Diagnosis
of coronary artery disease in women vs men
Dr Christopher S. Hayward, Dr Peter Collins
Department of Cardiac Medicine, National Heart and Lung Institute,
Imperial College School of Medicine, London, UK (peter.collins@ic.ac.uk)
Introduction
Epidemiological studies suggest that women lag behind men by approximately
20 years with respect to cardiovascular disease.[1] Gender
differences exist at each stage of cardiovascular disease: in its presentation,
investigation, treatment outcome and prognosis. This review focuses on gender
differences in the interpretation of investigations used in the diagnosis
of coronary artery disease. While differences do exist, most studies have
found that the same diagnostic tests remain valid for both sexes.
Symptoms
A number of studies have found that men and women react differently in response
to coronary occlusion. In a study of 1360 subjects which examined symptoms
due to definite myocardial infarction, men were less likely to have neck, jaw
and back pain, and were more likely to complain of diaphoresis or sweating
compared with women.[2] Description of actual chest pain was
similar between the sexes. In a further prospective study of a cohort of patients
undergoing angioplasty for single vessel disease, women were more likely than
men to have vagal activation (manifested as decreased heart rate and blood
pressure) in association with chest pain, as well as having greater associated
ST-segment change in response to a standardized protocol of coronary occlusion.[3] Another
significant feature concerning presentation with symptoms of a cardiac event,
is that women tend to seek medical care later than men.[4] In
the Scottish MONICA population, women were more likely to present to their
local doctor with myocardial infarction, contributing to the delay in their
presentation to hospital care.[5]
Electrocardiography
While baseline ‘ischaemic ECG’ abnormalities (in apparently disease-free subjects)
are more prevalent in women, the difference is due to mainly ST-T-wave changes.[6] After
correction for risk factors, however, the 10-year prognostic value of an
ischaemic ECG was found to be similar to that of men.[6] Thus,
the relative risk for women with an ischaemic ECG (compared with the remaining
women) was similar to the relative risk for men with resting ECG abnormalities
(when compared with the remaining men). A myocardial perfusion study found,
however, that ST-T abnormalities in women were not associated with increased
perfusion defects on diagnostic scanning, whereas men with baseline ST-T
abnormalities did have a significantly higher rate of perfusion defects.[7] It
is well recognized that the diagnosis of left ventricular hypertrophy on
ECG is less reliable in women, even when appropriate adjustments are performed.[8,9]
Exercise testing
It has been recognized for many years that treadmill exercise testing in women
is associated with a greater number of false-positive ECG changes. It continues
to be used, how-ever, because it remains a cost-effective test in women who
have at least ‘probable angina’.[10] Women typically have
lower exercise capacity and total workload, in association with more symptoms
at the time of index stress testing.[11] In a meta-analysis
of 19 studies which included at least 50 women and compared exercise testing
with coronary angiography, Kwok et al.[12] found the specificity
of exercise testing to be significantly lower in women compared with men (70
vs 77%). The reason for this is still unknown, but differences in electrical
repolarization are likely to play a role. It has been suggested that this difference
could be improved using gender-specific ST/heart rate slope partitions.[13] In
clinical practice, therefore, it is not surprising that women are more likely
to undergo a further non-invasive test (usually perfusion imaging) before coming
to angiography.[14] Shaw et al.[15] found
that despite a similar rate of positive treadmill testing or reversible thallium
defect, women were still less likely than men to undergo subsequent invasive
procedures, even in the presence of similar risk factors. In that cohort, men
were more likely to undergo subsequent revascularization procedures.
An important variable available from exercise testing, independent of ECG findings,
is the exercise capacity, which has been shown to give valuable prognostic
information independent of gender.[16]
Isotope scanning
Nuclear scanning has been shown to have superior accuracy to exercise testing
in both men and women.[12,17] An early meta-analysis found
both lower sensitivity and specificity of exercise thallium scanning in women
compared with men,[18] possibly related to breast attenuation
artefact in women.[19] Despite this, a large prospective
study using rest thallium in combination with sestamibi SPECT scanning showed
that low-risk patients of either gender were classified appropriately, but
that patients were classified to a high-risk category with greater accuracy
in women.[20] The use of technetium 99m sestamibi and ECG
gating has recently been shown to improve the specificity of nuclear scanning
in women, without any decrement in sensitivity.[21]
Stress echocardiography
A meta-analysis comparing exercise echocardiography with exercise SPECT found
similar sensitivity (85 and 87%, respectively), but higher specificity for
exercise echocardiography (77%) compared with exercise thallium (64%).[22] A
recent meta-analysis found slightly better accuracy for exercise echocardiography
over exercise thallium (sensitivity and specificity 0.86 and 0.79 vs 0.78 and
0.64, respectively).[12] While stress echocardiography has
been suggested as the investigation of choice for women undergoing cardiac
assessment,[23] a large study of 2748 consecutive subjects
(1209 women) found lower sensitivity in women compared with men both for single
and multivessel disease.[24] In that series, a low specificity
in both men and women was found and attributed to post-test referral bias.
