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Wentzel JJ, Bos D, White SJ, van der Heiden K, Kavousi M, Evans PC. Sex-related differences in coronary and carotid vessel geometry, plaque composition and shear stress obtained from imaging. Atherosclerosis 2024; 395:117616. [PMID: 38944895 DOI: 10.1016/j.atherosclerosis.2024.117616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/27/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024]
Abstract
Atherosclerosis manifests itself differently in men and women with respect to plaque initiation, progression and plaque composition. The observed delay in plaque progression in women is thought to be related to the hormonal status of women. Also features associated with the vulnerability of plaques to rupture seem to be less frequently present in women compared to men. Current invasive and non-invasive imaging modalities allow for visualization of plaque size, composition and high risk vulnerable plaque features. Moreover, image based modeling gives access to local shear stress and shear stress-related plaque growth. In this review, current knowledge on sex-related differences in plaque size, composition, high risk plaque features and shear stress related plaque growth in carotid and coronary arteries obtained from imaging are summarized.
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Affiliation(s)
- J J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, the Netherlands.
| | - D Bos
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - S J White
- Biosciences Institute, Newcastle University, UK
| | - K van der Heiden
- Department of Cardiology, Biomedical Engineering, Erasmus MC, the Netherlands
| | - M Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - P C Evans
- Centre for Biochemical Pharmacology, William Harvey Research Institute, Barts and The London, Faculty of Medicine and Dentistry, Queen Mary University of London, UK
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2
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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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3
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Olic JJ, Baessler A, Fischer M. [Chest pain and cardiovascular diseases in women : Diagnostics and treatment]. Herz 2023; 48:487-498. [PMID: 37930367 DOI: 10.1007/s00059-023-05215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 11/07/2023]
Abstract
Cardiovascular diseases (CVD) are the leading cause of global mortality not only in men but also in women. The incidence of CVD significantly increases in women, especially after the menopause. Sex and gender differences in the incidence, prevalence and mortality of CVD are due to hormonal, anatomical, and sociocultural differences. As part of the primary and secondary prevention of coronary heart disease (CHD), risk factors specific for women, such as autoimmune diseases and pregnancy-associated diseases (e.g., gestational diabetes and pre-eclampsia) should also be taken into account in addition to the classical cardiovascular risk factors. Furthermore, in women with angina pectoris it should be considered that women in particular frequently suffer from ischemia with nonobstructive coronary arteries (INOCA) that can be caused, for example, by coronary microvascular dysfunction (CMD) or coronary spasms. Based on this, the diagnostics should not be terminated in symptomatic women after coronary angiography with normal epicardial vessels. A targeted diagnostics for CMD and coronary spasms should be carried out at an early stage.
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Affiliation(s)
- Janet-Jacqueline Olic
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Andrea Baessler
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Marcus Fischer
- Caritas-Krankenhaus St. Lukas, Traubenweg 3, 93309, Kelheim, Deutschland
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4
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Kim HL, Kim MA. Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen'S chest pain rEgistry (KoROSE). Korean Circ J 2023; 53:655-676. [PMID: 37880830 PMCID: PMC10625849 DOI: 10.4070/kcj.2023.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 10/27/2023] Open
Abstract
Interest in sex differences in coronary artery disease (CAD) has been steadily increasing. Concurrently, most of the data on these differences have primarily been Western-oriented. The KoRean wOmen'S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men's. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Myung-A Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.
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5
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Vijayalakshmi IB, Nemani L, Kher M, Kumar A. The Gamut of Coronary Artery Disease in Indian Women. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2023. [DOI: 10.25259/mm_ijcdw_404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Coronary artery disease is the leading cause of death among women. Majority of women suffering from CAD have one or more risk factors for CAD in their parents. Women are at higher risk for cardiac events with respect to traditional risk factors including dyslipidemia, hypertension, diabetes, and smoking. Menopause, pregnancy complications, inflammation, anemia, migraines, and depression are important sex-specific novel risk factors for CVD, and it is important that clinicians should be aware of these risks to design strategies for prevention. Education, self-awareness in women, and timely recognition of CAD in women with lifestyle modifications and timely intervention result in better outcomes.
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Affiliation(s)
- I. B. Vijayalakshmi
- Department of Pediatric Cardiology, Super Specialty Hospital (Pradhana Mantri Swasthya Suraksha Yojana), Bengaluru Medical College and Research Institute, Bengaluru, Karnataka, India,
| | - Lalita Nemani
- Department of Cardiology, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, India,
| | - Monica Kher
- Department of Cardiology, Aster Hospital, Doha, Qatar,
| | - Achukatla Kumar
- Department of Health Research, ICMR, Port Blair, Andaman and Nicobar Islands, India,
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6
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Reynolds HR, Diaz A, Cyr DD, Shaw LJ, Mancini GBJ, Leipsic J, Budoff MJ, Min JK, Hague CJ, Berman DS, Chaitman BR, Picard MH, Hayes SW, Scherrer-Crosbie M, Kwong RY, Lopes RD, Senior R, Dwivedi SK, Miller TD, Chow BJW, de Silva R, Stone GW, Boden WE, Bangalore S, O'Brien SM, Hochman JS, Maron DJ. Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial. JACC Cardiovasc Imaging 2023; 16:63-74. [PMID: 36115814 PMCID: PMC9878463 DOI: 10.1016/j.jcmg.2022.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/10/2022] [Accepted: 06/23/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown. OBJECTIVES The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA. METHODS Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia. RESULTS Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]). CONCLUSIONS Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated with severity of nonobstructive atherosclerosis. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Harmony R Reynolds
- New York University Grossman School of Medicine, New York, New York, USA.
| | - Ariel Diaz
- CIUSSS-MCQ, University of Montreal, Campus Mauricie, Trois-Rivieres, Quebec, Canada
| | - Derek D Cyr
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Leslee J Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | - G B John Mancini
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Cameron J Hague
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Bernard R Chaitman
- St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis, Missouri, USA
| | - Michael H Picard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sean W Hayes
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | | | | | | | | | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Judith S Hochman
- New York University Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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7
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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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8
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Mikail N, Rossi A, Bengs S, Haider A, Stähli BE, Portmann A, Imperiale A, Treyer V, Meisel A, Pazhenkottil AP, Messerli M, Regitz-Zagrosek V, Kaufmann PA, Buechel RR, Gebhard C. Imaging of heart disease in women: review and case presentation. Eur J Nucl Med Mol Imaging 2022; 50:130-159. [PMID: 35974185 PMCID: PMC9668806 DOI: 10.1007/s00259-022-05914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Although major diagnostic and therapeutic advances have significantly improved the prognosis of patients with CVD in the past decades, these advances have less benefited women than age-matched men. Noninvasive cardiac imaging plays a key role in the diagnosis of CVD. Despite shared imaging features and strategies between both sexes, there are critical sex disparities that warrant careful consideration, related to the selection of the most suited imaging techniques, to technical limitations, and to specific diseases that are overrepresented in the female population. Taking these sex disparities into consideration holds promise to improve management and alleviate the burden of CVD in women. In this review, we summarize the specific features of cardiac imaging in four of the most common presentations of CVD in the female population including coronary artery disease, heart failure, pregnancy complications, and heart disease in oncology, thereby highlighting contemporary strengths and limitations. We further propose diagnostic algorithms tailored to women that might help in selecting the most appropriate imaging modality.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.,Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging - Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, Strasbourg, France.,Molecular Imaging - DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Vera Regitz-Zagrosek
- Charité, Universitätsmedizin, Berlin, Berlin, Germany.,University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland. .,Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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9
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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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10
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Ananthasubramaniam G, Ananthasubramaniam K. Stress Electrocardiography Testing in Coronary Artery Disease: Is It Time for Its Swan Song or To Redefine Its Role in the Modern Era ? Indian Heart J 2022; 74:81-85. [PMID: 35167825 PMCID: PMC9039687 DOI: 10.1016/j.ihj.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/27/2022] Open
Abstract
Stress electrocardiography (sECG) or treadmill stress testing is a well validated noninvasive diagnostic modality available to clinicians at low cost yet providing valuable functional data for coronary artery disease (CAD) diagnostic and prognostic evaluation. With the advances in cardiac imaging in both functional and anatomic fronts and the existing limitations of sECG testing, this modality appears less favored worldwide as reflected in some recent guideline updates. We review the past present and future of sECG to provide a viewpoint on where it stands in CAD evaluation and if it will remain relevant as a diagnostic modality or be retired going forward. We also provide our perspectives on how sECG can co-exist with other modalities such as calcium scoring and discuss the role of such testing in the Indian population.
