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Gender-specific research, strategies may improve accuracy of ischemic heart disease diagnosis in women
Gender-specific imaging strategies that clarify the roles of obstructive and nonobstructive CAD as contributors to ischemic heart disease are useful tools in treating women, according to a new scientific statement from the American Heart Association.
“For decades, doctors used the male model of [CHD] to identify the disease in women, automatically focusing on the detection of obstructive [CAD],” writing committee co-chair Jennifer H. Mieres, MD, FACC, FASNC, FAHA, professor of cardiology and population health at Hofstra North Shore–Long Island Jewish School of Medicine, Hempstead, N.Y., said in a press release. “As a result, symptomatic women who did not have classic obstructive coronary disease were not diagnosed with ischemic heart disease, and did not receive appropriate treatment, thereby increasing their risk for [MI].”
The writing group made recommendations for diagnostic testing based on women-specific evidence to identify symptomatic women with no CAD, nonobstructive CAD and obstructive CAD. Women are more likely than men to have nonobstructive CAD, and those with nonobstructive CAD in the past may have incorrectly been diagnosed with a false-positive stress test, according to the release.
Specific recommendations
Symptomatic women with intermediate risk for ischemic heart disease and a normal rest ECG should first have exercise treadmill testing performed, according to the writing group. In this population, imaging should be reserved for women who have resting ST-segment abnormalities or who are unable to exercise. If the exercise test is indeterminate or abnormal, additional diagnostic testing with stress imaging should be performed, and subsequent decisions should take into account the ongoing symptom burden and degree of abnormalities, the authors wrote.
Stress ECG to identify obstructive CAD and estimate prognosis should be performed on symptomatic women at intermediate-to-high risk for ischemic heart disease who have resting ST-segment abnormalities, functional disability or an indeterminate or intermediate-risk stress ECG, according to the statement.
For symptomatic women at intermediate-to-high risk for ischemic heart disease and with resting ST-segment abnormalities, functional disability or an indeterminate or intermediate-risk stress ECG, stress myocardial perfusion imaging with PET or single-photon emission CT is recommended for identification of obstructive CAD and estimation of prognosis, the authors wrote. If at all possible, radiation dose-reduction techniques should be used, and in younger women, radiation exposure should be a more important consideration than accuracy.
Stress cardiac MR, particularly vasodilator stress perfusion cardiac MR, may also be reasonable to perform in that population, according to the statement.
For symptomatic women at intermediate risk for ischemic heart disease and with resting ST-segment abnormalities, functional disability or an indeterminate or intermediate-risk stress ECG, it may be reasonable to use coronary CT angiography as the index procedure within the diagnostic evaluation, the authors wrote, noting that the same caveats apply as with stress myocardial perfusion imaging.
Women at low and intermediate risk
“Low-risk women, with some exceptions, are not candidates for diagnostic testing,” the authors wrote. “The present statement recommends an initial exercise ECG-first strategy for women at low and intermediate (ischemic heart disease) risk.”
Disclosure: See the full statement for the authors’ relevant financial disclosures.