Smaller studies have less consistent results. In a smaller study of 306 subjects
(96 women), dobutamine stress echocardiography was found to have higher accuracy
in women (82 vs 74% in men).[25] Pilot data (n = 92) from
the Women’s Ischemia Syndrome Evaluation (WISE) project showed that dobutamine
stress echocardiography reliably detected multivessel disease (sensitivity
of 82% with adequate heart rate response), but was usually negative in single
vessel disease.[26] While cavity obliteration in response
to dobutamine is more common in women and impairs the visualization of wall
motion abnormalities,[27] it has been shown to be a negative
predictive factor with respect to subsequent cardiac events.[28]
Cardiac catheterization
Whether there is a systematic under-referral or gender bias against women has
been examined in a number of studies. Some have found such a bias,[29,30]
while others have been able to account for the differences on the basis of
differences in comorbidities and age.[31]
It has been suggested that the difference exists when symptoms (angina) are
the basis for angiography, rather than infarction.[32] In
the USA National Hospital Discharge Survey, the lower angiography rate contributed
to the subsequent lower utilization of invasive procedures for women such as
cardiac surgery and PTCA.[30,33]
A significant role for physician bias in limiting referral of women for angiography
is suggested by a recent study which used actors of varying age, sex and race
to describe symptoms of chest pain.[34]
A likely contributor to the persistently lower catheterization rate in women
compared with men is the marked difference in likelihood of significant coronary
disease at angiography with reported rates of non-significant coronary disease
of 25–41% in women compared with only 8–14% in men.[33,35] A
significant proportion of these women will have syndrome X (the triad of chest
pain, a positive stress test and no significant angiographic coronary artery
disease).[36] Various theories have been proposed to account
for syndrome X, with microvascular dysfunction a favoured possibility.[37]
The lack of simple non-invasive measures of detection means that the number
of women undergoing coronary angiography with non-obstructive disease is likely
to remain significantly greater than the number of men.
Newer technologies
The roles of newer technologies such as cardiovascular MRI and electron beam
CT have not been defined.[38] MRI, in particular, shows promise
with greater resolution of perfusion defects even in patients with poor acoustic
windows for echocardiography, though there remains a small percentage (5%)
in whom it cannot be satisfactorily completed.[39] Further
improvements in resolution with imaging of coronary anatomy and plaque may
make MRI an attractive option in the future.
Electron beam CT has been shown to be very sensitive in predicting coronary
disease although there is a wide scatter in the degree of coronary calcification
both in the absence as well as the presence of coronary artery disease.[40] While
coronary calcification in women lags approximately 10 years behind that in
men, in a small group of women with triple vessel disease, Kajinami et al.[40] found
greater calcification compared with men with triple vessel disease. These findings
need to be confirmed in larger series.
Choice of investigation
The optimal choice of investigation for the diagnosis of coronary artery disease
remains a clinical decision based on the likelihood of actual disease. Non-invasive
tests increase or decrease that likelihood, but only coronary angiography remains
definitive. In patients with a high pre-test probability of coronary disease,
even angiography without prior investigation may be cost-effective.[41] Differences
in the sensitivity and specificity of the various tests need to be considered
particularly in light of local experience.
Acknowledgments
Dr Hayward is supported by an Overseas Research Fellowship from the National
Heart Foundation of Australia.
REFERENCES
-
Risk factors that attenuate the female
coronary disease advantage.
Kannel WB, Wilson PW.
Department of Medicine, Evans Memorial Research Foundation, Boston University
School of Medicine, Mass.
OBJECTIVE: To compare the coronary disease experience of men and women in
a community setting. DESIGN AND SETTING: Prospective cohort study. PATIENTS:
Long-term follow-up of a population-based sample of 5209 men and women. RESULTS:
Women outlive men and experience fewer cardiovascular events. By middle age,
women lag 20 years behind men in the incidence of myocardial infarction,
but the gap closes in the elderly, when cardiovascular disease becomes the
leading cause of death in women as well as in men. Menopause promptly escalates
coronary disease risk threefold and greatly erodes the advantage over men.
