1
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Mansour M, Alqaisi O, Gautam N, Vallurupalli S. Significance of abnormal stress electrocardiography with normal cardiac imaging during stress testing-a meta-analysis. J Electrocardiol 2024; 83:64-70. [PMID: 38340487 DOI: 10.1016/j.jelectrocard.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/19/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND AND AIMS Diagnostic testing for coronary artery disease frequently involves functional stress testing where imaging is often coupled with electrocardiogram (ECG) analysis. While decision-making is straightforward when both functional testing and ECG are either positive or negative, interpretation is challenging and prognostic importance uncertain with positive ECG and negative imaging since imaging is considered more sensitive. Prior studies have demonstrated mixed results. We sought to perform a meta-analysis of published studies to determine the significance of this particular type of discordant stress test result. METHODS AND RESULTS PubMed, Cochrane, and Google Scholar were searched to identify studies reporting results of functional imaging (pharmacological exercise echocardiography or SPECT) and ECG analysis, along with the major adverse cardiovascular events (MACE) at patient follow-up. Studies were stratified based on functional imaging modality used. Primary outcome was a composite of all-cause death or myocardial infarction, and secondary outcome was the need for coronary revascularization. Random effects model was used to calculate risk ratios (RR), and heterogeneity among studies was assessed using the Higgins I2 value. Nine studies with a total of 23,715 patients were included. Primary end point was more common with discordant results with exercise stress echocardiography (RR 1.33, 95% confidence intervals [1.08-1.63]) or pharmacological SPECT (RR 6.53 95% CI [2.31-18.48]). CONCLUSIONS Patients in the discordant exercise stress echocardiography and pharmacological SPECT groups were more likely to suffer the primary end point than those with a normal stress test. Discordant results should be interpreted carefully in the clinical context, given their prognostic impact based on the stress modality used.
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Affiliation(s)
- Munthir Mansour
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Omar Alqaisi
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nitesh Gautam
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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2
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Carvalho TD, Freitas OGAD, Chalela WA, Hossri CAC, Milani M, Buglia S, Precoma DB, Falcão AMGM, Mastrocola LE, Castro I, Albuquerque PFD, Coutinho RQ, Brito FSD, Alves JDC, Serra SM, Santos MAD, Colombo CSSDS, Stein R, Herdy AH, Silveira ADD, Castro CLBD, Silva MMFD, Meneghello RS, Ritt LEF, Malafaia FL, Marinucci LFB, Pena JLB, Almeida AEMD, Vieira MLC, Stier Júnior AL. Brazilian Guideline for Exercise Test in the Adult Population - 2024. Arq Bras Cardiol 2024; 121:e20240110. [PMID: 38896581 DOI: 10.36660/abc.20240110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
- Universidade do Estado de Santa Catarina, Florianópolis, SC - Brasil
| | | | - William Azem Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Milani
- Universidade de Brasília (UnB), Brasília, DF, Brasil
- Hasselt University, Hasselt - Bélgica
- Jessa Ziekenhuis, Hasselt - Bélgica
| | - Susimeire Buglia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | - Andréa Maria Gomes Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Iran Castro
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | - Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Linkcare Saúde, Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
| | - Anderson Donelli da Silveira
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | - Claudia Lucia Barros de Castro
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- CLINIMEX - Clínica de Medicina de Exercício, Rio de Janeiro, RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Instituto D'Or de Pesquisa e Ensino, Salvador, BA - Brasil
- Hospital Cárdio Pulmonar, Salvador, BA - Brasil
| | - Felipe Lopes Malafaia
- Hospital Samaritano Paulista, São Paulo, SP - Brasil
- UnitedHealth Group Brasil, São Paulo, SP - Brasil
| | - Leonardo Filipe Benedeti Marinucci
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Arnaldo Laffitte Stier Júnior
- Universidade Federal do Paraná (UFPR), Curitiba, PR - Brasil
- Secretaria Municipal de Saúde Curitiba, Curitiba, PR - Brasil
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3
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Civieri G, Kerkhof PLM, Montisci R, Iliceto S, Tona F. Sex differences in diagnostic modalities of coronary artery disease: Evidence from coronary microcirculation. Atherosclerosis 2023; 384:117276. [PMID: 37775426 DOI: 10.1016/j.atherosclerosis.2023.117276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/16/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
Although atherosclerosis is usually considered a disease of the large arteries, risk factors for atherosclerosis also trigger structural and functional abnormalities at a microvascular level. In cardiac disease, microvascular dysfunction is especially relevant in women, among whom the manifestation of ischemic disease due to impaired coronary microcirculation is more common than in men. This sex-specific clinical phenotype has important clinical implications and, given the higher pre-test probability of coronary microvascular dysfunction in females, different diagnostic modalities should be used in women compared to men. In this review, we summarize invasive and non-invasive diagnostic modalities to assess coronary microvascular function, ranging from catheter-based evaluation of endothelial function to Doppler echocardiography and positron emission tomography. Moreover, we discuss different clinical settings in which microvascular disease plays an important role, underlining the importance of choosing the right diagnostic modality depending on the sex of the patients.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Peter L M Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, the Netherlands
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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4
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Thoppil J, Kraut L, Montgomery C, Castillo W, Silverman R, Gupta S, Davis F. A retrospective analysis of gender among patients admitted to a clinical decision unit at risk for acute coronary syndrome. World J Emerg Med 2023; 14:133-137. [PMID: 36911051 PMCID: PMC9999137 DOI: 10.5847/wjem.j.1920-8642.2023.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Joby Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Texas 75002, USA
| | - Lauren Kraut
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Texas 75002, USA
| | - Collin Montgomery
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Wilfrido Castillo
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Robert Silverman
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Sanjey Gupta
- Department of Emergency Medicine, South Shore Hospital, Bay Shore NY 11706, USA
| | - Frederick Davis
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
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5
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Georgiopoulos G, Mavraganis G, Aimo A, Giorgetti A, Cavaleri S, Fabiani I, Giannoni A, Emdin M, Gimelli A. Sex-specific associations of myocardial perfusion imaging with outcomes in patients with suspected chronic coronary syndrome. Hellenic J Cardiol 2022; 71:8-15. [PMID: 36566838 DOI: 10.1016/j.hjc.2022.12.008] [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: 11/06/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Myocardial perfusion scintigraphy (MPS) is an established diagnostic technique for inducible ischemia in patients with suspected chronic coronary syndrome (CCS). Some MPS findings, most notably an ischemia extent>10% of the left ventricle (LV), hold prognostic significance and support maximization of anti-ischemic treatment. We aimed to assess sex-specific associations of MPS findings with cardiovascular (CV) events in a population at high risk of CCS. METHODS In a prospective cohort study, 1,229 consecutive patients (age 70 ± 9.5 years, 73.5% males) without known CCS were referred to stress-rest MPS. All patients were followed for a median of 4.6 years for CV events. RESULTS Men and women had comparable risk profiles and incidence rates of CV events (6.6% vs. 4.6% respectively, P = 0.186). A summed stress score (SSS) > 7 was associated with the primary endpoint, including CV death and/or nonfatal myocardial infarction (MI) (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], 1.79-5.46; P = 0.001), all-cause mortality (HR, 3.01; 95% CI, 1.31-6.93; P = 0.01), and incidence of late revascularization (HR, 1.84; 95% CI, 1.22-2.78; P = 0.004) in men but not women. A summed difference score (SDS) > 6 was related to a higher rate of the primary endpoint only in men (adjusted HR, 1.97; 95% CI, 1.18-3.30; P = 0.009). CONCLUSIONS Among patients undergoing a diagnostic workup for suspected CCS, stress perfusion and reversible ischemia abnormalities may independently predict worse survival and more CV events in men. However, the obtained results indicated the need for sex-specific cutoffs to refine risk stratification and assist in clinical decisions on anti-ischemic therapy beyond coronary artery anatomy.
