healthcare in women compared with other areas of cardiovascular medicine. METHODS To address this deficit, Duke University Medical Center convened a national Duke Clinical Research Institute (DCRI) Think Tank meeting, including basic science and clinical researchers, payers, legislators, clinical experts, government regulators, and members of the pharmaceutical and device industries. This report provides an overview of the discussions and proposed solutions. RESULTS Discussion concentrated on the development of strategies to improve the quality of health care for women with heart disease. Key components to improve quality care include: (1) enhance the quantity and quality of evidence-based medicine to guide care in women through improvements in trial design, enrollment and retention of women subjects, results analysis and reporting, and better incentives to perform research in women; (2) provide incentives to develop better data in women through mandating changes in the drug and device development and approval processes; (3) incorporate specific recommendations for women into guidelines when data are sufficient; and (4) apply proven sex-based differences in risk stratification, diagnostic testing, and drug usage and dosing in clinical care. Examples of possible strategies are included. CONCLUSION The above approach represents a necessary, but not sufficient, platform to improve the overall quality of healthcare in women with cardiovascular disease.
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Hsieh MC, Tien KJ, Chang SJ, Perng DS, Hsiao JY, Chen YW, Chang YH, Kuo HW, Lin PC. High-sensitivity C-reactive protein and silent myocardial ischemia in Chinese with type 2 diabetes mellitus. Metabolism 2008; 57:1533-8. [PMID: 18940390 DOI: 10.1016/j.metabol.2008.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 06/11/2008] [Indexed: 12/13/2022]
Abstract
Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients with type 2 diabetes mellitus. When diabetes exists in patients with established CAD, absolute risk for future events is very high. Diabetic patients often have severe, yet asymptomatic, CAD. Although high-sensitivity C-reactive protein (hsCRP) is a strong independent risk factor for cardiovascular events, there is an unclear association between it and silent myocardial ischemia in diabetic patients. In this study, we assess the relationship between hsCRP and silent myocardial ischemia in Chinese with type 2 diabetes mellitus. We designed a cross-sectional study with 225 asymptomatic diabetic patients having no known CAD. Ischemia was assessed by myocardial perfusion imaging. A total of 109 patients (48.4%) was found to have silent myocardial ischemia. Logistic regression analysis revealed age (odds ratio = 4.01, P = .002) (95% confidence interval, 1.98-7.44) and hsCRP (odds ratio = 2.58, P = .005) (95% confidence interval, 1.33-5.01) to be associated with greater risk of silent myocardial ischemia. Using the American Diabetes Association screening guidelines to evaluate risk, we found silent myocardial ischemia to be equally distributed between diabetic patients with 2 or more cardiac risk factors and those with less than 2 risk factors. Twenty-seven (24.8%) patients with silent myocardial ischemia were missed when the American Diabetes Association guidelines were used alone. High-sensitivity C-reactive protein was associated with silent myocardial ischemia in our study. High-sensitivity C-reactive protein might help detect silent myocardial ischemia in diabetic Chinese who may need aggressive treatment to reduce future CAD morbidity and mortality in Taiwan.
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Affiliation(s)
- Ming-Chia Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University/Chung-Ho Memorial Hospital, 80756 Kaohsiung, Taiwan.
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Stress Test: A Primer for Primary Care Physicians. South Med J 2008; 101:806-14. [DOI: 10.1097/smj.0b013e31817b07c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smanio P. [Cardiovascular disease in diabetic women without cardiac symptoms]. ACTA ACUST UNITED AC 2008; 51:305-11. [PMID: 17505639 DOI: 10.1590/s0004-27302007000200021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 01/08/2007] [Indexed: 11/22/2022]
Abstract
Cardiovascular disease is the main cause of cardiac death among diabetic patients. The myocardial ischemia is frequently asymptomatic, leading to late diagnosis and making prognosis worse. This is particularly true for women, for whom this diagnostic is possibility often disregarded. Appropriate screening can modify the coronary artery disease risk. The early diagnosis is highly beneficial, particularly regarding females. The decision of which non-invasive diagnostic method should be used in the initial evaluation is difficult. There are several diagnostic methods to make the preliminary investigation of coronary artery disease in diabetic women even without cardiac symptoms, but there is still no consensus about who should be investigated and when should the first cardiac evaluation start. The prevalence of the disease, as well as the cardiac risk, must be known in order to justify a broad survey, mainly in the female population.
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Affiliation(s)
- Paola Smanio
- Medicina Nuclear do Instituto Dante Pazzanese de Cardiologia, and Grupo de Cardiologia do Laboratório Fleury, São Paulo, Brazil.
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Dewey M, Rutsch W, Hamm B. Is there a gender difference in noninvasive coronary imaging? Multislice computed tomography for noninvasive detection of coronary stenoses. BMC Cardiovasc Disord 2008; 8:2. [PMID: 18230167 PMCID: PMC2268658 DOI: 10.1186/1471-2261-8-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 01/29/2008] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Multislice computed tomography (MSCT) coronary angiography is the foremost alternative to invasive coronary angiography. METHODS We sought to compare the diagnostic accuracy of MSCT in female and male patients with suspected coronary disease. Altogether 50 women and 95 men underwent MSCT with 0.5 mm detector collimation. Coronary artery stenoses of at least 50% on conventional coronary angiography were considered significant. RESULTS The coronary vessel diameters of all four main coronary artery branches were significantly larger in men than in women. The diagnostic accuracy of MSCT in identifying patients with coronary artery disease was significantly lower for women (72%) compared with men (89%, p < 0.05). Also sensitivity (70% vs. 95%), positive predictive value (64% vs. 93%), and the rate of nondiagnostic examinations (14% vs. 4%, all: p < 0.05) were significantly worse for women. The effective radiation dose of MSCT coronary angiography was significantly higher in the examination of women (13.7 +/- 1.2 mSv) than of men (11.7 +/- 0.9 mSv, p < 0.001), mainly as a result of the fact that the radiosensitive female breast (contributing 24.5% of the dose in women) is in the x-ray path. CONCLUSION Noninvasive coronary angiography with MSCT might be less accurate and sensitive for women than men. Also, women are exposed to a significantly higher effective radiation dose than men.
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Affiliation(s)
- Marc Dewey
- Department of Radiology, Charité, Medical School, Humboldt-Universität zu Berlin, Germany
| | - Wolfgang Rutsch
- Department of Cardiology, Charité, Medical School, Humboldt-Universität zu Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité, Medical School, Humboldt-Universität zu Berlin, Germany
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Abstract
Cardiovascular disease (CVD) is the primary cause of death among women worldwide. In the United States, more women than men die of CVD every year. Research has shown that there are important sex differences in terms of prevention, diagnosis, treatment, and outcomes in patients with CVD. Although women are being included in clinical trials in increasing numbers, lack of knowledge about sex differences persists because sex-specific analysis and reporting of sex-specific results remains limited. This knowledge gap limits the ability of health care professionals to provide optimal care for both women and men. Ongoing support and encouragement is needed for both the inclusion of sufficient numbers of women in clinical trials and for the reporting of sex-specific results of CVD trials. This increased knowledge and awareness can then be used to optimize high quality care for men and women.
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