Women and men share the same major risk factors for coronary disease, although
women experience a lower absolute risk. However, high ratios of total/high-density
lipoprotein cholesterol level ratios, left ventricular hypertrophy, and diabetes
tend to eliminate the female advantage. CONCLUSION: Coronary disease is not
a minor problem in women. Consequently, women should take vigorous preventive
measures. There is a need for particular attention to glucose tolerance and
blood lipid levels and a greater sense of urgency when hypertension progresses
to left ventricular hypertrophy.
PMID: 7802521 [PubMed - indexed for MEDLINE]
2. Goldberg RJ, O’Donnell C, Yarzebski J et al. Sex differences
in symptom presentation associated with acute myocardial infarction: a population-based
perspective. Am Heart J 1998; 136(2): 189–195.
-
Gender difference in autonomic and hemodynamic
reactions to abrupt coronary occlusion.
Airaksinen KE, Ikaheimo MJ, Linnaluoto M, Tahvanainen
KU, Huikuri HV.
Department of Medicine, University of Oulu, Finland. kari.airaksinen@.oulu.fi
OBJECTIVES: We sought to determine whether there are gender-related differences
in autonomic and hemodynamic responses to abrupt coronary occlusion. BACKGROUND:
The risk of sudden death before hospital admission is higher in men with
an acute myocardial infarction. The reasons for this gender-related difference
are not well understood. Cardiovascular autonomic regulation modifies the
outcome of acute coronary events, and there are gender differences in the
autonomic regulation of heart rate (HR) in normal physiologic circumstances.
METHODS: We analyzed the changes in HR, HR variability and blood pressure
and the occurrence of ventricular ectopic beats during a 2-min coronary occlusion
in 140 men and 65 women referred for single-vessel coronary angioplasty.
The ranges of nonspecific responses were determined by analyzing a control
group of 19 patients with no ischemia during a 2-min balloon inflation in
a totally occluded coronary artery. RESULTS: Women more often had ST segment
changes (p < 0.01) and chest pain (p < 0.05) during the occlusion.
Significant bradycardia or increase in HR variability as a sign of vagal
activation occurred more often in women than in men (31% vs. 13%, p < 0.01
and 25% vs. 11%, p < 0.05, respectively). Coronary occlusion also more
often caused (28% vs. 11%, p < 0.01) a decrease in blood pressure in women.
The most pronounced female preponderance was in the incidence of Bezold-Jarisch-type
reaction (i.e., simultaneous bradycardia and decrease in blood pressure [16%
vs. 0.7%, p < 0.0001]). Logistic regression models developed to analyze
the significance of gender while controlling for baseline variables and signs
of ischemia identified female gender to be an independent predictor of bradycardic
reactions (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.7,
p < 0.01), hypotensive reactions (OR 2.6, 95% CI 1.1 to 6.0, p < 0.05)
and Bezold-Jarisch-type response (OR 22.2, 95% CI 2.5 to 200, p < 0.01).
Significance of female gender as a protector against early coronary occlusion-induced
ventricular ectopic beats emerged as having borderline significance (OR 0.4,
CI 0.1 to 1.1, p = 0.07). CONCLUSIONS: Vagal activation is more common in
women than in men during abrupt coronary occlusion and may have beneficial
antiarrhythmic effects, modifying the outcome of acute coronary events.
PMID: 9462571 [PubMed - indexed for MEDLINE]
-
Factors influencing the time to thrombolysis
in acute myocardial infarction. Time to Thrombolysis Substudy
of the National Registry of Myocardial Infarction-1.
Lambrew CT, Bowlby LJ, Rogers WJ, Chandra NC, Weaver
WD.
Maine Medical Center, Portland 04102, USA.
