Consider sex-specific imaging differences for women presenting with angina
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Sex-specific differences in the performance of noninvasive testing for ischemic heart disease necessitate a sex-based diagnostic workup with a multimodality approach to better understand women’s chest pain symptoms, researchers reported.
Women have a unique phenotype of ischemic heart disease with less calcified lesions, more nonobstructive plaques and a higher prevalence of microvascular disease compared with men, which may explain in part why current risk models to detect obstructive CAD may not work as well in women, Michael Salerno, MD, PhD, MS, professor of medicine and radiology and section chief of cardiovascular imaging at Stanford University department of medicine, and colleagues wrote in a state-of-the-art review published in JACC: Cardiovascular Imaging. Salerno and colleagues wrote that a change in thinking that considers sex-specific difference in risk factors, coronary physiology and pathophysiology, and clinical symptoms is needed to provide optimal care for women presenting with angina.
“There is a growing recognition in the last few years that CAD is different in men and women, with more nonobstructive disease and higher prevalence of microvascular disease,” Salerno told Healio. “We have been stuck in the same mindset for a long time, thinking about this as one disease that is the same in men and women. At the same time, we have had an evolution in our imaging techniques that allow us to look at things like nonobstructive coronary disease by CT, or flow reserve by MRI or PET. A lot of our strategies to identify what people’s problems are based on the concept of looking for obstructive CAD is not serving our patients who have chest pain that is not related to blockages in the arteries.”
CV imaging differences by sex
Salerno and colleagues noted that women have smaller epicardial coronary arteries than men, even after adjustment for age, BMI, body surface area and left ventricular mass, which complicates accurate assessment of distal coronary arteries by coronary CT angiography. Women also have thinner myocardial walls, challenging the evaluation of nontransmural ischemia by cardiac MRI. PET imaging studies have shown that, compared with men, women have higher coronary blood flow at both rest and peak stress, but similar coronary flow reserve, he said.
“When you have thinner structures or smaller vessels, those are more technically challenging to image by any of the modalities, which may result in a different performance of those techniques in men as compared with women,” Salerno said.
Salerno said when evaluating women for suspected CAD, the pretest probability must be considered, and testing should be chosen wisely according to appropriateness.
“Given that we know women are less likely to have obstructive disease, it is important that before we go on to invasive studies, we are able to noninvasively look at the anatomy as well as the perfusion, so we are only sending people to the cath lab if they are likely to have obstructive disease or they are going to need an intervention, or we can’t figure out what is going on noninvasively,” Salerno said.
The authors noted that, given the low prevalence of obstructive CAD in women, in patients initially undergoing a functional test, proceeding with an anatomical test such as CT angiography may be a “reasonable approach.”
“Use of CT angiography after stress testing can diagnose or exclude obstructive CAD and identify patients who may benefit from referral to invasive coronary angiography,” the researchers wrote.
For women who initially undergo a CT angiography showing nonobstructive disease but with ongoing symptoms, particularly among women, cardiometabolic disease like obesity, diabetes or chronic kidney disease, quantitative functional study (PET or cardiac MRI) should be pursued to establish the diagnosis of coronary microvascular dysfunction, the researchers wrote.
More data needed
The authors called for a greater focus on primary prevention in women with nonobstructive CAD; evaluation of ischemia with nonobstructive CAD (INOCA) and MI with nonobstructive CAD (MINOCA) is needed and supported with the recent chest pain guidelines, published by the American Heart Association and the American College of Cardiology in October.
Salerno said more research is needed on microvascular disease in women.
“We can identify microvascular disease, but we have yet to find any treatments to help symptoms,” Salerno said. “Both improving patient symptoms as well as improving longer-term prognosis is important. First, we need to be able to quantify the disease and then we need innovative treatments to help our patients.”
For more information:
Michael Salerno, MD, PhD, MS, can be reached at msalerno@stanford.edu; Twitter: @salernomdphd.
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