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Affiliation(s)
- Georgios Georgiopoulos
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Vasilissis Sofias 80 str, 11528, Athens, Greece; School of Biomedical Engineering and Imaging Sciences, King's College, Strand, London WC2R 2LS, London, UK.
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Vasilissis Sofias 80 str, 11528, Athens, Greece
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Assuero Giorgetti
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Samuele Cavaleri
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Iacopo Fabiani
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Alberto Giannoni
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
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6
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Parry M, Van Spall HG, Mullen KA, Mulvagh SL, Pacheco C, Colella TJ, Clavel MA, Jaffer S, Foulds HJ, Grewal J, Hardy M, Price JA, Levinsson AL, Gonsalves CA, Norris CM. The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment. CJC Open 2022; 4:589-608. [PMID: 35865023 PMCID: PMC9294990 DOI: 10.1016/j.cjco.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/12/2022] [Indexed: 10/26/2022] Open
Abstract
This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.
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Affiliation(s)
- Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Harriette G.C. Van Spall
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Research Institute of St. Joe’s, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kerri-Anne Mullen
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Tracey J.F. Colella
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de pneumologie de Québec— Université Laval, Quebec City, Quebec, Canada
| | - Shahin Jaffer
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jasmine Grewal
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marsha Hardy
- Canadian Women's Heart Health Alliance, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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7
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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: 5] [Impact Index Per Article: 2.5] [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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8
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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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9
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Cardiovascular Disease in Older Women. Clin Geriatr Med 2021; 37:651-665. [PMID: 34600729 DOI: 10.1016/j.cger.2021.05.010] [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: 11/20/2022]
Abstract
Cardiovascular disease is the major cause of death in women. Older women remain at risk for coronary artery disease/cardiovascular disease, but risk-modifying behavior can improve outcomes. Women have a different symptom profile and have been underdiagnosed and undertreated as compared with men. Although older women are underrepresented in trials, clinicians should be more attuned to the prevention, diagnosis, and treatment of cardiovascular disease in older women.
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10
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GURZĂU DA, CALOIAN B, COMŞA H, SITAR-TĂUT A, ZDRENGHEA D, POP D. The importance of stratifying ischemic risk by using the Duke score in women with ischemic heart disease and hypothyroidism before inclusion in cardiovascular rehabilitation programs. BALNEO AND PRM RESEARCH JOURNAL 2021. [DOI: 10.12680/balneo.2021.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: The relationship between abnormal thyroid function and coronary heart disease has been known for a long time, and particularly, hypothyroidism is associated with an increased risk of cardiovascular disease. The aim of this study was to evaluate the ischemic risk by using the Duke score in women with ischemic heart disease and associated hypothyroidism before inclusion in cardiovascular rehabilitation program.
Materials and methods: We included in the study 150 female patients admitted to the Cardiology Department of the Clinical Rehabilitation Hospital Cluj-Napoca. All the patients included had ischemic heart disease and performed an exercise stress testing to evaluate the effort capacity and also to stratify the ischemic risk by calculating the Duke Score. After dosing the thyroid stimulating hormone (TSH) we divided the patients in two groups: with hypothyroidism and a control group.
Results: Patients with hypothyroidism were more frequently hypertensive, (98% vs 87%, p-0.035), and they had diabetes mellitus in a higher proportion (51% vs 22%, p-0.005). HDL cholesterol was significantly decreased in the group of patients with hypothyroidism: 40.36±10.39mg/dl vs 44.85±10.29mg/dl (p-0.01). Regarding the ischemic risk assessed by the Duke score, the statistically significant differences between the two groups were registered only for the category of high-risk patients, 5.55% vs 18% (p-0.048). Also, the TSH value was higher in the group with high-risk Duke score, 4.21±3.73µIU/ml, compared to the moderate-risk score group, 1.95±1.12µIU/ml(p-0.05).
Conclusion: In women with ischemic heart disease, assessing thyroid function can be useful to identify patients at high risk of ischemia. Patients with hypothyroidism tend to have a higher prevalence of cardiovascular risk factors, a higher ischemic risk objectified by the Duke score and more commonly multivascular coronary lesions. For these patients, the inclusion in cardiovascular rehabilitation programs is essential, but it is very important that the programs to be customized for each patient.