BACKGROUND: The Time to Thrombolysis Substudy of the National Registry for
Myocardial Infarction provided the opportunity to identify factors that delay
thrombolytic treatment of patients with ST-segment elevation acute myocardial
infarction. PARTICIPANTS: Forty-two participating registry hospitals volunteered
for the Time to Thrombolysis Substudy. METHODS: A case report form was developed
to collect time points for emergency department arrival (door), recording
of the electrocardiogram (ECG) (data), entry of the order to give a thrombolytic
drug (decision), and initiation of the thrombolytic infusion (drug) as defined
by the National Heart Attack Alert Program. The impact of mode of transportation
to the hospital, sex, policy-driven cardiology consultation and/or contact
of the primary care physician on door-to-drug time, and each component interval
were determined in 1755 patients who were treated with recombinant tissue-type
plasminogen activator (A1-teplase). The t test was used for comparison of
means and the nonparametric sign test was used for medians. RESULTS: A minority
of patients arrived at the hospital by ambulance, although more women (49.6%)
arrived by ambulance than men (40.9%). However, women arrived at hospitals
significantly later after onset of symptoms than men. It took half as long
for patients arriving by ambulance to be seen by the physician than those
who transported themselves to the hospital. It took longer for women to have
the initial 12-lead ECG recorded than men. The decision to order a thrombolytic
agent was delayed by 22 minutes and median door-to-drug time by 21 minutes
in those patients who had a cardiac consultation over those in whom the drug
was ordered and infusion was initiated by the emergency physician. Although
the initial 12-lead ECG showed ST-segment elevation in 86% of patients who
received the thrombolytic drugs, with no difference between men and women
and no difference in the rate of cardiology consultation between men and
women (77%), door-to-decision time and door-to-drug time were substantially
longer for women having consultation than men. There was no significant difference
in door-to-decision time between men and women when no consultation was performed,
but it still took longer for a drug infusion to be initiated in women. Contacting
the primary care physician delayed the decision to give a thrombolytic drug
by 18 minutes and the administration of the drug by 20 minutes, but there
were no differences between men and women. Preparation of the drug in the
pharmacy resulted in significant delay compared with mixing it in the emergency
department. CONCLUSIONS: Hospital practices and policies, including contacting
the primary care physician prior to the initiation of a lytic drug, cardiology
consultation, and preparation of the drug in the pharmacy rather than in
the emergency department, significantly delay the goal of early treatment
of patients with ST segment elevation acute myocardial infarction. Delays
in hospital arrival for women are compounded by delays in the decision to
treat them with a thrombolytic drug and initiation of the drug therapy in
those women who receive consultation compared with men. Other delays in acquiring
the first ECG and initiating the drug infusion in women are not explained.
PMID: 9531226 [PubMed - indexed for MEDLINE]
-
Sex differences in myocardial infarction
and coronary deaths in the Scottish MONICA population of
Glasgow 1985 to 1991. Presentation, diagnosis, treatment,
and 28-day case fatality of 3991 events in men and 1551 events
in women.
Tunstall-Pedoe H, Morrison C, Woodward M, Fitzpatrick
B, Watt G.
Scottish MONICA Project: Cardiovascular Epidemiology Unit, University of
Dundee, Ninewells Hospital, Glasgow, Scotland, UK.
BACKGROUND: Scottish MONICA used medical and medico-legal records and World
Health Organization MONICA Project criteria to register coronary events in
25- to 64-year-old residents of the high-incidence area of north Glasgow
from 1985 to 1991. METHODS AND RESULTS: Age-standardized data from 3991 episodes
of nonfatal definite myocardial infarction and coronary deaths in men (mean
age, 55.5 years) were compared with 1551 in women (57.0 years). Many results,
such as the overall 28-day fatality rates of 49.8% in men and 48.5% in women,
showed insignificant differences. However, 74.3% of deaths in men occurred
out of hospital versus 67.8% in women (P = .0004). After admission to hospital,
fatality rates in women were 14% higher (P = .07) and after admission to
coronary care, 22% higher (P = .04). Women were more often widowed. Fewer
had a history of previous myocardial infarction, but the prevalence of angina
pectoris, of smoking, and of chest pain in the attack was the same as in
men; more had shock, syncope, and breathlessness. More consulted a doctor
before admission to hospital, which delayed their coming under care. More
men had ECG Q-wave progression, and more women had smaller ECG changes. This,
and marginally reduced chances of direct admission to coronary care, of thrombolysis,
of aspirin, and of beta-blockers, did not explain women's excess hospital
fatality. CONCLUSIONS: Acute coronary events appear to be recognized and
treated fairly equally in men and women 25 to 64 years old in Glasgow, so
differences are small but subtle. More men die suddenly out of hospital;
the reason why more women die after arrival may be because the equivalent
number of men have already died outside.
PMID: 8640972 [PubMed - indexed for MEDLINE]
-
-
Prognostic value of ischemic electrocardiographic
findings for cardiovascular mortality in men and women.
De Bacquer D, De Backer G, Kornitzer M, Myny K, Doyen
Z, Blackburn H.
Department of Public Health, University of Ghent, Belgium. dirk.debacquer@rug.ac.be
OBJECTIVES: The aim of this study was to investigate the independent prognostic
value of ischemic electrocardiographic (ECG) findings for cardiovascular
mortality and to evaluate a possible sex-differential in this regard. BACKGROUND:
In previous reports, ST segment and T wave changes on the resting ECG were
described as independent risk factors for development of coronary heart disease.