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11
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Prabakaran S, Vitter S, Lundberg G. Cardiovascular Disease in Women Update: Ischemia, Diagnostic Testing, and Menopause Hormone Therapy. Endocr Pract 2021; 28:199-203. [PMID: 34974184 DOI: 10.1016/j.eprac.2021.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/13/2021] [Accepted: 10/28/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This update will address 3 areas specifically that are essential to improving cardiovascular outcomes for women. METHODS The current literature has been reviewed and three important areas of cardiovascular care in women are highlighted. First is that even though women and men share many traditional risk factors for ischemic heart disease, several of these risk factors affect women disproportionately when it comes to CVD risk and events. There are also unique sex-specific risk factors for women and risk factors that are more common in women than in men. Adverse outcomes of pregnancy and hypertensive disorders of pregnancy are associated with an increased long-term risk of CVD and events. At menopause, cardiovascular risks increase, and lipids become unfavorable. Second is that diagnostic testing for ischemic heart disease presents different specificities and sensitivities between men and women and testing should be determined according to what is best and safest for women. Third is that currently, menopause hormone therapy is approved by the U.S. Food and Drug Administration for the treatment of vasomotor and genitourinary symptoms, prevention of osteoporosis, and estrogen replacement in the setting of surgical menopause, hypogonadism, or premature ovarian insufficiency. It is not recommended for the primary or secondary prevention of CVD and not recommended for women with high atherosclerotic CVD risk. RESULTS Cardiovascular disease (CVD) remains the most common cause of death in women in the United States despite tremendous improvements in cardiovascular care for men and women. The prevention of CVD in women with early detection and implementation of preventive therapies before atherosclerotic CVD develops is critical to improving outcomes for women.
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Affiliation(s)
- Sindhu Prabakaran
- Emory University School of Medicine, Department of Medicine, Atlanta, Georgia
| | - Sophie Vitter
- Emory University School of Medicine, Department of Medicine, Atlanta, Georgia
| | - Gina Lundberg
- Emory University School of Medicine, Department of Medicine, Atlanta, Georgia; Emory Heart and Vascular, Emory Women's Heart Center, Atlanta, Georgia.
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12
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Butaish Z, Alajmi M, Elahi A, Bafaraj SM. Evaluation of Cardiac Scan in Diagnosing Coronary-artery Disease. Curr Med Imaging 2021; 16:1022-1028. [PMID: 32473003 DOI: 10.2174/1573405616666200530211415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND With the evaluation of focal epicardial coronary stenosis and non-obstructive atherosclerosis, the cardiac scans play a significant role in diagnosing coronary artery disease (CAD). Moreover, the advancements in the imaging techniques leading to improved risk assessment and timely therapies help in early diagnosis of CAD with greater accuracy. AIMS To evaluate the role of cardiac scan in diagnosing CAD. METHODS Recruited 100 individuals without any history of CAD that refers to the assessment of suspected angina, conducted the prospective study. Electrocardiogram (ECG) findings assisted in the evaluation of left bundle branch blockage, abnormalities of ST-segment, and pathological Q waves. RESULTS The results depicted negative N.M findings among 38 respondents; whereas, ischemia and myocardial infarctions were diagnosed in 26% and 19% of the respondents, respectively. The majority of the males (59) were positive in contrast to 37 females with positive results. Similarly, 24 respondents were presented with mild dilated left atria (LA), 37 respondents suffered from impaired relaxation pattern of left ventricular (LV) diastolic filling; while, 40 of the respondents had normal global LV systolic function. CONCLUSION The study results have concluded that non-invasive, low-risk, and cost-effective technique like ECG is an important beneficial advancement in the diagnosis of CAD.
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Affiliation(s)
- Zubaida Butaish
- Diagnostic Radiology Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Masheal Alajmi
- Diagnostic Radiology Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Arouba Elahi
- Diagnostic Radiology Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Saeed M Bafaraj
- Diagnostic Radiology Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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13
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Garg K, Patel TR, Kanwal A, Villines TC, Aggarwal NR, Nasir K, Blumenthal RS, Blaha MJ, Douglas PS, Shaw LJ, Sharma G. The evolving role of coronary computed tomography in understanding sex differences in coronary atherosclerosis. J Cardiovasc Comput Tomogr 2021; 16:138-149. [PMID: 34654676 DOI: 10.1016/j.jcct.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
Our understanding of sex differences in subclinical atherosclerosis and plaque composition and characteristics have greatly improved with the use of coronary computed tomography (CCTA) over the past years. CCTA has emerged as an important frontline diagnostic test for women, especially as we continue to understand the impact of non-obstructive atherosclerosis as well as diffuse, high risk plaque as precursors of acute cardiac events in women. Based on its ability to identify complex plaque morphology such as low attenuation plaque, high risk non calcified plaque, positive remodeling, fibrous cap, CCTA can be used to assess plaque characteristics. CCTA can avoid false positive of other imaging studies, if included earlier in assessment of ischemic symptoms. In the contemporary clinical setting, CCTA will prove useful in further understanding and managing cardiovascular disease in women and those without traditional obstructive coronary disease.
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Affiliation(s)
- Keva Garg
- Division of Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Toral R Patel
- Department of Cardiovascular Disease, University of Virginia, Charlottesville, VA, USA
| | - Arjun Kanwal
- Medstar Union Memorial Hospital, Baltimore, MD, USA
| | - Todd C Villines
- Department of Cardiovascular Disease, University of Virginia, Charlottesville, VA, USA
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Khurram Nasir
- Center for Outcomes Research, Division of Cardiology, Houston Methodist, Houston, TX, USA
| | - Roger S Blumenthal
- Division of Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Division of Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslee J Shaw
- Department of Population Health Science, Blavatnik Women's Health Research Institute, Mount Sinai School of Medicine, NY, USA
| | - Garima Sharma
- Division of Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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14
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Zhu M, Wang H, Li S, Liang X, Zhang M, Dai X, Zhang Y. Flexible Electrodes for In Vivo and In Vitro Electrophysiological Signal Recording. Adv Healthc Mater 2021; 10:e2100646. [PMID: 34050635 DOI: 10.1002/adhm.202100646] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/10/2021] [Indexed: 12/19/2022]
Abstract
A variety of electrophysiological signals (electrocardiography, electromyography, electroencephalography, etc.) are generated during the physiological activities of human bodies, which can be collected by electrodes and thus provide critical insights into health status or facilitate fundamental scientific research. The long-term stable and high-quality recording of electrophysiological signals is the premise for their further applications, leading to demands for flexible electrodes with similar mechanical modulus and minimized irritation to human bodies. This review summarizes the latest advances in flexible electrodes for the acquisition of various electrophysiological signals. First, the concept of electrophysiological signals and the characteristics of different subcategory signals are introduced. Second, the invasive and noninvasive methods are reviewed for electrophysiological signal recording with a highlight on the design of flexible electrodes, followed by a discussion on their material selection. Subsequently, the applications of the electrophysiological signal acquisition in pathological diagnosis and restoration of body functions are discussed, showing the advantages of flexible electrodes. Finally, the main challenges and opportunities in this field are discussed. It is believed that the further exploration of materials for flexible electrodes and the combination of multidisciplinary technologies will boost the applications of flexible electrodes for medical diagnosis and human-machine interface.
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Affiliation(s)
- Mengjia Zhu
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
| | - Huimin Wang
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
| | - Shuo Li
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
| | - Xiaoping Liang
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
| | - Mingchao Zhang
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
| | - Xiaochuan Dai
- Department of Biomedical Engineering School of Medicine Tsinghua University Beijing 100084 P. R. China
| | - Yingying Zhang
- Key Laboratory of Organic Optoelectronics and Molecular Engineering of the Ministry of Education Department of Chemistry Tsinghua University Beijing 100084 P. R. China
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15
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Turhan Caglar FN, Gok G, Oztimer G, Katkat F, Karakozak D, Oztas DM, Beyaz MO, Ugurlucan M. Addition of the duration of ST segment depression to Duke treadmill score for diagnostic accuracy of exercise electrocardiography to predict obstructive coronary artery disease. Acta Cardiol 2021; 77:494-500. [PMID: 34412552 DOI: 10.1080/00015385.2021.1964210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Exercise electrocardiography (EET) is a safe and cost-effective method to predict the presence, prognosis, and severity of coronary artery disease (CAD). Various score models have been developed to increase predictive power of EET. In this study, we aimed to evaluate whether adding ST depression duration could have an effect on increasing the value of Duke treadmill score (DTS) in predicting obstructive CAD. METHODS In this single centred, cross-sectional study, we evaluated a total of 258 patients who presented with a complaint of chest pain and undergone coronary angiogram in result of a positive EET. DTS was calculated for all the patients. The new score-revised DTS- was calculated by adding total ST depression time to classical DS parameters. We compared area under the curve (AUC) of DTS and revised DTS by Delongi method. RESULTS Mean age of the group was 58.43 ± 9.37, and 37.2% (n = 96) were female. Mean total ST-depression duration was 171.72 ± 91.43 msec in normal artery group,241.54 ± 118.11 msec in non-obstructive CAD group, and 281.26 ± 113.64 in obstructive CAD group.ST-depression duration in both exercise and recovery, and total ST depression duration were significantly higher in obstructive CAD group than non-obstructive and normal artery groups (p = 0.024, p = 0.01, p < 0.01, and p < 0.01, respectively). Revised DTS had significantly higher predictive value of obstructive CAD compared to classical DS (AUC (95%CI): 0.744 vs. 0.626, p < 0.001). The AUC of DS was significantly lower than the new score (z-score:3.274, p = 0.011). CONCLUSION In conclusion, adding ST depression duration to DTS calculation is increasing the discriminative value of DTS to predict obstructive CAD. Benefits of EET within the context of the management of CAD is well-known, hence, it is clear that physicians may use revised DTS.