Keywords: coronary heart disease in women, exercise ECG, Duke score, ischemic risk, hypothyroidism, cardiovascular rehabilitation programs
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Affiliation(s)
| | - Bogdan CALOIAN
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Horaţiu COMŞA
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adela SITAR-TĂUT
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dumitru ZDRENGHEA
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana POP
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
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11
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Crousillat DR, Wood MJ. Echocardiography in Women: How Are Mars and Venus Different? Curr Cardiol Rep 2021; 23:149. [PMID: 34427784 DOI: 10.1007/s11886-021-01562-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Sex is an important determinant of cardiac structure and function. We review key sex differences in universal echocardiographic parameters and discuss the clinical implications of using sex-specific algorithms to increase the diagnostic accuracy of echocardiography and improve the timely treatment of common cardiovascular disorders, and the unique role of echocardiography in pregnancy and the evaluation of ischemic heart disease. RECENT FINDINGS Emerging echocardiographic findings have begun to define important sex-based differences in chamber size and ventricular function. We advocate for additional research and the consideration of sex-specific algorithms in future expert consensus guidelines for the diagnosis and treatment of valvular heart disease, heart failure, and thoracic aortic disease. Echocardiography is an essential diagnostic tool in our armamentarium of imaging modalities for the sex-specific diagnosis and guidance of treatment for a broad spectrum of cardiovascular disorders.
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Affiliation(s)
- Daniela R Crousillat
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street Blake 256, Boston, MA, 02114, USA
| | - Malissa J Wood
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street Blake 256, Boston, MA, 02114, USA.
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12
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Coutinho RQ, Montarroyos UR, Barros IMLD, Guimarães MJB, Leão APD, Costa LOBF, Medeiros AKDL, Monteiro MDF, Ferreira MDNL, Chalela WA, Pedrosa RP. Exercise Testing, Family History, and Subclinical Atherosclerosis Markers for Cardiovascular Risk Reclassification in Middle-Aged Women. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200414] [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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13
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Koilpillai P, Aggarwal NR, Mulvagh SL. State of the Art in Noninvasive Imaging of Ischemic Heart Disease and Coronary Microvascular Dysfunction in Women: Indications, Performance, and Limitations. Curr Atheroscler Rep 2020; 22:73. [PMID: 33009953 DOI: 10.1007/s11883-020-00894-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Establishing a diagnosis of ischemic heart disease (IHD) in women, including assessment for coronary microvascular dysfunction (CMD) when indicated, can be challenging. Access to performance of invasive testing when appropriate may be limited, and noninvasive imaging assessments have evolved. This review will summarize the various noninvasive imaging modalities available for the diagnosis of IHD and CMD in women, outlining indications, performance modalities, advantages, and limitations. RECENT FINDINGS While stress echocardiography and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are widely available and can detect IHD in women, their ability to specifically identify CMD is limited. Novel developments in cardiac magnetic resonance (CMR) imaging, including spectroscopy, and positron emission tomography (PET) have changed the diagnostic landscape. Coronary computed tomographic angiography (CCTA), while unable to diagnose CMD, is developing an emerging role in the risk stratification of ischemic syndromes. Despite the discovery of increased CMD prevalence in symptomatic women and technological advances in diagnostic imaging, practitioners are limited by user expertise and center availability when choosing a diagnostic imaging modality. Knowledge of this evolving field is imperative as it highlights the need for sex-specific assessment of cardiovascular syndromes.
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Affiliation(s)
- Priya Koilpillai
- Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Niti R Aggarwal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sharon L Mulvagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax Infirmary Site, Dalhousie University, 1796 Summer Street, Suite 2148.5, Halifax, NS, B3H 3A7, Canada.
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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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15
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Stress cardiac MRI in stable coronary artery disease. Curr Opin Cardiol 2020; 35:566-573. [PMID: 32649360 DOI: 10.1097/hco.0000000000000776] [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] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Non-invasive testing is often the first step in the evaluation of stable coronary artery disease (CAD). Stress cardiac magnetic resonance imaging (CMR) is an established modality with high diagnostic accuracy and prognostic value. This review will focus on the recent advances in understanding how stress CMR can help guide patient care. RECENT FINDINGS Diagnostic accuracy of stress CMR has been validated against coronary angiography with fractional flow reserve (FFR) in patients with stable CAD. Large registry data have shown stress CMR to have important prognostic importance and that its cost-effectiveness compares favorably to alternatives. In patients with stable CAD, guidance using a CMR based strategy led to equivalent outcomes when compared to coronary angiography with FFR. SUMMARY In persons with stable CAD, Stress CMR is an accurate and cost-effective imaging modality that should be considered in patients at intermediate pre-test probability of CAD. Prognostic studies have shown it to have excellent negative predictive value and that it can safely serve as a "gatekeeper" for invasive angiography.
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16
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Norris CM, Yip CYY, Nerenberg KA, Clavel M, Pacheco C, Foulds HJA, Hardy M, Gonsalves CA, Jaffer S, Parry M, Colella TJF, Dhukai A, Grewal J, Price JAD, Levinsson ALE, Hart D, Harvey PJ, Van Spall HGC, Sarfi H, Sedlak TL, Ahmed SB, Baer C, Coutinho T, Edwards JD, Green CR, Kirkham AA, Srivaratharajah K, Dumanski S, Keeping‐Burke L, Lappa N, Reid RD, Robert H, Smith G, Martin‐Rhee M, Mulvagh SL. State of the Science in Women's Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender. J Am Heart Assoc 2020; 9:e015634. [PMID: 32063119 PMCID: PMC7070224 DOI: 10.1161/jaha.119.015634] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Kara A. Nerenberg
- Department of Medicine/Division of General Internal MedicineUniversity of CalgaryAlbertaCanada
| | | | | | | | - Marsha Hardy
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | | | - Shahin Jaffer
- Department of Medicine/Community Internal MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Tracey J. F. Colella
- University Health Network/Toronto Rehab Cardiovascular Prevention and Rehabilitation ProgramTorontoOntarioCanada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Jasmine Grewal
- Division of CardiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Jennifer A. D. Price
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
| | - Anna L. E. Levinsson
- Montreal Heart InstituteMontrealQuebecCanada
- Beaulieu‐Saucier Université de Montréal Pharmacogenomics CentreMontrealQuebecCanada
- Faculty of MedicineUniversité de MontréalMontrealQuebecCanada
| | - Donna Hart
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Paula J. Harvey
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
- Women's College Research Institute and Division of CardiologyDepartment of Medicine Women's College HospitalUniversity of TorontoOntarioCanada
| | | | - Hope Sarfi
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Tara L. Sedlak
- Leslie Diamond Women's Heart CentreVancouver General HospitalUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sofia B. Ahmed
- Department of Medicine and Libin Cardiovascular InstituteUniversity of CalgaryAlbertaCanada
| | - Carolyn Baer
- Division of General Internal MedicineDepartment of MedicineMoncton HospitalDalhousie UniversityHalifaxNova ScotiaCanada
| | - Thais Coutinho
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Jodi D. Edwards
- School of Epidemiology and Public HealthUniversity of Ottawa and University of Ottawa Heart InstituteOttawaOntarioCanada
| | - Courtney R. Green
- Society of Obstetricians and Gynaecologists of CanadaOttawaOntarioCanada
| | - Amy A. Kirkham
- Department of Biomedical EngineeringUniversity of AlbertaEdmontonAlbertaCanada
| | - Kajenny Srivaratharajah
- Division of General Internal MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | | | - Nadia Lappa
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Robert D. Reid
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Helen Robert
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Graeme Smith
- Department of Obstetrics and GynecologyKingston Health Sciences CentreQueen's UniversityKingstonOntarioCanada
| | | | - Sharon L. Mulvagh
- Division of CardiologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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Abstract
Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.