Although more prevalent in women, they are often given less clinical importance
than in men. METHODS: Ten-year follow-up data from the Belgian Interuniversity
Research on Nutrition and Health study were used. The results presented here
are based on ECGs of the 4,797 men and 4,320 women, aged 25 to 74 years,
who were free of angina pectoris at the start of follow-up, had no history
of myocardial infarction (MI) and showed no Q wave evidence of an old MI
on their ECG. RESULTS: At baseline, the age-standardized prevalence of an "ischemic
ECG" (Minnesota codes I3, IV1-3, V1-3 or VII1) was 8.4% in men and 10.6%
in women. Cardiovascular mortality rates in men and women with an ischemic
ECG were respectively 7.7 and 2.6 per 1,000 person-years, compared with 2.3
and 1.0 in those with no such ECG findings. After correction for the potential
confounding effects of established cardiovascular disease (CVD) risk factors,
the multivariately adjusted risk ratios were 2.45 (95% confidence interval
[CI]: 1.70 to 3.53) for men and 2.16 (95% CI: 1.30 to 3.58) for women. Testing
the interaction between an ischemic ECG and sex on CVD mortality revealed
that the risk ratios were not significantly changed (p=0.95). The etiologic
fraction of CVD deaths attributable to an ischemic ECG was estimated as 19.3%
for men and 22.4% for women. Both men and women with major ischemic findings
in their baseline electrocardiogram (Minnesota codes IV1,2, V1,2 or VII1)
had a fourfold increased risk of CVD death. CONCLUSION: These results support
the hypothesis that women with ischemic ECG findings are at the same increased
risk for CVD mortality as men.
PMID: 9741511 [PubMed - indexed for MEDLINE]
-
-
Gender differences in the relation between
ST-T-wave abnormalities at baseline electrocardiogram and
stress myocardial perfusion abnormalities in patients with
suspected coronary artery disease.
Elhendy A, van Domburg RT, Bax JJ, Roelandt JR.
Thoraxcenter, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands.
The presence of ST-T-wave abnormalities in the resting electrocardiogram
was reported as a predictor of coronary artery disease (CAD) and increased
morbidity and mortality. However, the independent value of ST-T abnormalities
for predicting the presence and severity of perfusion abnormalities during
stress testing has not been studied in a homogenous patient group without
known CAD. We evaluated the relation between resting ST-T abnormalities and
myocardial perfusion abnormalities in 246 patients (age 59 +/- 13 years,
114 men and 132 women) without known CAD or previous myocardial infarction
referred for evaluation of possible myocardial ischemia by dobutamine (up
to 40 microg/kg/min) stress sestamibi or tetrofosmin single-photon emission
computed tomographic imaging. Resting ST-T abnormalities were present in
123 patients, whereas 123 patients with normal resting electrocardiograms
served as a matched control group. Abnormal myocardial perfusion (fixed or
reversible perfusion defects) was detected in 72% of men with and in 35%
of men without resting ST-T abnormalities (p <0.0001), whereas the prevalence
of myocardial perfusion abnormalities was not different in women with and
without resting ST-T abnormalities (27% vs 23%, p = NS). In the entire population,
independent predictors of an abnormal perfusion by multivariate analysis
of clinical characteristics and risk factors were male gender (p <0.001,
chi-square 10.5) and resting ST-T abnormalities (p <0.05, chi-square 3).
Separate analysis of patients based on gender revealed resting ST-T abnormalities
as independent predictors of abnormal perfusion in men (p <0.05, chi-square
4) but not in women. Stress perfusion defect score was higher in men with
than without ST-T abnormalities (887 +/- 545 vs 207 +/- 180, p <0.001).
It is concluded that resting ST-T wave abnormalities are associated with
a higher prevalence and severity of resting and dobutamine-induced myocardial
perfusion abnormalities in men but not in women. Resting ST-T wave abnormalities
are powerful predictors of compromised myocardial perfusion independent of
other clinical risk factors of CAD in men.
PMID: 10532501 [PubMed - indexed for MEDLINE]
-
Gender differences and the electrocardiogram
in left ventricular hypertrophy.
Okin PM, Roman MJ, Devereux RB, Kligfield P.
Department of Medicine, New York Hospital-Cornell Medical Center, NY 10021.