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Affiliation(s)
| | - Gulay Gok
- Cardiology Department, Bakirkoy Medipol Hospital, Istanbul, Turkey
| | - Gulsum Oztimer
- Cardiology Department, Cerkezkoy State Hospital, Cerkezkoy, Turkey
| | - Fahrettin Katkat
- Cardiology Department, Bagcilar Education and Research Hospital, Istanbul, Turkey
| | - Dilay Karakozak
- Cardiology Department, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Didem Melis Oztas
- Cardiovascular Surgery Department, Bagcilar Education and Research Hospital, Istanbul, Turkey
| | - Metin Onur Beyaz
- Cardiovascular Surgery Department, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Murat Ugurlucan
- Cardiovascular Surgery Department, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
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16
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Arslan M, Schaap J, Moelker A, Rood PPM, Boersma E, Nieman K, Dubois EA, Dedic A. Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences. Neth Heart J 2021; 29:518-524. [PMID: 34357558 PMCID: PMC8455783 DOI: 10.1007/s12471-021-01607-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2021] [Indexed: 12/12/2022] Open
Abstract
Aim The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC). Methods In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC. Results Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008). Conclusion Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS. Supplementary Information The online version of this article (10.1007/s12471-021-01607-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Arslan
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - J Schaap
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - A Moelker
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - P P M Rood
- Department of Emergency Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - E Boersma
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - K Nieman
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Departments of Cardiovascular Medicine and Radiology, Stanford University School of Medicine and Cardiovascular Institute, Stanford, CA, USA
| | - E A Dubois
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A Dedic
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Associations between cardiorespiratory fitness, sex and long term mortality amongst adults undergoing exercise treadmill testing. Int J Cardiol 2021; 342:103-107. [PMID: 34363868 DOI: 10.1016/j.ijcard.2021.07.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/07/2021] [Accepted: 07/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiorespiratory fitness (CRF) varies with sex and is an independent predictor of mortality. We sought to investigate sex differences in the exercise protocol selected, CRF levels, and their relationships with long term all-cause mortality. METHODS In a 25-year stress testing registry spanning from 1991 to 2014, consecutive all-comer patients who underwent exercise stress testing at Cleveland Clinic were categorized by sex, stress protocol and imaging modality. All tests were conducted by one or more of stress test technicians, sonographers and nuclear medicine technologists, and interpreted by cardiologists. The primary outcome all-cause mortality was analyzed in using multivariable Cox regression. RESULTS In 120,705 patients, the mean age was 53.3 ± 12.5 years, and 41% were female. Females were more commonly referred for non-Bruce exercise protocols (modified Bruce, Cornell 0, 5 and 10, Naughton and modified Naughton) with odds ratio of 2.62; 95% confidence interval (95%CI) (2.54-2.70) after adjusting for age and comorbidities. When also adjusting for the protocol chosen, females achieved lower CRF with beta -1.40, 95% CI (-1.43, -1.37). There were 8426 (6.9%) deaths during a mean follow-up of 8.7 years. Both female sex and CRF were independently associated with lower all-cause mortality with hazards ratio (95%CI) of 0.44 (0.41-0.46) and 0.41 (0.39-0.42) respectively, after adjusting for age, co-morbidities and protocol chosen. CONCLUSIONS Women were more likely referred for less demanding exercise protocols, more imaging protocols and achieved lower CRF than men. Despite this, female sex was associated with significantly lower long term mortality for equivalent CRF level in adjusted analyses.
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Khandelwal A, Bakir M, Bezaire M, Costello B, Gomez JMD, Hoover V, Nazir NT, Nichols K, Reisenberg A, Rao A, Sanghani R, Tracy M, Volgman AS. Managing Ischemic Heart Disease in Women: Role of a Women's Heart Center. Curr Atheroscler Rep 2021; 23:56. [PMID: 34345945 PMCID: PMC8331213 DOI: 10.1007/s11883-021-00956-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Heart centers for women (HCW) were developed due to the rising cardiovascular morbidity and mortality in women in the United States in the early 1990s. Our review encompasses the epidemiology, risk factors, diagnostic strategies, treatments, and the role of HCW in managing women with ischemic heart disease (IHD). RECENT FINDINGS HCW use a multidisciplinary team to manage women with IHD. Due to the paucity of randomized controlled trials investigating various manifestations of IHD, some treatments are not evidence-based such as those for coronary microvascular dysfunction and spontaneous coronary artery dissection. Sex-specific risk factors have been identified and multimodality cardiac imaging is improving in diagnosing IHD in women. Treatments are being studied to help improve symptoms and outcomes in women with IHD. There has been progress in the care of women with IHD. HCW can be instrumental in treating women with IHD, doing research, and being a source of research study participants.
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Affiliation(s)
- Abha Khandelwal
- Division of Cardiology, Women's Heart Health, Stanford University, Palo Alto, CA, USA
| | - May Bakir
- Division of Cardiology, Women's Heart Health Center, Loyola University, Chicago, IL, USA
| | - Meghan Bezaire
- Rush Heart Center for Women, Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Briana Costello
- Center for Women's Heart & Vascular Health, Texas Heart Institute, and Baylor St. Luke's Medical Center Hospital, Houston, TX, USA
| | | | - Valerie Hoover
- Department of Psychology, Stanford University, Palo Alto, CA, USA
| | - Noreen T Nazir
- Division of Cardiology, Department of Medicine, University of Illinois, Chicago, Chicago, USA
| | - Katherine Nichols
- Division of Cardiology, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Amy Reisenberg
- Stanford Healthcare, Stanford University, Palo Alto, CA, USA
| | - Anupama Rao
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Rupa Sanghani
- Rush Heart Center for Women, Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Melissa Tracy
- Rush Heart Center for Women, Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Annabelle Santos Volgman
- Rush Heart Center for Women, Division of Cardiology, Rush University Medical Center, Chicago, IL, USA. .,, Chicago, USA.
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Lindner IDA, Oliveira PSD, Bacca CDOF, Matsuda JB, Rocha FRD, Visentainer J, Bacca LE. Early Use of Handgrip Exercise Associated with Dobutamine Stress Echocardiography in Women. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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Desai S, Munshi A, Munshi D. Gender Bias in Cardiovascular Disease Prevention, Detection, and Management, with Specific Reference to Coronary Artery Disease. J Midlife Health 2021; 12:8-15. [PMID: 34188420 PMCID: PMC8189342 DOI: 10.4103/jmh.jmh_31_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/01/2021] [Accepted: 03/10/2021] [Indexed: 01/09/2023] Open
Abstract
Even though cardiovascular disease (CVD) kills more women than men each year and remains a leading cause of death in women, it is a common misconception that women are less likely to develop CVD. Considerable sex difference exists between men and women with regard to prevention, investigations, and management of CVD. Coronary artery disease (CAD) is a major contributor to CVD morbidity and mortality and hence is specifically addressed in this article. With an explosive increase in the incidence of conventional risk factors for coronary artery disease in India, there has been an alarming increase in women's coronary events as much as men. A false sense of gender-based protection by estrogen leads to less aggressive and late prevention or management strategies that contribute to women's CAD. Metabolic syndrome (MetS) is an important contributor to future development of CAD and is also an indicator for earlier interventions for prevention. Due to physical inactivity and central obesity, MetS is more prevalent in women, especially postmenopausal. With estrogen loss, menopause marks a critical cardiovascular biological transition, with a significantly increased CVD risk in women aged >55 years. Certain female-specific risk factors, such as history of polycystic ovarian syndrome, pregnancy-induced hypertension, and gestational diabetes, also seem to play an essential role in the development of CVD in later life. Certain vascular and biological factors, such as smaller coronary vessel size, higher prevalence of small vessel disease, and lesser development of collateral flow, also play an important role. This review article is an attempt to provide important information on gender differences in CVD with specific emphasis on CAD.