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18
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Female False Positive Exercise Stress ECG Testing – Fact Versus Fiction. Heart Lung Circ 2019; 28:735-741. [DOI: 10.1016/j.hlc.2018.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/27/2018] [Accepted: 02/08/2018] [Indexed: 11/18/2022]
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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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20
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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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21
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Adigun RO, Boler AN, Mankad R. Disparities in Cardiac Care of Women: Current Data and Possible Solutions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:87. [PMID: 30242773 DOI: 10.1007/s11936-018-0688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women. RECENT FINDINGS Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.
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Affiliation(s)
- Rosalyn O Adigun
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Amber N Boler
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Rekha Mankad
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA.
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22
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Ouellette ML, Löffler AI, Beller GA, Workman VK, Holland E, Bourque JM. Clinical Characteristics, Sex Differences, and Outcomes in Patients With Normal or Near-Normal Coronary Arteries, Non-Obstructive or Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:JAHA.117.007965. [PMID: 29720503 PMCID: PMC6015317 DOI: 10.1161/jaha.117.007965] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Normal or near‐normal coronary arteries (NNCAs) or nonobstructive coronary artery disease (CAD) are found on invasive coronary angiography in ≈55% of patients. Some attribute this to frequent referral of low‐risk patients. We sought to identify the referral indications, pretest risk, key clinical characteristics, sex, and outcomes in patients with NNCAs and nonobstructive CAD versus obstructive CAD on nonemergent invasive coronary angiography. Methods and Results Over 24 months, 925 consecutive patients were classified as having NNCAs (≤20% stenosis), nonobstructive CAD (21–49% stenosis), or obstructive CAD (≥50% stenosis). Outcomes included cardiac death, nonfatal myocardial infarction, and late revasclarization. NNCAs were found in 285 patients (31.0%), nonobstructive CAD in 125 (13.5%), and obstructive CAD in 513 (55.5%). NNCAs or nonobstructive CAD was found in 40.5% with stress ischemia, 27.9% after a non‐ST‐elevation myocardial infarction, and in 55.5% with stable or unstable angina. More women than men (53.5% versus 37.2%; P<0.001) had NNCAs or nonobstructive CAD across all referral indications. Pretest risk was high and ICA appropriate in 75.5% and 99.2% of patients, respectively. Annual rates of cardiac death or nonfatal myocardial infarction were 1.0%, 1.1%, and 6.7%, respectively, for patients with NNCAs, nonobstructive CAD, and obstructive CAD (P<0.001). No sex differences in outcomes were observed with either NNCAs, nonobstructive CAD, or obstructive CAD (P=0.84). Conclusions Many (44.5%) patients undergoing nonemergent invasive coronary angiography have NNCAs or nonobstructive CAD despite high pretest risk, including ischemia and troponin elevation. Although women had more NNCAs or nonobstructive CAD, there were no differences in event rates by sex. Patients with NNCAs and nonobstructive CAD had very low event rates.
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Affiliation(s)
- Michelle L Ouellette
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Adrián I Löffler
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Virginia K Workman
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Eric Holland
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
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23
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Abdelmoneim SS, Ball CA, Mantovani F, Hagen ME, Eifert-Rain S, Wilansky S, Castello R, Pellikka PA, Best PJ, Mulvagh SL. Prognostic Utility of Stress Testing and Cardiac Biomarkers in Menopausal Women at Low to Intermediate Risk for Coronary ARTery Disease (SMART Study): 5-Year Outcome. J Womens Health (Larchmt) 2018; 27:542-551. [DOI: 10.1089/jwh.2017.6506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Sahar S. Abdelmoneim
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Cardiovascular Diseases, Assiut University, Assuit, Egypt
| | - Caroline A. Ball
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Francesca Mantovani
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Arcispedale Santa Maria Nuova (IRCCS), Reggio Emilia, Italy
| | - Mary E. Hagen
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Eifert-Rain
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Wilansky
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | - Patricia A. Pellikka
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Patricia J.M. Best
- Women's Heart Clinic, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Catheterization Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sharon L. Mulvagh
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Women's Heart Clinic, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
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24
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Knol RJJ, Kan H, Wondergem M, Cornel JH, Umans VAWM, van der Ploeg T, van der Zant FM. Exercise Electrocardiogram Neither Predicts Nor Excludes Coronary Artery Disease in Women with Low to Intermediate Risk. J Womens Health (Larchmt) 2018; 27:476-484. [PMID: 29297745 DOI: 10.1089/jwh.2017.6433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM The value of exercise electrocardiogram (ExECG) in symptomatic female patients with low to intermediate risk for significant coronary artery disease (CAD) has been under debate for many years, and nondiagnostic or even erroneous test results are frequently encountered. Cardiac-CT may be more appropriate to exclude CAD in women. This study compares the results of ExECGs with those of cardiac-CTs, performed within a time frame of 1 month in an all-comers female chest pain population. PATIENTS AND METHODS Five hundred fifty-one consecutive female patients from a patient registry were included. ExECGs were negative in 324 (59%), positive in 14 (3%), and nondiagnostic in 213 (39%) patients. CAD was revealed by cardiac-CT in 57% of the women with negative ExECG. No signs of CAD were present on cardiac-CT in 64% of the women with a positive ExECG. Cardiac-CT showed presence of CAD in 268/551 (49%) patients, of whom 56/268 (21%) was diagnosed with ≥50% stenosis. The ExECG of the latter group was negative in 26 (46%), inconclusive in 29 (52%), and positive in 1 (2%). Considering ≥50% stenosis at cardiac-CT as the reference, sensitivity, specificity, PPV, and NPV of ExECG for the present population were 3.7%, 95.7%, 7.1%, and 91.7%, respectively. Similar diagnostic performance was calculated when considering ≥70% stenosis at cardiac-CT as the reference. CONCLUSION ExECG failed to detect CAD in more than half of this cohort and in almost half of women with >50% stenosis at cardiac-CT. Importantly, no CAD was detected by cardiac-CT in 64% of women with a positive ExECG. ExECG is therefore questionable as a diagnostic strategy in women with low-to-intermediate risk of CAD, although prospective studies are warranted to determine whether replacing ExECG by cardiac-CT provides better prognoses.