We examined the relations of gender differences in electrocardiographic (ECG)
voltages and QRS duration to differences in cardiac dimensions and body size
between men and women and gender differences in test performance of ECG criteria
for the detection of echocardiographic left ventricular hypertrophy in 389
subjects (112 women and 277 men). ECG voltage-duration products were calculated
as the product of QRS duration and voltages. Among subjects with normal left
ventricular mass and also among subjects with left ventricular hypertrophy,
men had longer QRS duration, higher Cornell voltage, higher 12-lead sum of
QRS voltage, and higher Cornell and 12-lead voltage-duration products than
did women. Significant gender differences in QRS duration, Cornell voltage,
the 12-lead sum of voltage and their voltage-duration products remained after
adjusting for the greater left ventricular mass, height, and weight in men
than women. Comparison of areas under receiver operating characteristic curves
using gender-specific criteria demonstrated higher performance of QRS duration,
Cornell voltage, the 12-lead sum of QRS voltage, and the respective voltage-duration
products for the identification of left ventricular hypertrophy in men than
women. Thus, gender differences in body size and left ventricular mass do
not completely account for gender differences in QRS duration and voltage
measurements, and ECG criteria for left ventricular hypertrophy have lower
accuracy in women even when gender differences in partition value selection
are taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)
PMID: 7843774 [PubMed - indexed for MEDLINE]
-
Left-ventricular hypertrophy in the elderly:
unreliability of ECG criteria in 477 subjects aged 65 years
or more. The CArdiovascular STudy in the ELderly (CASTEL).
Casiglia E, Maniati G, Daskalakis C, Colangeli G, Tramontin
P, Ginocchio G, Spolaore P.
Department of Internal Medicine, University of Padova, Italy.
AIM: To evaluate the diagnostic reliability of the ECG diagnosis of left-ventricular
hypertrophy (LVH) in a cohort of elderly subjects taken from a general population.
PATIENTS: The 447 subjects with perfect echocardiography and ECG results
of the 2,254 included in the Cardiovascular Study in the Elderly. METHODS:
Sensitivity, specificity, positive and negative predictive value of the most
commonly used ECG tests of LVH were calculated versus the gold standard,
echocardiography. RESULTS: All ECG tests had a very low sensitivity. Furthermore,
except for the Cornell index and (at least in the normotensives) the Minnesota
code, they were not able to demonstrate the higher prevalence of LVH in elderly
females in comparison to males. The predictive value of ECG was constantly
higher in males than females when negative; when positive, some tests were
more predictive in males, some in females, and in others, equally predictive
in both sexes. CONCLUSIONS: ECG is not a reliable method for screening LVH
in elderly populations. Echocardiography and ECG give different information,
and their reliability may be different if positive or negative.
PMID: 8894265 [PubMed - indexed for MEDLINE]
-
Comment in:
Diagnosis of suspected coronary artery disease in women:
a cost-effectiveness analysis.
Kim C, Kwok YS, Saha S, Redberg RF.
Department of Medicine and the Division of Cardiology, University of California,
San Francisco, CA 94131-0214, USA.
BACKGROUND: The optimal strategy for the diagnosis of coronary artery disease
(CAD) in women is not well defined. We compared the cost-effectiveness of
several strategies for diagnosing CAD in women with chest pain. METHODS:
We performed decision and cost-effectiveness analyses with simulations of
55-year-old ambulatory women with chest pain. With a Markov model, simulations
of patients underwent exercise electrocardiography, exercise testing with
thallium scintigraphy, exercise echocardiography, angiography, or no workup.
RESULTS: Diagnosis with angiography cost less than $17, 000 per quality-adjusted
life-year compared with exercise echocardiography if the patient had definite
angina and less than $76,000 per life-year if she had probable angina. If
she had nonspecific chest pain, diagnosis with exercise echocardiography
increased life-years compared with no testing. CONCLUSIONS: Cost-effectiveness
of first-line diagnostic strategy for diagnosis of CAD in women varies mostly
according to pretest probability of CAD. Diagnosis of coronary artery disease
with angiography is cost-effective in 55-year-old women with definite angina.
In 55-year-old women with probable angina, diagnosis with angiography would
increase quality-adjusted life-years but significantly increase costs. Use
of exercise echocardiography as a first-line diagnosis for CAD is cost effective
in 55-year-old women with probable angina and nonspecific chest pain.
PMID: 10347326 [PubMed - indexed for MEDLINE
-
-
Gender differences in use of stress testing
and coronary heart disease mortality: a population-based
study in Olmsted County, Minnesota.
Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey
KR, Gersh BJ.