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Affiliation(s)
- Shailesh Desai
- Consulting Preventive Cardiologist, Above Star Bazaar, Satellite Road, Ahmedabad, India
| | - Atul Munshi
- Consulting Obstetrician and Gynecologist, Ahmedabad, India.,Ex- Prof. & HOD, OBGYN, GCS & NHL Medical College, Ahmedabad, Munshi Group of Hospitals 50, Pritamnagar Society, Ellisbridge, Ahmedabad, India
| | - Devangi Munshi
- Department of OBGYN, Ahmedabad Municipal Corporation MET Medical College, Ahmedabad, India
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Greco A, Capodanno D. Differences in coronary artery disease and outcomes of percutaneous coronary intervention with drug-eluting stents in women and men. Expert Rev Cardiovasc Ther 2021; 19:301-312. [PMID: 33706641 DOI: 10.1080/14779072.2021.1902806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite common perceptions, coronary artery disease (CAD) is not a male-specific condition, and sex-based differences do occur in many aspects, including clinical outcomes after percutaneous coronary intervention (PCI) with stent implantation. New-generation drug-eluting stents (DES) significantly improved post-PCI outcomes. However, no sex-specific guidelines on PCI and the use of DES are available as current evidence was derived from clinical trials enrolling predominantly male patients. AREAS COVERED This review aims at exploring sex-based disparities in CAD characteristics and manifestations, and comparing PCI outcomes and the efficacy and safety profiles of DES according to sex. In addition, a critical approach to trials' interpretation with an analysis of sources of bias is provided to inform future research and clinical practice. EXPERT OPINION Sex gap in clinical outcomes after PCI with DES implantation is narrowing due to improved performances of new-generation DES. However, scientific research and biomedical engineering are striving to optimize DES profiles and generate new iterations of devices. At the same time, gender initiatives and sex-specific trials are accruing to overcome current issues in the field. Advances in these areas will foster improvements in early and long-term clinical outcomes of both women and men.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - S. Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - S. Marco", University of Catania, Catania, Italy
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22
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Dzaye O, Dardari ZA, Cainzos-Achirica M, Blankstein R, Agatston AS, Duebgen M, Yeboah J, Szklo M, Budoff MJ, Lima JAC, Blumenthal RS, Nasir K, Blaha MJ. Warranty Period of a Calcium Score of Zero: Comprehensive Analysis From MESA. JACC Cardiovasc Imaging 2020; 14:990-1002. [PMID: 33129734 DOI: 10.1016/j.jcmg.2020.06.048] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study sought to quantify and model conversion of a normal coronary artery calcium (CAC) scan to an abnormal CAC scan. BACKGROUND Although the absence of CAC is associated with excellent prognosis, progression to CAC >0 confers increased risk. The time interval for repeated scanning remains poorly defined. METHODS This study included 3,116 participants from the MESA (Multi-Ethnic Study of Atherosclerosis) with baseline CAC = 0 and follow-up scans over 10 years after baseline. Prevalence of incident CAC, defined by thresholds of CAC >0, CAC >10, or CAC >100, was calculated and time to progression was derived from a Weibull parametric survival model. Warranty periods were modeled as a function of sex, race/ethnicity, cardiovascular risk, and desired yield of repeated CAC testing. Further analysis was performed of the proportion of coronary events occurring in participants with baseline CAC = 0 that preceded and followed repeated CAC testing at different time intervals. RESULTS Mean participants' age was 58 ± 9 years, with 63% women, and mean 10-year cardiovascular risk of 14%. Prevalence of CAC >0, CAC >10, and CAC >100 was 53%, 36%, and 8%, respectively, at 10 years. Using a 25% testing yield (number needed to scan [NNS] = 4), the estimated warranty period of CAC >0 varied from 3 to 7 years depending on sex and race/ethnicity. Approximately 15% of participants progressed to CAC >10 in 5 to 8 years, whereas 10-year progression to CAC >100 was rare. Presence of diabetes was associated with significantly shorter warranty period, whereas family history and smoking had small effects. A total of 19% of all 10-year coronary events occurred in CAC = 0 prior to performance of a subsequent scan at 3 to 5 years, whereas detection of new CAC >0 preceded 55% of future events and identified individuals at 3-fold higher risk of coronary events. CONCLUSIONS In a large population of individuals with baseline CAC = 0, study data provide a robust estimation of the CAC = 0 warranty period, considering progression to CAC >0, CAC >10, and CAC >100 and its impact on missed versus detectable 10-year coronary heart disease events. Beyond age, sex, race/ethnicity, diabetes also has a significant impact on the warranty period. The study suggests that evidence-based guidance would be to consider rescanning in 3 to 7 years depending on individual demographics and risk profile.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Radiology and Neuroradiology, Charité, Berlin, Germany
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur S Agatston
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Matthias Duebgen
- Department of Radiology and Neuroradiology, Charité, Berlin, Germany
| | - Joseph Yeboah
- Heart and Vascular Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Moyses Szklo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Matthew J Budoff
- Department of Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California, USA
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Relation between pharmacological stress ECG, 13NH3-PET/CT outcome and the occurrence of cardiac events during follow-up in women with chest pain. Nucl Med Commun 2020; 41:783-789. [DOI: 10.1097/mnm.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gurunathan S, Shanmuganathan M, Hampson R, Khattar R, Senior R. Role of adjuvant carotid ultrasound in women undergoing stress echocardiography for the assessment of suspected coronary artery disease. Open Heart 2020; 7:openhrt-2019-001188. [PMID: 32587105 PMCID: PMC7319702 DOI: 10.1136/openhrt-2019-001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/10/2020] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Objective Due to the low prevalence of obstructive coronary artery disease (CAD) in women, stress testing has a relatively low predictive value for this. Additionally, conventional cardiovascular risk scores underestimate risk in women. This study sought to evaluate the role of atherosclerosis assessment using carotid ultrasound (CU) in women attending for stress echocardiography (SE). Methods This was a prospective study in which consecutive women with recent-onset suspected angina, who were referred for clinically indicated SE, underwent CU. Results 415 women (mean age 61±10 years, 29% diabetes mellitus, mean body mass index 28) attending for SE underwent CU. 47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (carotid plaque in 41%, carotid intima-media thickness >75th percentile in 15%). Women with CD were older (65 vs 58 years, p<0.001), and more likely to have diabetes (41% vs 21%, p=0.001), hypertension (67% vs 36%, p<0.01) and a higher pretest probability of CAD (59% vs 41%, p<0.001). 40% of women classified as low Framingham risk were found to have evidence of CD. The positive predictive value of SE for flow-limiting CAD was 51%, but with the presence of carotid plaque, this was 71% (p<0.01). Carotid plaque (p=0.004) and ischaemia (p=0.01) were the only independent predictors of >70% angiographic stenosis. In women with ischaemia on SE and no carotid plaque, the negative predictive value for flow-limiting disease was 88%. During a follow-up of 1058±234 days, there were 15 events (defined as all-cause mortality, non-fatal myocardial infarction, heart failure admissions and late coronary revascularisation). Age (HR 1.07 (1.00–1.15), p=0.04), carotid plaque burden (HR 1.65 (1.36–2.00), p<0.001) and ischaemic burden (HR 1.41 (1.18–1.68), p<0.001) were associated with outcome. There was a stepwise increase in events/year from 0.3% when there were no ischaemia and atherosclerosis, 1.1% when there was atherosclerosis and no ischaemia, 2.2% when there was ischaemia and no atherosclerosis and 10% when there were both ischaemia and atherosclerosis (p<0.001). Conclusion CU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography, and improves risk stratification in women attending for SE, as well identifying a subset of women who may benefit from primary preventative measures.
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Affiliation(s)
- Sothinathan Gurunathan
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Mayooran Shanmuganathan
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | | | - Rajdeep Khattar
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Roxy Senior
- National Heart and Lung Institute, Imperial College London, London, UK .,Department of Cardiology, Northwick Park Hospital, Harrow, UK.,Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Current Advances in the Diagnostic Imaging of Atherosclerosis: Insights into the Pathophysiology of Vulnerable Plaque. Int J Mol Sci 2020; 21:ijms21082992. [PMID: 32340284 PMCID: PMC7216001 DOI: 10.3390/ijms21082992] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/02/2020] [Accepted: 04/15/2020] [Indexed: 12/13/2022] Open
Abstract
Atherosclerosis is a lipoprotein-driven inflammatory disorder leading to a plaque formation at specific sites of the arterial tree. After decades of slow progression, atherosclerotic plaque rupture and formation of thrombi are the major factors responsible for the development of acute coronary syndromes (ACSs). In this regard, the detection of high-risk (vulnerable) plaques is an ultimate goal in the management of atherosclerosis and cardiovascular diseases (CVDs). Vulnerable plaques have specific morphological features that make their detection possible, hence allowing for identification of high-risk patients and the tailoring of therapy. Plaque ruptures predominantly occur amongst lesions characterized as thin-cap fibroatheromas (TCFA). Plaques without a rupture, such as plaque erosions, are also thrombi-forming lesions on the most frequent pathological intimal thickening or fibroatheromas. Many attempts to comprehensively identify vulnerable plaque constituents with different invasive and non-invasive imaging technologies have been made. In this review, advantages and limitations of invasive and non-invasive imaging modalities currently available for the identification of plaque components and morphologic features associated with plaque vulnerability, as well as their clinical diagnostic and prognostic value, were discussed.