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Affiliation(s)
- Remco J J Knol
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Huub Kan
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Maurits Wondergem
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Jan H Cornel
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,3 Department of Cardiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Victor A W M Umans
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,3 Department of Cardiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Tjeerd van der Ploeg
- 4 Department of Statistics and Clinical Epidemiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Friso M van der Zant
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
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25
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Keller K, Stelzer K, Geyer M, Münzel T, Ostad MA. Gender differences in bicycle exercise stress echocardiography testing. Artery Res 2018. [DOI: 10.1016/j.artres.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Affiliation(s)
- Andrew D'Silva
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
| | - Sanjay Sharma
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
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27
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Knobf MT, Jeon S, Smith B, Harris L, Thompson S, Stacy MR, Insogna K, Sinusas AJ. The Yale Fitness Intervention Trial in female cancer survivors: Cardiovascular and physiological outcomes. Heart Lung 2017; 46:375-381. [PMID: 28803675 PMCID: PMC6129386 DOI: 10.1016/j.hrtlng.2017.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Induced premature menopause and cardio-toxic therapy increase cardiovascular disease risk in female cancer survivors. OBJECTIVE To compare the effects of a 12 month aerobic-resistance fitness center intervention to home based physical activity on cardiovascular function and metabolic risk factors. METHODS Subjects (N = 154) who had completed primary and/or adjuvant chemotherapy (past 3 years) were randomized to a fitness center intervention or a home based group. The fitness center intervention was a structured thrice weekly aerobic (30 min brisk walking treadmill in target heart range) combined with resistance (30 min of lower body strength training) exercise program, supervised for the first 6 months. The home based group received national guidelines for 30 min moderate intensity exercise most days of the week. Fasting serum samples were collected at baseline, 6 and 12 months for insulin, glucose, lipids and hemoglobin A-1C. A graded exercise stress test was also performed at baseline and 6 months. RESULTS The majority of subjects were white (85.7%), had breast cancer (83.1%) and the average age was 51.9 years. Subjects in the fitness center intervention had significantly improved time on treadmill (p = .039), improved heart rate recovery at 1 min (p = .028), greater MET minutes/week (p ≤ .0001), a trend for improved insulin resistance (p = .067) and stable insulin levels (p = .045) compared to the home based physical activity group. CONCLUSIONS Exercise represents a potential cardiac risk reduction intervention for cancer survivors. CLINICAL TRIALS.GOV: NCT01102985.
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Taqueti VR, Dorbala S, Wolinsky D, Abbott B, Heller GV, Bateman TM, Mieres JH, Phillips LM, Wenger NK, Shaw LJ. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations. J Nucl Cardiol 2017; 24:1402-1426. [PMID: 28585034 PMCID: PMC5942593 DOI: 10.1007/s12350-017-0926-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.
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Affiliation(s)
- Viviany R Taqueti
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Wolinsky
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Brian Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Cardiovascular Institute, The Miriam and Newport Hospitals, Providence, RI, USA
| | - Gary V Heller
- Gagnon Cardiovascular Center, Morristown Medical Center, Morristown, NJ, USA
| | - Timothy M Bateman
- Saint Luke's Health System, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, USA
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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Soh MC, Nelson-Piercy C, Westgren M, McCowan L, Pasupathy D. Do adverse pregnancy outcomes contribute to accelerated cardiovascular events seen in young women with systemic lupus erythematosus? Lupus 2017; 26:1351-1367. [PMID: 28728509 DOI: 10.1177/0961203317719146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal-placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.
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Affiliation(s)
- M C Soh
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,3 Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - C Nelson-Piercy
- 1 Women's Health Academic Centre, King's College London, United Kingdom
| | - M Westgren
- 2 Department of Clinical Science, Karolinska Institutet, Sweden
| | - L McCowan
- 3 Faculty of Medical and Health Science, University of Auckland, New Zealand.,4 National Women's Health, South Auckland Clinical School of Medicine and Counties Manukau Health, Auckland, New Zealand
| | - D Pasupathy
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,5 Biomedical Research Centre at Guy's & St Thomas's NHS Foundation Trust and King's College London, United Kingdom
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Ruckel SM, Gulati M. Coronary Calcium Scoring as the Gate Keeper for Stress Myocardial Perfusion Imaging: Antagonist. J Nucl Cardiol 2017; 24:832-834. [PMID: 28144907 DOI: 10.1007/s12350-017-0793-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Shane M Ruckel
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Martha Gulati
- Division of Cardiology, University of Arizona-Phoenix, 1111 East McDowell Road, Suite 200, Phoenix, AZ, 85008, USA.
