Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain

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

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

Prognostic value of combined coronary CT angiography and myocardial perfusion imaging in women and men

AIMS

Combined anatomical and functional imaging enables detection of non-obstructive and obstructive coronary artery disease (CAD) as well as myocardial ischaemia. We evaluated sex differences in disease profile and outcomes after combined computed tomography angiography (CTA) and positron emission tomography (PET) perfusion imaging in patients with suspected obstructive CAD.

METHODS AND RESULTS

We retrospectively evaluated 1948 patients (59% women) referred for coronary CTA due to suspected CAD during the years 2008-2016. Patients with a suspected obstructive lesion on coronary CTA (n = 657) underwent 15O-water PET to assess stress myocardial blood flow (MBF). During a mean follow-up of 6.8 years, 182 adverse events (all-cause death, myocardial infarction, or unstable angina) occurred. Women had more often normal coronary arteries (42% vs. 22%, P < 0.001) and less often abnormal stress MBF (9% vs. 28%, P < 0.001) than men. The annual adverse event rate was lower in women vs. men (1.2% vs. 1.7%, P = 0.02). Both in women and men, coronary calcification, non-obstructive CAD, and abnormal stress MBF were independent predictors of events. Abnormal stress MBF was associated with 5.0- and 5.6-fold adverse event rates in women and men, respectively. There was no interaction between sex and coronary calcification, non-obstructive CAD, or abnormal stress MBF in terms of predicting adverse events.

CONCLUSION

Among patients evaluated for chronic chest pain, women have a lower prevalence of ischaemic CAD and a lower rate of adverse events. Combined coronary CTA and PET myocardial perfusion imaging predict outcomes equally in women and men.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Imaging of heart disease in women: review and case presentation

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.

Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial

INTRODUCTION

Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs.

METHODS AND ANALYSIS

CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier.

ETHICS AND DISSEMINATION

CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen.

TRIAL REGISTRATION NUMBER

NTR 7475; Pre-results.

Advances in Cardiac Computed Tomography Functional Imaging Technology

Cardiovascular disease (CVD) is the leading cause of death among patients in China, and cardiac computed tomography (CT) is one of the most commonly used examination methods for CVD. Coronary artery CT angiography can be used for the morphologic evaluation of the coronary artery. At present, cardiac CT functional imaging has become an important direction of development of CT. At present, common CT functional imaging technologies include transluminal attenuation gradient, stress dynamic CT myocardial perfusion imaging, and CT-fractional flow reserve. These three imaging modes are introduced and analyzed in this review.

Sex associations and computed tomography coronary angiography-guided management in patients with stable chest pain

AIMS

The relative benefits of computed tomography coronary angiography (CTCA)-guided management in women and men with suspected angina due to coronary heart disease (CHD) are uncertain.

METHODS AND RESULTS

In this post hoc analysis of an open-label parallel-group multicentre trial, we recruited 4146 patients referred for assessment of suspected angina from 12 cardiology clinics across the UK. We randomly assigned (1:1) participants to standard care alone or standard care plus CTCA. Fewer women had typical chest pain symptoms (n = 582, 32.0%) when compared with men (n = 880, 37.9%; P < 0.001). Amongst the CTCA-guided group, more women had normal coronary arteries [386 (49.6%) vs. 263 (26.2%)] and less obstructive CHD [105 (11.5%) vs. 347 (29.8%)]. A CTCA-guided strategy resulted in more women than men being reclassified as not having CHD {19.2% vs. 13.1%; absolute risk difference, 5.7 [95% confidence interval (CI): 2.7-8.7, P < 0.001]} or having angina due to CHD [15.0% vs. 9.0%; absolute risk difference, 5.6 (2.3-8.9, P = 0.001)]. After a median of 4.8 years follow-up, CTCA-guided management was associated with similar reductions in the risk of CHD death or non-fatal myocardial infarction in women [hazard ratio (HR) 0.50, 95% CI 0.24-1.04], and men (HR 0.63, 95% CI 0.42-0.95; Pinteraction = 0.572).