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The cardiovascular risk profile of middle age women previously diagnosed with premature ovarian insufficiency: A case-control study. PLoS One 2020; 15:e0229576. [PMID: 32134933 PMCID: PMC7058320 DOI: 10.1371/journal.pone.0229576] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 02/10/2020] [Indexed: 11/19/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of death in women worldwide. The cardiovascular risk profile deteriorates after women enter menopause. By definition, women diagnosed with premature ovarian insufficiency (POI) experience menopause before 40 years of age, which may render these women even more susceptible to develop CVD later in life. However, prospective long-term follow up data of well phenotyped women with POI are scarce. In the current study we compare the CVD profile and risk of middle aged women previously diagnosed with POI, to a population based reference group matched for age and BMI. Methods and findings We compared 123 women (age 49.0 (± 4.3) years) and diagnosed with POI 8.1 (IQR: 6.8–9.6) years earlier, with 123 population controls (age 49.4 (± 3.9) years). All women underwent an extensive standardized cardiovascular screening. We assessed CVD risk factors including waist circumference, BMI, blood pressure, lipid profile, pulse wave velocity (PWV), and the prevalence of diabetes mellitus, metabolic syndrome (MetS) and carotid intima media thickness (cIMT), in both women with POI and controls. We calculated the 10-year CVD Framingham Risk Score (FRS) and the American Heart Association’s suggested cardiovascular health score (CHS). Waist circumference (90.0 (IQR: 83.0–98.0) versus 80.7 (IQR: 75.1–86.8), p < 0.01), waist-to-hip ratio (0.90 (IQR: 0.85–0.93) versus 0.79 (IQR: 0.75–0.83), p < 0.01), systolic blood pressure (124 (IQR 112–135) versus 120 (IQR109-131), p < 0.04) and diastolic blood pressure (81 (IQR: 76–89) versus 78 (IQR: 71–86), p < 0.01), prevalence of hypertension (45 (37%) versus 21 (17%), p < 0.01) and MetS (19 (16%) versus 4 (3%), p < 0.01) were all significantly increased in women with POI compared to healthy controls. Other risk factors, however, such as lipids, glucose levels and prevalence of diabetes were similar comparing women with POI versus controls. The arterial stiffness assessed by PWV was also similar in both populations (8.1 (IQR: 7.1–9.4) versus 7.9 (IQR: 7.1–8.4), p = 0.21). In addition, cIMT was lower in women with POI compared to controls (550 μm (500–615) versus 684 μm (618–737), p < 0.01). The calculated 10-year CVD risk was 5.9% (IQR: 3.7–10.6) versus 6.0% (IQR: 3.9–9.0) (p = 0.31) and current CHS was 6.1 (1.9) versus 6.5 (1.6) (p = 0.07), respectively in POI versus controls. Conclusions Middle age women with POI presented with more unfavorable cardiovascular risk factors (increased waist circumference and a higher prevalence of hypertension and MetS) compared to age and BMI matched population controls. In contrast, the current study reveals a lower cIMT and similar 10-year cardiovascular disease risk and cardiovascular health score. In summary, neither signs of premature atherosclerosis nor a worse cardiovascular disease risk or health score were observed among middle age women with POI compared to population controls. Longer-term follow-up studies of women of more advanced age are warranted to establish whether women with POI are truly at increased risk of developing CVD events later in life. Trial registration ClinicalTrials.gov Identifier: NCT02616510.
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Norris CM, Yip CY, Nerenberg KA, Jaffer S, Grewal J, Levinsson AL, Mulvagh SL. Introducing the Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Diseases in Women. CJC Open 2020; 2:145-150. [PMID: 32462128 PMCID: PMC7242496 DOI: 10.1016/j.cjco.2020.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/02/2020] [Indexed: 12/12/2022] Open
Abstract
Despite a global understanding that indicators and outcomes of cardiovascular disease (CVD) are known to differ between men and women, uptake of the recognition of sex and gender influences on the clinical care of women has been slow or absent. The Canadian Women’s Heart Health Alliance (CWHHA) was established as a network of experts and advocates to develop and disseminate evidence-informed strategies to transform clinical practice and augment collaborative action on women’s cardiovascular health in Canada. As an initial project, the CWHHA membership undertook an environmental scan of CVD in women in Canada from which a scientific statement could be developed to summarize critical sex- and gender-specific issues in CVD. This comprehensive review of the evidence focused on the sex- and gender-specific differences in comorbidity, risk factors, disease awareness, presentation, diagnosis, and treatment across the entire spectrum of CVD. In the process of creating the review, it was recognized that the team of CWHHA experts had also assembled an expansive collection of original research articles that were synthesized into detailed chapters reporting on the present state of the evidence unique to each cardiovascular condition in women. This work comprises an “ATLAS” on the epidemiology, diagnosis, and management of CVD in women. The overall goal of the ATLAS is to create a living document that will help clinicians and the public recognize the unique aspects of women’s heart health care and provide policy makers with information they need to ensure equitable care for women with CVD.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Dr Colleen M. Norris, Faculty of Nursing, 3rd Floor ECHA, University of Alberta, Edmonton, Alberta T6G 1C9, Canada,. Tel.: +1-780-492-0784; fax: +1-780-492-2551.
| | - Cindy Y.Y. Yip
- Heart and Stroke Foundation of Canada, Toronto, Ontario, Canada
| | - Kara A. Nerenberg
- Department of Medicine/Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna L.E. Levinsson
- Montréal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Hasbek Z, Ertürk SA, Çakmakçılar A, Gül İ, Yılmaz A. Evaluation of Myocardial Perfusion Imaging SPECT Parameters and Pharmacologic Stress Test with Adenosine Versus Coronary Angiography Findings: Are They Diagnostically Concordant? Mol Imaging Radionucl Ther 2019; 28:53-61. [PMID: 31237135 PMCID: PMC6592312 DOI: 10.4274/mirt.galenos.2019.47450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives: In this study our first aim was to evaluate the diagnostic concordance of myocardial perfusion scintigraphy (MPS) by pharmacological stress test with adenosine (APST) with coronary angiography (CAG). The secondary aim of this study was to evaluate the correlation between CAG findings and automated analysis parameters such as left ventricular ejection fraction, summed stress score (SSS), summed rest score, summed difference score (SDS), stress MPS defect percentage ratio (extent) and transient ischemic dilation (TID) obtained by myocardial perfusion imaging single-photon emission computed tomography (SPECT). Methods: A total of 129 patients (62 male, 67 female, median age: 60.02) undergoing MPS due to suspicion of coronary ischemia who also underwent subsequent CAG in the last year were included in this study, their MPS data and CAG results were compared. Results: There was no statistically significant diagnostic concordance when visual evaluation of MPS, quantitative MPS parameters and exercise treadmill test (ETT) electrocardiography results were used alone. In fact, diagnostic concordance was higher when automated analysis parameters like TID, SSS and extent values were added to MPS SPECT visual analyses. There was diagnostic concordance in 57.9% of APST patients and 41.7% of ETT patients. There was diagnostic concordance in 75.8% of APST patients and 52.6% of ETT patients who were older than 65 years of age. Conclusion: In our study, we found that the use of APST during MPS increases diagnostic concordance with CAG. Therefore, we think that it would be appropriate to use APST in women and elderly patients with limited exercise habits. The CAG diagnostic mismatch is far above what it should be when MPS reporting is only done with visual data, and it is not supported by quantitative data such as TID, SSS, SDS and extent.
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Affiliation(s)
- Zekiye Hasbek
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - Seyit Ahmet Ertürk
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - Ali Çakmakçılar
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - İbrahim Gül
- Cumhuriyet University Faculty of Medicine, Department of Cardiology, Sivas, Turkey
| | - Ahmet Yılmaz
- Cumhuriyet University Faculty of Medicine, Department of Cardiology, Sivas, Turkey
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Accuracy of non-invasive stress testing in women and men with angina in the absence of obstructive coronary artery disease. Int J Cardiol 2019; 282:7-15. [DOI: 10.1016/j.ijcard.2018.10.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/17/2018] [Accepted: 10/22/2018] [Indexed: 12/19/2022]
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Malahfji M, Mahmarian JJ. Imaging to Stratify Coronary Artery Disease Risk in Asymptomatic Patients with Diabetes. Methodist Debakey Cardiovasc J 2019; 14:266-272. [PMID: 30788012 DOI: 10.14797/mdcj-14-4-266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. Patients with diabetes have a higher prevalence of CAD and a larger magnitude of ischemia, and they are more likely to have silent myocardial ischemia and myocardial infarction. However, recent large cohort studies demonstrate that diabetic patients are not a homogenous group with similar high risk for cardiac events. In fact, more than 30% of asymptomatic diabetic patients do not have evidence of coronary atherosclerosis and have a very low annual cardiac event rate. Accordingly, there has been a recent paradigm shift as to whether the detection of subclinical coronary atherosclerosis through imaging can best guide therapeutic decision making. This review discusses the role of various cardiac imaging techniques for stratifying cardiovascular risk and optimizing therapy in asymptomatic diabetic patients.
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ASEMPTOMATİK TİP 2 DİYABETES MELLİTUS TANILI HASTALARDA KORONER ARTERLERİN 64-DEDEKTÖRLÜ BİLGİSAYARLI TOMOGRAFİ İLE DEĞERLENDİRİLMESi. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/gopctd.419200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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High-Resolution Body Surface Potential Mapping in Exercise Assessment of Ischemic Heart Disease. Ann Biomed Eng 2019; 47:1300-1313. [PMID: 30790099 PMCID: PMC6454081 DOI: 10.1007/s10439-019-02231-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/13/2019] [Indexed: 11/01/2022]
Abstract
Standard 12-lead ECG exercise testing is commonly used for screening of ischemic heart disease (IHD). We studied if high-resolution body surface potential mapping (HR-BSPM) during exercise offers advantages over current standards in noninvasive evaluation of IHD. This study was carried out on 90 IHD patients and 33 healthy controls. The 67-lead HR-BSPM was recorded at rest and during exercise. Twenty-one ECG parameters including classical ST criteria were compared. The effectiveness of methods was verified based on the results of SPECT and coronary angiography. The most effective parameters in the diagnosis of IHD were: amplitude parameter ΔST60 and δT parameter showing T-wave morphology changes during exercise. The sensitivities/specificities of ΔST60 and δT parameters for the HR-BSPM were 70/69 and 59/62%, while for the standard 12-lead ECG system they were: 63/62 and 59/56%. These results demonstrate the usefulness of HR-BSPM measurements during exercise. HR-BSPM resulted in higher sensitivities and specificities compared to the standard 12-lead exercise test. The advantage was partially associated with observed ischemic changes outside standard precordial leads position that were not visible when using the standard 12-lead exercise test. This justifies research into the optimization of the number and position of ECG leads in exercise testing.