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31
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Ibrahim NE, Januzzi JL, Magaret CA, Gaggin HK, Rhyne RF, Gandhi PU, Kelly N, Simon ML, Motiwala SR, Belcher AM, van Kimmenade RR. A Clinical and Biomarker Scoring System to Predict the Presence of Obstructive Coronary Artery Disease. J Am Coll Cardiol 2017; 69:1147-1156. [DOI: 10.1016/j.jacc.2016.12.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 01/09/2023]
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32
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Worrall-Carter L, MacIsaac A, Scruth E, Rahman MA. Gender difference in the use of coronary interventions for patients with acute coronary syndrome: Experience from a major metropolitan hospital in Melbourne, Australia. Aust Crit Care 2017; 30:3-10. [DOI: 10.1016/j.aucc.2016.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/20/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023] Open
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33
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Tailor TD, Kicska GA, Jacobs JE, Pampaloni MH, Litmanovich DE, Reddy GP. Imaging of Heart Disease in Women. Radiology 2017; 282:34-53. [DOI: 10.1148/radiol.2016151643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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34
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Michelsen MM, Mygind ND, Frestad D, Prescott E. Women with Stable Angina Pectoris and No Obstructive Coronary Artery Disease: Closer to a Diagnosis. Eur Cardiol 2017; 12:14-19. [PMID: 30416544 DOI: 10.15420/ecr.2016:33:2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A large proportion of women with chest pain have no obstructive coronary artery disease. Recent studies have demonstrated that these women continue to have symptoms and are at increased risk of cardiovascular morbidity and mortality. Coronary microvascular dysfunction (CMD) leads to an impairment of blood flow regulation to the myocardium and possible transient ischaemia. CMD is a disease entity with several pathophysiologic aspects and diagnostic modalities continue to be developed. However, due to the complexity of the disease, it remains elusive whether CMD is the explanation for the symptoms and the poor prognosis in women with angina and no obstructive coronary artery disease.
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Affiliation(s)
- Marie Mide Michelsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen Copenhagen, Denmark
| | - Naja Dam Mygind
- Department of Cardiology, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Daria Frestad
- Department of Cardiology, Hvidovre Hospital, University of Copenhagen Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen Copenhagen, Denmark
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35
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Padang R, Pellikka PA. The role of stress echocardiography in the evaluation of coronary artery disease and myocardial ischemia in women. J Nucl Cardiol 2016; 23:1023-1035. [PMID: 27457525 DOI: 10.1007/s12350-016-0592-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/08/2016] [Indexed: 01/06/2023]
Abstract
Considering the unfavorable prognosis of women with ischemic heart disease, an aggressive but safe approach to evaluate women presenting with chest pain is warranted so that coronary artery disease (CAD) can be identified and treated early. Stress echocardiography (SE) has matured into an invaluable technique for the noninvasive detection of obstructive epicardial CAD. Its versatility, accuracy, safety, noninvasiveness, and lack of radiation exposure make SE an attractive technique to apply to the assessment of women with known or suspected heart disease. This article focuses on the current evidence supporting the role of SE in the assessment of CAD and myocardial ischemia in women.
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Affiliation(s)
- Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Standbridge K, Reyes E. The role of pharmacological stress testing in women. J Nucl Cardiol 2016; 23:997-1007. [PMID: 27515346 DOI: 10.1007/s12350-016-0602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.
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Affiliation(s)
- Katherine Standbridge
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom.
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37
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Park SJ, Chung S, Chang SA, Choi JO, Choi JH, Lee SC, Park SW. Independent and incremental prognostic value of exercise stress echocardiography in low cardiovascular risk female patients with chest pain. Echocardiography 2016; 34:69-77. [DOI: 10.1111/echo.13388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sung-Ji Park
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Seungmin Chung
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sung-A Chang
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jin-Oh Choi
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jin-Ho Choi
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sang-Chol Lee
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Seung Woo Park
- Division of Cardiology; Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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38
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Bourque JM, Beller GA. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies. JACC Cardiovasc Imaging 2016; 8:1309-21. [PMID: 26563861 DOI: 10.1016/j.jcmg.2015.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023]
Abstract
Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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39
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Swaminathan RV, Feldman DN, Pashun RA, Patil RK, Shah T, Geleris JD, Wong SC, Girardi LN, Gaudino M, Minutello RM, Singh HS, Bergman G, Kim LK. Gender Differences in In-Hospital Outcomes After Coronary Artery Bypass Grafting. Am J Cardiol 2016; 118:362-8. [PMID: 27269585 DOI: 10.1016/j.amjcard.2016.05.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p <0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p <0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p <0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend <0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.
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Affiliation(s)
- Rajesh V Swaminathan
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Raymond A Pashun
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Rupa K Patil
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Tara Shah
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Joshua D Geleris
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Shing-Chiu Wong
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York; Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Robert M Minutello
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Harsimran S Singh
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Geoffrey Bergman
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Luke K Kim
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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Kim MN, Kim SA, Kim YH, Hong SJ, Park SM, Shin MS, Kim MA, Hong KS, Shin GJ, Shim WJ. Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women. J Cardiovasc Ultrasound 2016; 24:135-43. [PMID: 27358706 PMCID: PMC4925391 DOI: 10.4250/jcu.2016.24.2.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/16/2022] Open
Abstract
Background Exercise-stress electrocardiography (ECG) is initially recommended for the diagnosis of coronary artery disease. But its value has been questioned in women because of suboptimal diagnostic accuracy. Stress echocardiography had been reported to have comparable test accuracy in women. But the data comparing the diagnostic accuracy of exercise-stress ECG and stress echocardiography directly are few. The aim of the study was to compare the diagnostic accuracy of exercise-stress ECG and dobutamine stress echocardiography (DSE) in Korean women. Methods 202 consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The diagnostic accuracy TET and DSE were calculated by the definition of > 50% or > 75% coronary artery stenosis (CAS). Results The sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CAS. The higher accuracy of DSE was maintained after exclusion of the patients who could not achieve over 85% age predicted heart rate before ischemia induction. DSE also showed greater diagnostic accuracy than TET by > 75% CAS criteria, and in subsets of patient with intermediate pretest probability. Conclusion In the diagnosis of CAS, DSE showed higher accuracy than TET in female patients who presented with chest pain. As well as the test accuracy, adequate stress was more feasible with DSE than TET. These finding suggests DSE may be used as the first-line diagnostic tool in the detection of CAS in women with chest pain.