CONCLUSION

Following the addition of CTCA, women were more likely to be found to have normal coronary arteries than men. This led to more women being reclassified as not having CHD, resulting in more downstream tests and treatments being cancelled. There were similar prognostic benefits of CTCA for women and men.

Gender differences in the diagnostic performance of machine learning coronary CT angiography-derived fractional flow reserve -results from the MACHINE registry

PURPOSE

This study investigated the impact of gender differences on the diagnostic performance of machine-learning based coronary CT angiography (cCTA)-derived fractional flow reserve (CT-FFR_ML) for the detection of lesion-specific ischemia.

METHOD

Five centers enrolled 351 patients (73.5% male) with 525 vessels in the MACHINE (Machine leArning Based CT angiograpHy derIved FFR: a Multi-ceNtEr) registry. CT-FFR_ML and invasive FFR ≤ 0.80 were considered hemodynamically significant, whereas cCTA luminal stenosis ≥50% was considered obstructive. The diagnostic performance to assess lesion-specific ischemia in both men and women was assessed on a per-vessel basis.

RESULTS

In total, 398 vessels in men and 127 vessels in women were included. Compared to invasive FFR, CT-FFR_ML reached a sensitivity, specificity, positive predictive value, and negative predictive value of 78% (95%CI 72-84), 79% (95%CI 73-84), 75% (95%CI 69-79), and 82% (95%CI: 76-86) in men vs. 75% (95%CI 58-88), 81 (95%CI 72-89), 61% (95%CI 50-72) and 89% (95%CI 82-94) in women, respectively. CT-FFR_ML showed no statistically significant difference in the area under the receiver-operating characteristic curve (AUC) in men vs. women (AUC: 0.83 [95%CI 0.79-0.87] vs. 0.83 [95%CI 0.75-0.89], p = 0.89). CT-FFR_ML was not superior to cCTA alone [AUC: 0.83 (95%CI: 0.75-0.89) vs. 0.74 (95%CI: 0.65-0.81), p = 0.12] in women, but showed a statistically significant improvement in men [0.83 (95%CI: 0.79-0.87) vs. 0.76 (95%CI: 0.71-0.80), p = 0.007].

CONCLUSIONS

Machine-learning based CT-FFR performs equally in men and women with superior diagnostic performance over cCTA alone for the detection of lesion-specific ischemia.

Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis

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.

Evolving, innovating, and revolutionary changes in cardiovascular imaging: We've only just begun!

In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.

Naringin protects against steroid‑induced avascular necrosis of the femoral head through upregulation of PPARγ and activation of the Notch signaling pathway

Naringin, a flavonoid, is the effective pharmaceutical ingredient of drynaria, with the effects of healing fractures, strengthening bones and promoting kidney function. The aim of the present study was to investigate the potential effect of naringin on steroid‑induced avascular necrosis of the femoral head (SANFH). Treatment with naringin markedly protected against the steroid‑induced decrease in serum osteocalcin levels, and the rate of osteonecrosis in a model of SANFH. In addition, naringin decreased the total cholesterol and low density lipoprotein/high density lipoprotein ratio in the SANFH rabbit. It was observed that naringin markedly inhibited caspase‑3 activity, increased runt‑related transcription factor 2 and transcription factor sp7 mRNA expression, promoted alkaline phosphatase activity and upregulated collagen I, peroxisome proliferator‑activated receptor (PPAR) γ2, neurogenic locus notch homolog protein (Notch), β‑catenin and phosphorylated‑Rac‑α serine/threonine protein kinase protein expression in the SANFH rabbit. The results of the present study demonstrated that naringin protects against SANFH through upregulation of PPARγ2 and activation of the Notch signaling pathway, and may be a useful addition to the treatment options for diseases of the femoral head.

Utility of Imaging in Risk Stratification of Chest Pain in Women

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.