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Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis. Neth Heart J 2019; 27:272-280. [PMID: 30734147 PMCID: PMC6470243 DOI: 10.1007/s12471-019-1234-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Sex differences in the calculation of coronary heart disease risk have been analysed extensively. However, data on coronary plaque morphology diverge. We analysed plaque characteristics in patients with suspected coronary artery disease (CAD) and defined prognostic factors using coronary computed tomography angiography (CCTA). Methods A total of 6,050 consecutive patients underwent CCTA and were enrolled in the registry. Patients with known CAD were excluded. The patients were propensity score matched (1:1 male:female) for age and known coronary risk factors. Coronary arteries were evaluated for stenosis, plaque types (non-calcified, mixed and calcified) and high-risk plaque features (napkin-ring sign, low-attenuation plaque, spotty calcifications, positive remodelling). Clinical follow-up was performed. Results A total of 1,050 patients (525 female, 525 male) in matched cohorts were selected for analysis. CCTA showed significantly higher calcium scores for males (mean 180.5 vs 67.8 AU, p < 0.0001) and a higher rate of CAD (66.0% vs 34.1%, p < 0.0001). In a total of 16,800 segments, males had significantly more plaques (861 vs 752, p < 0.0001) with a significantly larger proportion of calcified plaques, while females had more mixed and non-calcified plaques (33.5% vs 24.4%, p = 0.006 and 24.1% vs 13.6%, p = 0.22, respectively). After a mean follow-up of 5.6 years, major adverse cardiac event (MACE) rate was 5.3% in male and 1.9% in female patients (p < 0.05). The relative odds ratio for high-risk plaque features to predict MACE was higher in females. Conclusion Based on a higher relative risk for women with high-risk plaque features, the findings of our study support the increased importance of a differentiated qualitative plaque analysis to improve the risk stratification for both sexes.
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Gul B, Lansky A, Budoff MJ, Sharp D, Maniet B, Herman L, Kuo JZ, Huang L, Monane M, Ladapo JA. The Clinical Utility of a Precision Medicine Blood Test Incorporating Age, Sex, and Gene Expression for Evaluating Women with Stable Symptoms Suggestive of Obstructive Coronary Artery Disease: Analysis from the PRESET Registry. J Womens Health (Larchmt) 2019; 28:728-735. [PMID: 30653377 PMCID: PMC6537117 DOI: 10.1089/jwh.2018.7203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Evaluating women with symptoms suggestive of coronary artery disease (CAD) remains challenging. A blood-based precision medicine test yielding an age/sex/gene expression score (ASGES) has shown clinical validity in the diagnosis of obstructive CAD. We assessed the effect of the ASGES on the management of women with suspected obstructive CAD in a community-based registry. Materials and Methods: The prospective PRESET (A Registry to Evaluate Patterns of Care Associated with the Use of Corus® CAD in Real World Clinical Care Settings) Registry (NCT01677156) enrolled 566 patients presenting with symptoms suggestive of stable obstructive CAD from 21 United States primary care practices from 2012 to 2014. Demographics, clinical characteristics, and referrals to cardiology or further functional and/or anatomical cardiac studies after ASGES testing were collected for this subgroup analysis of women from the PRESET Registry. Patients were followed for 1-year post-ASGES testing. Results: This study cohort included 288 women with a median age 57 years. The median body mass index was 29.2, with hyperlipidemia and hypertension present in 48% and 43% of patients, respectively. Median ASGES was 8.5 (range 1–40), with 218 (76%) patients having low (≤15) ASGES. Clinicians referred 9% (20/218) low ASGES versus 44% (31/70) elevated ASGES women for further cardiac evaluation (odds ratio 0.14, p < 0.0001, adjusted for patient demographics and clinical covariates). Across the score range, higher ASGES were associated with a higher likelihood of posttest cardiac referral. At 1-year follow-up, low ASGES women experienced fewer major adverse cardiac events than elevated ASGES women (1.3% vs. 4.2% respectively, p = 0.16). Conclusions: Incorporation of ASGES into the diagnostic workup demonstrated clinical utility by helping clinicians identify women less likely to benefit from further cardiac evaluation.
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Affiliation(s)
- Burcu Gul
- 1 Section of Cardiology, Yale University, New Haven, Connecticut
| | - Alexandra Lansky
- 1 Section of Cardiology, Yale University, New Haven, Connecticut
| | | | | | | | - Lee Herman
- 5 Johns Creek Primary Care, Suwanee, Georgia
| | - Jane Z Kuo
- 6 CardioDx, Inc., Redwood City, California
| | - Lin Huang
- 6 CardioDx, Inc., Redwood City, California
| | | | - Joseph A Ladapo
- 7 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
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Heart rate reserve during pharmacological stress is a significant negative predictor of impaired coronary flow reserve in women. Eur J Nucl Med Mol Imaging 2019; 46:1257-1267. [PMID: 30648200 DOI: 10.1007/s00259-019-4265-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/04/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Evidence to date has failed to adequately explore determinants of cardiovascular risk in women with coronary microvascular dysfunction (CMVD). Heart rate responses to adenosine mirror autonomic activity and may carry important prognostic information for the diagnosis of CMVD. METHODS Hemodynamic changes during adenosine stress were analyzed in a propensity-matched cohort of 404 patients (202 women, mean age 65.9 ± 11.0) who underwent clinically indicated myocardial perfusion 13N-ammonia Positron-Emission-Tomography (PET) at our institution between September 2013 and May 2017. RESULTS Baseline heart rate (HR) was significantly higher in patients with abnormal coronary flow reserve (CFR, p < 0.001 vs normal CFR). Accordingly, a blunted HR response to adenosine (=reduced heart rate reserve, %HRR) was seen in patients with abnormal CFR, with a most pronounced effect being observed in female patients free of myocardial ischemia (45.9 ± 34.9 vs 26.5 ± 18.0, p < 0.001 in women and 29.1 ± 16.9 vs 24.3 ± 21.7, p = 0.15 in men). Hence, a fully-adjusted multivariate logistic regression model identified HRR as the strongest negative predictor of reduced CFR in women free of myocardial ischemia, but not in men. Accordingly, receiver operating characteristics (ROC) curves for the presence of reduced CFR revealed that a %HRR <35 was a powerful predictor for abnormal CFR with a sensitivity of 81% and a specificity of 60% in women. CONCLUSION A blunted HRR <35% is associated with abnormal CFR in women. Taking into account HR responses during stress test in women may help to risk stratify the heterogeneous female population of patients with non-obstructive coronary artery disease (CAD).
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Coutinho RQ, Montarroyos UR, de Barros IML, Guimarães MJB, Costa LOBF, de Lima Medeiros AK, de Fátima Monteiro M, de Novaes Lima Ferreira M, Chalela WA, Pedrosa R. Non Electrocardiographic alterations in exercise testing in asymptomatic women. Associations with cardiovascular risk factors. Clinics (Sao Paulo) 2019; 74:e1005. [PMID: 31531567 PMCID: PMC6735271 DOI: 10.6061/clinics/2019/e1005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/24/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To estimate the prevalence of exercise testing alterations in middle-aged women without symptoms of heart disease and to verify the associations of functional capacity and heart rate behavior during and after exercise with cardiovascular risk factors. METHODS A cross-sectional study was conducted with 509 asymptomatic women aged between 46 and 65 years who underwent clinical evaluations and exercise testing (Bruce protocol). The heart rate behavior was evaluated by the maximal predicted heart rate achieved, chronotropic index and recovery heart rate. RESULTS The mean age was 56.4±4.8 years, and 13.4% of the patients had a Framingham risk score above 10%. In the exercise treadmill testing, 58.0% presented one or more of the following alterations (listed in order of ascending prevalence): symptoms (angina, dyspnea, and dizziness), ST-segment depression, arrhythmia, reduction in recovery heart rate of ≤12 bpm at 1 minute, altered maximal predicted heart rate achieved, abnormal blood pressure, functional capacity deficiency, and altered chronotropic index. In the multivariate analysis, the following associations (odds ratio) were observed for these alterations: chronotropic index was associated with obesity (2.08) and smoking (4.47); maximal predicted heart rate achieved was associated with smoking (6.45); reduction in the recovery heart rate at 1 minute was associated with age (1.09) and obesity (2.78); functional capacity was associated with age (0.92), an overweight status (2.29) and obesity (6.51). CONCLUSIONS More than half of middle-aged women without cardiovascular symptoms present alterations in one or more exercise testing parameters. Alterations in the functional capacity or heart rate behavior, as verified by exercise testing, are associated with age, smoking, an overweight status and obesity.