Mayo Medical Center, Rochester, Minnesota 55905, USA. roger.veronique@mayo.edu
OBJECTIVES: We sought to examine the utilization of exercise stress testing
in relation to age and gender in a population-based setting. BACKGROUND:
The utilization of noninvasive procedures has been shown to be associated
with the subsequent use of invasive procedures. Yet, there are no population-based
data on the utilization of stress testing; in particular, although gender
differences in the use of invasive procedures have been reported, the use
of noninvasive procedures has not been examined in relation to gender. METHODS:
In Olmsted County, Minnesota, passive surveillance of the medical care of
the community is provided through the Rochester Epidemiology Project. A population-based
cohort of Olmsted County residents undergoing exercise tests was identified.
The medical records of residents with prevalent and incident exercise tests
in 1987 and 1988 were reviewed. For persons with an initial test (incidence
cohort), data on clinical presentation, test indications and results were
abstracted. Stress test utilization rates were calculated, and crude rates
were directly adjusted to the age distribution of the 1980 U.S. population.
To help interpret patterns of use at the population level, coronary heart
disease mortality rates (International Classification of Diseases, 9th revision,
codes 410 to 414) were calculated (crude and directly adjusted to the overall
age distribution of the 1980 U.S. population) and used as an indicator of
coronary disease burden. RESULTS: A total of 2,624 tests were performed.
The crude utilization rate (per 100,000) was 1,888 for men and 703 for women
(rate ratio for men over women 2.7, 95% confidence interval [CI] 2.5 to 2.9);
it remained significantly higher in men across all age strata. The crude
incidence rate (per 100,000) of initial stress tests was 1,112 for men and
517 for women (rate ratio 2.2, 95% CI 1.9 to 2.4). For both men and women,
the incidence increased with age; however, incidence remained lower in women
in all age strata. At the time that they underwent an initial test, women
were more symptomatic and had poorer exercise performance than men. The rate
ratio of men over women for coronary heart disease mortality was 1.1 (95%
CI 0.9 to 1.2). The age-adjusted rate ratios for stress test utilization
were 2.8 (95% CI 2.5 to 3.0), and that for coronary heart disease mortality
was 1.9 (95% CI 1.7 to 2.2). CONCLUSIONS: These population-based data show
that during the study period, the utilization of stress testing in Olmsted
County was lower in women than in men. Women in the incidence cohort were
older and more symptomatic and had poorer exercise performance than men.
Such differences should be considered when examining the utilization of subsequent
invasive procedures according to gender.
PMID: 9708459 [PubMed - indexed for MEDLINE]
-
Comment in:
Meta-analysis of exercise testing to detect coronary
artery disease in women.
Kwok Y, Kim C, Grady D, Segal M, Redberg R.
Department of Medicine, University of California, San Francisco, USA.
To determine the accuracy of the exercise electrocardiogram (ECG), exercise
thallium, and exercise echocardiogram (echo) for the diagnosis of coronary
artery disease in women, English language studies published between 1966
and 1995 were identified through a MEDLINE search. Studies that contained
data on at least 50 women who underwent both an exercise test and coronary
angiography were examined. Studies were reviewed for sensitivity, specificity,
and methodologic characteristics by 2 independent reviewers. Nineteen studies
met the inclusion criteria for exercise electrocardiography, 5 studies for
exercise thallium, and 3 studies for exercise echo. The exercise ECG had
a weighted mean sensitivity, specificity, and a likelihood ratio (LR) of
0.61 (95% confidence intervals 0.54 to 0.68), 0.70 (0.64 to 0.75), (+) LR
2.25 (1.84 to 2.66), (-) LR 0.55 (0.47 to 0.62), respectively. The exercise
thallium had a weighted mean sensitivity, specificity, and LRs of 0.78 (0.72
to 0.83), 0.64 (0.51 to 0.77), (+) LR 2.87 (1.0 to 4.96), (-) LR 0.36 (0.27
to 0.45). The exercise echo had a weighted mean sensitivity, specificity,
and LRs of 0.86 (0.75 to 0.96), 0.79 (0.72 to 0.86), (+) LR 4.29 (2.93 to
5.65), (-) LR 0.18 (0.05 to 0.31). Thallium subset analysis revealed that
studies using planar imaging were more specific than those using tomographic
imaging. Thus, currently available exercise tests are only moderately sensitive
and specific for the diagnosis of coronary artery disease in women.
Publication Types:
PMID: 10080415 [PubMed - indexed for MEDLINE
-
-
Gender-specific criteria and performance
of the exercise electrocardiogram.
Okin PM, Kligfield P.
Department of Medicine, New York Hospital-Cornell Medical Center, New York
10021, USA.