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Affiliation(s)
- Mi-Na Kim
- Department of Cardiology, Korea University Anam Hospital, Seoul, Korea
| | - Su-A Kim
- Department of Cardiology, Dankook University Cheil General Hospital & Women's Healthcare Center, Seoul, Korea
| | - Yong-Hyun Kim
- Department of Cardiology, Korea University Ansan Hospital, Ansan, Korea
| | - Soon Jun Hong
- Department of Cardiology, Korea University Anam Hospital, Seoul, Korea
| | - Seong-Mi Park
- Department of Cardiology, Korea University Anam Hospital, Seoul, Korea
| | - Mi Seung Shin
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Myung-A Kim
- Department of Cardiology, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kyoung-Soon Hong
- Department of Cardiology, Hallym University Medical Center, Chuncheon, Korea
| | - Gil Ja Shin
- Department of Cardiology Ewha Womans University Medical Center, Seoul, Korea
| | - Wan-Joo Shim
- Department of Cardiology, Korea University Anam Hospital, Seoul, Korea
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41
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Kim YH, Shim WJ, Kim MA, Hong KS, Shin MS, Park SM, Cho KI, Kim M, Kim S, Kim HL, Yoon HJ, Na JO, Kim SE. Utility of Pretest Probability and Exercise Treadmill Test in Korean Women with Suspected Coronary Artery Disease. J Womens Health (Larchmt) 2016; 25:617-22. [DOI: 10.1089/jwh.2015.5242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yong-Hyun Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan, Korea
| | - Wan-Joo Shim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Myung-A Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, Seoul, Korea
| | - Kyung-Soon Hong
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Mi-Seung Shin
- Cardiovascular Center, Gachon University Gil Hospital, Incheon, Korea
| | - Seong-Mi Park
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Kyoung Im Cho
- Cardiovascular Center, Kosin University Gospel Hospital, Busan, Korea
| | - Mina Kim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Sihun Kim
- Cardiovascular Center, Gachon University Gil Hospital, Incheon, Korea
| | - Hak-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, Seoul, Korea
| | - Hyun-Ju Yoon
- Cardiovascular Center, Chonnam University Hospital, Gwangju, Korea
| | - Jin-Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sung-Eun Kim
- Cardiovascular Center, Kangdong Sacred Heart Hospital, Seoul, Korea
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42
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La maladie coronaire de la femme : de vraies spécificités à bien connaître pour améliorer les prises en charge. Presse Med 2016; 45:577-87. [DOI: 10.1016/j.lpm.2016.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 03/07/2016] [Accepted: 03/08/2016] [Indexed: 11/18/2022] Open
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Bajaj NS, Singh S, Farag A, El-Hajj S, Heo J, Iskandrian AE, Hage FG. The prognostic value of non-perfusion variables obtained during vasodilator stress myocardial perfusion imaging. J Nucl Cardiol 2016; 23:390-413. [PMID: 26940574 DOI: 10.1007/s12350-016-0441-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/21/2016] [Indexed: 11/25/2022]
Abstract
Myocardial perfusion imaging (MPI) is an established diagnostic test that provides useful prognostic data in patients with known or suspected coronary artery disease. In more than half of the patients referred for stress testing, vasodilator stress is used in lieu of exercise. Unlike exercise, vasodilator stress does not provide information on exercise and functional capacity, heart rate recovery, and chronotropy, and ECG changes are less frequent. These non-perfusion data provide important prognostic and patient management information. Further, event rates in patients undergoing vasodilator MPI are higher than in those undergoing exercise MPI and even in those with normal images probably due to higher pretest risk. However, there are a number of non-perfusion variables that are obtained during vasodilator stress testing, which have prognostic relevance but their use has not been well emphasized. The purpose of this review is to summarize the prognostic values of these non-perfusion data obtained during vasodilator MPI.
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Affiliation(s)
- Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Siddharth Singh
- Division of Cardiovascular Disease, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ayman Farag
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Stephanie El-Hajj
- Division of Cardiovascular Disease, Medical University of South Carolina, Charleston, SC, USA
| | - Jack Heo
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA.
- Section of Cardiology, Birmingham Veteran's Administration Medical Center, Birmingham, AL, USA.
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Keller K, Stelzer K, Munzel T, Ostad MA. Hypertension is strongly associated with false-positive bicycle exercise stress echocardiography testing results. Blood Press 2016; 25:351-359. [PMID: 27163258 DOI: 10.1080/08037051.2016.1182419] [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: 10/21/2022]
Abstract
INTRODUCTION Exercise echocardiography is a reliable routine test in patients with known or suspected coronary artery disease. However, in ∼15% of all patients, stress echocardiography leads to false-positive stress echocardiography results. We aimed to investigate the impact of hypertension on stress echocardiographic results. METHODS We performed a retrospective study of patients with suspected or known stable coronary artery disease who underwent a bicycle exercise stress echocardiography. Patients with false-positive stress results were compared with those with appropriate results. RESULTS 126 patients with suspected or known coronary artery disease were included in this retrospective study. 23 patients showed false-positive stress echocardiography results. Beside comparable age, gender distribution and coronary artery status, hypertension was more prevalent in patients with false-positive stress results (95.7% vs. 67.0%, p = 0.0410). Exercise peak load revealed a borderline-significance with lower loads in patients with false-positive results (100.0 (IQR 75.0/137.5) vs. 125.0 (100.0/150.0) W, p = 0.0601). Patients with false-positive stress results showed higher systolic (2.05 ± 0.69 vs. 1.67 ± 0.39 mmHg/W, p = 0.0193) and diastolic (1.03 ± 0.38 vs. 0.80 ± 0.28 mmHg/W, p = 0.0165) peak blood pressure (BP) per wattage. In a multivariate logistic regression test, hypertension (OR 17.6 [CI 95% 1.9-162.2], p = 0.0115), and systolic (OR 4.12 [1.56-10.89], p = 0.00430) and diastolic (OR 13.74 [2.46-76.83], p = 0.00285) peak BP per wattage, were associated with false-positive exercise results. ROC analysis for systolic and diastolic peak BP levels per wattage showed optimal cut-off values of 1.935mmHg/W and 0.823mmHg/W, indicating false-positive exercise echocardiographic results with AUCs of 0.660 and 0.664, respectively. CONCLUSIONS Hypertension is a risk factor for false-positive stress exercise echocardiographic results in patients with known or suspected coronary artery disease. Presence of hypertension was associated with 17.6-fold elevated risk of false-positive results.