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Affiliation(s)
- Ricardo Quental Coutinho
- Faculdade de Ciencias Medicas, Universidade de Pernambuco, Recife, PE, BR
- Corresponding author. E-mail:
| | - Ulisses Ramos Montarroyos
- Programa de Doutorado em Ciencias da Saude, Instituto de Ciencias Biologicas, Faculdade de Ciencias Medicas, Universidade de Pernambuco, Recife, PE, BR
| | - Isly Maria Lucena de Barros
- Nucleo de Pos-Graduacao, Hospital Universitario Oswaldo Cruz, Universidade de Pernambuco, Recife, PE, BR
- Pronto Socorro Cardiologico de Pernambuco, Universidade de Pernambuco, Recife, PE, BR
| | | | | | | | | | - Moacir de Novaes Lima Ferreira
- Programa de Doutorado em Ciencias da Saude, Instituto de Ciencias Biologicas, Faculdade de Ciencias Medicas, Universidade de Pernambuco, Recife, PE, BR
| | - William Azem Chalela
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Pedrosa
- Programa de Doutorado em Ciencias da Saude, Instituto de Ciencias Biologicas, Faculdade de Ciencias Medicas, Universidade de Pernambuco, Recife, PE, BR
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Wada H, Miyauchi K, Daida H. Gender differences in the clinical features and outcomes of patients with coronary artery disease. Expert Rev Cardiovasc Ther 2018; 17:127-133. [PMID: 30569774 DOI: 10.1080/14779072.2019.1561277] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Women have been at a higher risk for adverse cardiac events following percutaneous coronary intervention (PCI), compared with men. Areas covered: In this review, authors discuss the gender differences that can affect the clinical outcomes after PCI and the important points that can be improved on. Expert commentary: Various factors, such as old age and higher prevalence of comorbidities, have been considered to account for the worse clinical outcomes of PCI in women than in men. In addition, men and women have different presentations of angina or acute coronary syndrome (ACS); atypical symptoms are more frequent in women. This variation of the clinical presentation in women likely contributes to the misdiagnosis or delayed recognition of ischemia, which may explain the worse clinical outcomes. In addition, compared with men, women are less likely to be referred for revascularization for coronary artery disease (CAD) and receive less of these guideline-recommended therapies. Recently, sex differences in cardiovascular events have decreased, especially among stable CAD patients, but sex differences in the clinical outcomes of ACS remain. Further evolution of treatment is expected to narrow these sex differences among patients with CAD and improve the clinical outcomes of both men and women.
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Affiliation(s)
- Hideki Wada
- a Department of Cardiology , Juntendo University Shizuoka Hospital , Izunokuni , Japan
| | - Katsumi Miyauchi
- b Department of Cardiovascular Medicine , Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Hiroyuki Daida
- b Department of Cardiovascular Medicine , Juntendo University Graduate School of Medicine , Tokyo , Japan
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Dippe T, Cunha CLPD, Cerci RJ, Stier AL, Vítola JV. Study of Myocardial Perfusion in Obese Individuals without Known Ischemic Heart Disease. Arq Bras Cardiol 2018; 112:121-128. [PMID: 30570066 PMCID: PMC6371823 DOI: 10.5935/abc.20180250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022] Open
Abstract
Background Obesity is associated with an increased risk of type 2 diabetes mellitus
(DM), ischemic heart disease (IHD) and cardiovascular mortality. Several
studies have demonstrated the diagnostic and prognostic value of single
photon computed tomography-myocardial perfusion scintigraphy (SPECT-MPI) in
the evaluation of patients with suspected IHD, including in obese
population. Data on clinical risk factors and their association with
abnormal myocardial perfusion in obese patients are scarce in the Brazilian
population. Objective To determine the factors associated with abnormal myocardial perfusion in
obese individuals without known IHD. Methods We studied obese patients without known IHD who were referred for evaluation
through SPECT-MPI between January 2011 and December 2016. Clinical variables
and results of SPECT-MPI were obtained systematically. The distribution of
continuous variables was assessed using the Shapiro-Wilk and Shapiro-Francia
tests. We used the unpaired Student t test to compare the means of
continuous variables with normal distribution and the Chi Square test for
binomial variables analysis. A p value < 0.05 was considered
statistically significant. The association of the clinical variables for the
presence of factors associated with abnormal myocardial perfusion was
determined by univariate and multivariate logistic regression analysis, and
respective odds ratios (OR) and 95% confidence intervals (CI). Results The study sample consisted of 5,526 obese patients. Mean body mass index
(BMI) of our patients was 33.9 ± 3.7 kg/m2, 31% had DM,
and myocardial perfusion abnormalities was observed in 23% of the total
sample. The factors associated with abnormal myocardial perfusion on
multivariate analysis were: age (OR: 1.02, 95% CI 1.01-1.03, p < 0.001),
DM (OR: 1.57, 95% CI 1.31-1.88, p < 0.001), typical angina before the
test (OR: 2.45, 95% CI: 1.82-3.31, p < 0.001), need for pharmacologic
stress test (OR: 1.61, 95% CI: 1.26-2.07, p < 0.001), less physical
effort evaluated in metabolic equivalents (METs) during the exercise
treadmill test (OR: 0.89, 95% CI: 0.85-0.94, p < 0.001) and a lower
post-stress left ventricular ejection fraction after stress (LVEF; OR:
0.989, 95% CI: 0.984-0.994, p < 0.001). Conclusion The factors associated with abnormal myocardial perfusion in obese patients
without known IHD were age, DM, presence of typical angina, ventricular
dysfunction, and inability to undergo physical stress as clinical variables,
in addition to functional capacity during physical stress.
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Affiliation(s)
- Tufi Dippe
- Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR - Brazil
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Marcadet DM, Pavy B, Bosser G, Claudot F, Corone S, Douard H, Iliou MC, Vergès-Patois B, Amedro P, Le Tourneau T, Cueff C, Avedian T, Solal AC, Carré F. French Society of Cardiology guidelines on exercise tests (part 2): Indications for exercise tests in cardiac diseases. Arch Cardiovasc Dis 2018; 112:56-66. [PMID: 30093255 DOI: 10.1016/j.acvd.2018.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subject's pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient.
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Affiliation(s)
| | - Bruno Pavy
- Cardiac Rehabilitation Department, Loire-Vendée-Océan Hospital, boulevard des Régents, BP2, 44270 Machecoul, France.
| | - Gilles Bosser
- Paediatric and Congenital Cardiology Department, M3C Regional Competences Centre, University Hospital, 54511 Vandoeuvre-les-Nancy, France; EA 3450, Development, Adaptation and Disadvantage, Faculty of Medicine, University of Lorraine, 54600 Villers-lès-Nancy, France
| | - Frédérique Claudot
- Platform for Clinical Research Assistance, University Hospital, 54511 Vandoeuvre-les-Nancy, France; EA 4360 APEMAC, Faculty of Medicine, University of Lorraine, 54600 Villers-lès-Nancy, France
| | - Sonia Corone
- Cardiac Rehabilitation Department, Bligny Medical Centre, 91640 Briis-sous-Forges, France
| | - Hervé Douard
- Cardiac Rehabilitation Department, Bordeaux University Hospital, 33604 Pessac, France
| | - Marie-Christine Iliou
- Cardiac Rehabilitation Department, Corentin-Celton Hospital, 92130 Issy-Les-Moulineaux, France
| | | | - Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Physiology and Experimental Biology of Heart and Muscles Laboratory, PHYMEDEXP, UMR CNRS 9214-Inserm U1046, University of Montpellier, 34295 Montpellier, France
| | - Thierry Le Tourneau
- Cardiology Functional Evaluation Department, University Hospital Laennec, 44800 Nantes, France
| | - Caroline Cueff
- Cardiology Functional Evaluation Department, University Hospital Laennec, 44800 Nantes, France
| | - Taniela Avedian
- Cardiac Rehabilitation Department, Turin Clinic, 75008 Paris, France
| | | | - François Carré
- Department of Sport Medicine, Pontchaillou Hospital, University of Rennes 1, Inserm 1099, 35043 Rennes, France
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40
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Maseroli E, Scavello I, Vignozzi L. Cardiometabolic Risk and Female Sexuality-Part II. Understanding (and Overcoming) Gender Differences: The Key Role of an Adequate Methodological Approach. Sex Med Rev 2018; 6:525-534. [PMID: 29661689 DOI: 10.1016/j.sxmr.2018.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/01/2018] [Accepted: 03/04/2018] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Although basic science and clinical research indicate that the vascular physiopathology of male and female sexual dysfunction (FSD) is similar, to date the association between FSD and cardiovascular (CV) diseases has been only marginally explored. AIM To discuss the potential reasons for differences in the role of CV diseases and risk factors in sexual function in women vs men in the 2nd part of a 2-part review. METHODS A thorough literature search of peer-reviewed publications on the topic was performed using the PubMed database. MAIN OUTCOME MEASURES We present a review of the main factors that could account for this gap: (i) actual physiologic discrepancies and (ii) factors related to the inadequacy of the methodologic approach used to investigate CV risk in patients with FSD. A summary of the available methods to assess female sexual response, focusing on genital vascularization, is reported. RESULTS The microanatomy and biochemistry of the male and female peripheral arousal response are similar; in contrast, there are differences in the interplay between the metabolic profile and sex steroid milieu, in the relative weighting of cardiometabolic risk factors in the pathogenesis of CV disease, and their clinical presentation and management. CV diseases in women are under-recognized, leading to less aggressive treatment strategies and poorer outcomes. Moreover, evaluation of hemodynamic events that regulate the female sexual response has thus far been plagued by methodologic problems. CONCLUSION To clarify whether sexuality can be a mirror for CV health in women, the female genital vascular district should be objectively assessed with standardized and validated methods. Studies designed to establish normative values and longitudinal intervention trials on the effect of the treatment of CV risk factors on FSD are urgently needed. Maseroli E, Scavello I, Vignozzi L. Cardiometabolic Risk and Female Sexuality-Part II. Understanding (and Overcoming) Gender Differences: The Key Role of an Adequate Methodological Approach. Sex Med Rev 2018;6:525-534.