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Affiliation(s)
- Karsten Keller
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Kathrin Stelzer
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Thomas Munzel
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,c German Center for Cardiovascular Research, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Mir Abolfazl Ostad
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
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Brewer LC, Svatikova A, Mulvagh SL. The Challenges of Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. Cardiovasc Drugs Ther 2016. [PMID: 26210899 DOI: 10.1007/s10557-015-6607-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Increasing evidence suggests that there are significant differences in the presentation, diagnosis and treatment of ischemic heart disease in women compared to men. Women often present with atypical symptoms, and this, in association with a consistent underestimation of their risk for ischemic heart disease, leads to underdiagnosis and undertreatment in women. Cardiovascular risk factors unique to women have only recently been recognized, and moreover, traditional risk factors have recently been shown to have greater impacts on women. Consequently, women suffer more disability and poorer clinical outcomes, with higher cardiovascular morbidity and mortality. These discrepancies may in part be secondary to the higher prevalence of nonobstructive coronary artery disease in women with persistent chest pain symptoms as compared to men when evaluated invasively. Focused diagnostic and therapeutic strategies unique to women are thus needed, but unfortunately, such sex-specific guidelines do not yet exist, largely due to lack of awareness, both on the part of providers and patients, as well as a paucity of evidence-based research specific to women. Although underutilized in women, diagnostic modalities, including functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, are useful for establishing the diagnosis and prognosis of suspected ischemic heart disease in women. This review discusses the current challenges of prevention, diagnosis and treatment of ischemic heart disease in women.
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Harvey RE, Coffman KE, Miller VM. Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease. ACTA ACUST UNITED AC 2015; 11:239-257. [PMID: 25776297 DOI: 10.2217/whe.14.64] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the era of individualized medicine, gaps in knowledge remain about sex-specific risk factors, diagnostic and treatment options that might reduce mortality from cardiovascular disease (CVD) and improve outcomes for both women and men. In this review, contributions of biological mechanisms involving the sex chromosomes and the sex hormones on the cardiovascular system will be discussed in relationship to the female-specific risk factors for CVD: hypertensive disorders of pregnancy, menopause and use of hormonal therapies for contraception and menopausal symptoms. Additionally, sex-specific factors to consider in the differential diagnosis and treatment of four prevalent CVDs (hypertension, stroke, coronary artery disease and congestive heart failure) will be reviewed with emphasis on areas where additional research is needed.
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Affiliation(s)
- Ronée E Harvey
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kirsten E Coffman
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Virginia M Miller
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.,Department of Surgery, Medical Sciences, 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Abstract
Heart disease is the number one killer of women. Although there are many similarities between men and women, the evolving understanding of ischemic heart disease in women allow us to emphasize the important differences that need to be recognized. These differences, including symptoms at presentation, importance of particular risk factors, pathophysiology of disease, and treatments/outcomes, will be discussed in this review.
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Ovadia-Blechman Z, Avrahami I, Weizman-Shammai E, Sharir T, Eldar M, Chouraqui P. Peripheral microcirculatory hemodynamic changes in patients with myocardial ischemia. Biomed Pharmacother 2015; 74:83-8. [PMID: 26349967 DOI: 10.1016/j.biopha.2015.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Patients with coronary heart disease demonstrate changes in skin microcirculation and a decrease in cutaneous blood mass. OBJECTIVE The goal of this study was to assess the feasibility of diagnosing myocardial ischemia based on peripheral microcirculatory variables. METHODS The skin microcirculatory measurements were monitored using an LPT system comprising a Laser Doppler Flowmeter (LDF), a photoplethysmograph (PPG) and a transcutaneous oxygen tension device (tc-PO2). Concurrently, heart rate and blood pressure were monitored. Measurements were performed before and after exercise stress test. Subjects were divided into ischemic (20) and nonischemic (27) patients based on myocardial perfusion imaging (MPI). RESULTS The results indicate differences in LPT variables between ischemic and nonischemic patients following exercise, while no differences in the central variable values were observed between the two groups. CONCLUSIONS Peripheral microcirculatory variables may be useful for non-invasive assessment of myocardial ischemia. The system has clinical potential for sensitive and noninvasive monitoring of vital variables during medical procedures in clinics, as well as in home care for patients who suffer from ischemic cardiac diseases.
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Affiliation(s)
- Zehava Ovadia-Blechman
- Department of Medical Engineering, Afeka Tel Aviv Academic College of Engineering, 218 Bney-Efraim Rd., Tel Aviv, Israel; Neufeld Cardiac Research Institute, Tel Aviv University, Sheba Medical Center, Tel-Hashomer, Israel.
| | - Idit Avrahami
- Department of Mechanical Engineering and Mechatronics, Ariel University, Israel
| | - Einat Weizman-Shammai
- Neufeld Cardiac Research Institute, Tel Aviv University, Sheba Medical Center, Tel-Hashomer, Israel
| | - Tali Sharir
- Nuclear Cardiology Unit, Assuta Medical Centers, Israel
| | - Michael Eldar
- Neufeld Cardiac Research Institute, Tel Aviv University, Sheba Medical Center, Tel-Hashomer, Israel; Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Pierre Chouraqui
- Nuclear Medicine Institute, Hillel Yaffe Medical Center, Hadera, affiliated to the Rappaport Medical School, The Technion Israel Institute of Technology, Haifa, Israel
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Crea F, Battipaglia I, Andreotti F. Sex differences in mechanisms, presentation and management of ischaemic heart disease. Atherosclerosis 2015; 241:157-68. [DOI: 10.1016/j.atherosclerosis.2015.04.802] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/10/2015] [Accepted: 04/21/2015] [Indexed: 01/24/2023]
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Lam T, Burns K, Dennis M, Cheung NW, Gunton JE. Assessment of cardiovascular risk in diabetes: Risk scores and provocative testing. World J Diabetes 2015; 6:634-641. [PMID: 25987961 PMCID: PMC4434084 DOI: 10.4239/wjd.v6.i4.634] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/30/2015] [Accepted: 02/12/2015] [Indexed: 02/05/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus, who have a risk of cardiovascular mortality two to four times that of people without diabetes. An individualised approach to cardiovascular risk estimation and management is needed. Over the past decades, many risk scores have been developed to predict CVD. However, few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice. Currently, guidelines are focused on testing for CVD in symptomatic patients. Atypical symptoms or silent ischemia are more common in the diabetic population, and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy, these guidelines can be difficult to interpret. We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing. The modalities for investigation of CVD are discussed.
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