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Affiliation(s)
- Elisa Maseroli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Irene Scavello
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Linda Vignozzi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy; Istituto Nazionale Biostrutture e Biosistemi, Rome, Italy.
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41
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Optimizing Risk Stratification and Noninvasive Diagnosis of Ischemic Heart Disease in Women. Can J Cardiol 2018; 34:400-412. [DOI: 10.1016/j.cjca.2018.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/09/2018] [Accepted: 01/17/2018] [Indexed: 01/17/2023] Open
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42
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Reynolds HR, Hausvater A, Carney K. Test Selection for Women with Suspected Stable Ischemic Heart Disease. J Womens Health (Larchmt) 2018; 27:867-874. [PMID: 29583082 DOI: 10.1089/jwh.2017.6587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.
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Affiliation(s)
- Harmony R Reynolds
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Anais Hausvater
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Kerrilynn Carney
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
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43
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Exámenes diagnósticos cardiovasculares: ¿diferencias de género en su interpretación? REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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44
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Regitz-Zagrosek V. Unsettled Issues and Future Directions for Research on Cardiovascular Diseases in Women. Korean Circ J 2018; 48:792-812. [PMID: 30146804 DOI: 10.4070/kcj.2018.0249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
Biological sex (being female or male) significantly influences the course of disease. This simple fact must be considered in all cardiovascular diagnosis and therapy. However, major gaps in knowledge about and awareness of cardiovascular disease in women still impede the implementation of sex-specific strategies. Among the gaps are a lack of understanding of the pathophysiology of women-biased coronary artery disease syndromes (spasms, dissections, Takotsubo syndrome), sex differences in cardiomyopathies and heart failure, a higher prevalence of cardiomyopathies with sarcomeric mutations in men, a higher prevalence of heart failure with preserved ejection fraction in women, and sex-specific disease mechanisms, as well as sex differences in sudden cardiac arrest and long QT syndrome. Basic research strategies must do more to include female-specific aspects of disease such as the genetic imbalance of 2 versus one X chromosome and the effects of sex hormones. Drug therapy in women also needs more attention. Furthermore, pregnancy-associated cardiovascular disease must be considered a potential risk factor in women, including pregnancy-related coronary artery dissection, preeclampsia, and peripartum cardiomyopathy. Finally, the sociocultural dimension of gender should be included in research efforts. The organization of gender medicine must be established as a cross-sectional discipline but also as a centered structure with its own research resources, methods, and questions.
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Affiliation(s)
- Vera Regitz-Zagrosek
- CHARITÉ Universitätsmedizin Berlin, Institute of Gender in Medicine and CCR, and DZHK (partner site Berlin), Berlin, Germany.
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45
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Healthcare Policy Statement on the Utility of Coronary Computed Tomography for Evaluation of Cardiovascular Conditions and Preventive Healthcare: From the Health Policy Working Group of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:404-414. [DOI: 10.1016/j.jcct.2017.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/14/2017] [Accepted: 08/14/2017] [Indexed: 12/14/2022]
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46
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Shaw LJ, Pepine CJ, Xie J, Mehta PK, Morris AA, Dickert NW, Ferdinand KC, Gulati M, Reynolds H, Hayes SN, Itchhaporia D, Mieres JH, Ofili E, Wenger NK, Bairey Merz CN. Quality and Equitable Health Care Gaps for Women: Attributions to Sex Differences in Cardiovascular Medicine. J Am Coll Cardiol 2017; 70:373-388. [PMID: 28705320 DOI: 10.1016/j.jacc.2017.05.051] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 12/20/2022]
Abstract
The present review synthesizes evidence and discusses issues related to health care quality and equity for women, including minority population subgroups. The principle of "sameness" or women and men receiving equitable, high-quality care is a near-term target, but optimal population health cannot be achieved without consideration of the unique, gendered structural determinants of health and the development of unique care pathways optimized for women. The aim of this review is to promote enhanced awareness, develop critical thinking in sex and gender science, and identify strategic pathways to improve the cardiovascular health of women. Delineation of the components of high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for or living with cardiovascular disease.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
| | | | - Joe Xie
- Emory University School of Medicine, Atlanta, Georgia
| | - Puja K Mehta
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Martha Gulati
- University of Arizona College of Medicine, Phoenix, Arizona
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47
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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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48
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Le TT, Huang W, Bryant JA, Cook SA, Chin CWL. Stress cardiovascular magnetic resonance imaging: current and future perspectives. Expert Rev Cardiovasc Ther 2017; 15:181-189. [DOI: 10.1080/14779072.2017.1296356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Thu-Thao Le
- Department of cardiovascular medicine, National Heart Centre Singapore, Singapore, Singapore
| | - Weiting Huang
- Department of cardiovascular medicine, National Heart Centre Singapore, Singapore, Singapore
| | - Jennifer Ann Bryant
- Department of cardiovascular medicine, National Heart Centre Singapore, Singapore, Singapore
| | - Stuart Alexander Cook
- Department of cardiovascular medicine, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Calvin Woon-Loong Chin
- Department of cardiovascular medicine, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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49
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Zeljkovic I, Pintaric H, Vrsalovic M, Kruljac I. Effectiveness of cardiogoniometry compared with exercise-ECG test in diagnosing stable coronary artery disease in women. QJM 2017; 110:89-95. [PMID: 27664232 DOI: 10.1093/qjmed/hcw162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Indexed: 11/12/2022] Open
Abstract
AIMS To investigate the effectiveness of cardiogoniometry, a novel, non-invasive method, in diagnosing coronary artery disease (CAD) in women and compare it with exercise-ECG test, by using coronary angiography as a reference method. METHODS It was a single-centre, case-series study including consecutive female patients with stable angina pectoris (AP) undergoing coronary angiography. Exercise-ECG test, done according to the Bruce protocol, and cardiogoniometry were obtained prior to coronary angiography. Clinically significant CAD has been defined as one or more coronary lesions with >70% stenosis. RESULTS Study included 114 consecutive female patients with median age of 64.0 (58.0-71.0) years, out of which 32 (28.1%) had CAD. Cardiogoniometry yielded a total accuracy of 74.6% with a sensitivity of 75.0% (95% CI 56.6-88.5) and specificity of 74.4% (95% CI 63.6-83.4). Exercise-ECG test yielded a total accuracy of 45.1% with a sensitivity of 68.1% (95% CI 42.7-83.6) and specificity 36.6% (95% CI 25.2-50.3). Cardiogoniometry showed higher accuracy than exercise-ECG test ( P < 0.001). Pathological cardiogoniometry was associated with almost nine times higher risk for CAD (OR 8.7, 95%CI 3.4-22.3, P < 0.001), which remained significant after adjustment for age, and hypokinesia. CONCLUSION Cardiogoniometry is a non-invasive, easy-to-use and free-of-risk method which showed high effectiveness in diagnosing stable CAD in women and superior to exercise-ECG test. Cardiogoniometry could be introduced as a part of the diagnostic algorithm of screening women for stable CAD and is suitable for use in the primary setting, especially in women unable to undergo stress-testing.
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Affiliation(s)
- I Zeljkovic
- From the Department of Cardiology, Sisters of Charity University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia
| | - H Pintaric
- From the Department of Cardiology, Sisters of Charity University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Gundulićeva 5, Zagreb, Croatia
| | - M Vrsalovic
- From the Department of Cardiology, Sisters of Charity University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia
| | - I Kruljac
- Department of Internal Medicine, Sisters of Charity University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia
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50
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Lubbers M, Coenen A, Bruning T, Galema T, Akkerhuis J, Krenning B, Musters P, Ouhlous M, Liem A, Niezen A, Dedic A, van Domburg R, Hunink M, Nieman K. Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005295. [DOI: 10.1161/circimaging.116.005295] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/19/2016] [Indexed: 01/18/2023]
Abstract
Background—
Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency.
Methods and Results—
The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (
P
interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (
P
interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all
P
interactions≥0.097).
Conclusions—
Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01393028.
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Affiliation(s)
- Marisa Lubbers
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Adriaan Coenen
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Tobias Bruning
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Tjebbe Galema
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Jurgen Akkerhuis
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Boudewijn Krenning
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Paul Musters
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Mohamed Ouhlous
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Ahno Liem
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Andre Niezen
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Admir Dedic
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Ron van Domburg
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Miriam Hunink
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
| | - Koen Nieman
- From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and
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