BACKGROUND: Significant gender differences have been found in performance
of the exercise ECG for the identification of coronary artery disease. However,
identical exercise ECG ST segment criteria have been used in men and women,
which might contribute to the lower accuracy of these methods in women than
in men. METHODS AND RESULTS: To assess the effect of gender-specific test
partitions on relative performance of standard and heart rate-adjusted ST
segment depression criteria in men and women, the exercise ECGs of 143 women
and 477 men were examined. Non-gender-specific test partitions, selected
to have matched specificities of 96% for each test method, were determined
in all 283 normal subjects, and gender-specific test partitions with identical
specificity were determined separately in the 52 normal women and 231 normal
men; sensitivity of these criteria was then examined in the 91 women and
246 men with coronary disease. Standard ST segment depression criteria (0.1
mV of additional horizontal or downsloping ST segment depression at end exercise)
with identical 96% specificity in the entire group of normal subjects and
separately in women and men had a significantly lower sensitivity of 51%
in women compared with 67% in men (P < .01). Among women, performance
of the ST segment/heart rate (ST/HR) slope was more improved than that of
the ST/HR index by the use of gender-specific criteria. Compared with the
performance of non-gender-specific criteria, application of gender-specific
ST/HR slope partitions with matched specificity of 96% resulted in a significant
increase in sensitivity in women from 84% to 91% (P < .01), with no significant
change in sensitivity in men (89% to 88%) and with no residual difference
in sensitivity between men and women. Although the use of gender-specific
ST/HR slope criteria significantly improved sensitivity in both men and women
with respect to standard criteria (each P < .0001), the relative increase
in sensitivity provided by heart rate adjustment was significantly greater
in women than in men (40% versus 21%, P < .001). Similar gender differences
in improvement in performance using gender-specific criteria for the ST/HR
slope were observed when analysis of test performance was restricted to the
detection of three-vessel coronary disease (50% versus 9%, P = .002). CONCLUSIONS:
At high specificity, gender-specific test partitions improve sensitivity
of the ST/HR slope for the identification of coronary disease in women, with
no decrease in sensitivity in men. In contrast, gender-specific partitions
do not change performance of standard test criteria, which is lower in women
than in men. Accordingly, the relative benefit of heart rate adjustment by
the ST/HR slope method is greater in women than in men. These findings support
use of the ST/HR slope with use of gender-specific partitions for the identification
and quantification of coronary artery disease in both men and women.
PMID: 7648667 [PubMed - indexed for MEDLINE
-
-
Sex and diagnostic evaluation of possible
coronary artery disease after exercise treadmill testing
at one academic teaching center.
Lauer MS, Pashkow FJ, Snader CE, Harvey SA, Thomas JD,
Marwick TH.
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Controversy exists as to whether a sex bias exists that affects the diagnostic
approach to suspected coronary artery disease: previous studies have used
coronary angiography, but not other noninvasive testing, as a primary end
point. This investigation examined posttest sex differences in diagnostic
evaluation after exercise treadmill testing according to a broader end point
than just coronary angiography alone. The design was a cohort analytic study
with a 90-day follow-up. The study was done at the Cleveland Clinic Foundation,
an academic group practice. Patients included consecutive adults (1023 men
and 579 women) with chest pain but no documented coronary disease who were
referred for symptom-limited exercise treadmill testing without adjunctive
imaging; none had undergone prior invasive cardiac procedures. Main outcome
measures included (1) performance of any subsequent diagnostic study (invasive
or noninvasive) and (2) performance of coronary angiography as the next diagnostic
study. During follow-up, 89 (8.7%) men and 48 (8.3%) women underwent a second
diagnostic study (odds ratio 0.95; 95% confidence interval 0.66 to 1.37;
p > 0.8), whereas 64 (6.3%) men and 21 (3.6%) women went straight to coronary
angiography (odds ratio 0.56; 95% confidence interval 0.34 to 0.93; p = 0.02).
In multivariable logistic regression analyses, which considered baseline
clinical characteristics, the ST-segment response, and other prognostically
important exercise responses, women tended to be less likely than men to
be referred to any second test (adjusted odds ratio 0.70; 95% confidence
interval 0.42 to 1.19; p > 0.1) but were markedly and significantly less
likely to be referred straight to coronary angiography (adjusted odds ratio
0.33; 95% confidence interval 0.17 to 0.65). After exercise treadmill testing,
women were only slightly less likely than men to be referred for subsequent
diagnostic testing; they were, however, much less likely to be referred straight
to coronary angiography as opposed to another noninvasive study.
PMID: 9398092 [PubMed - indexed for MEDLINE]
-
Gender differences in the noninvasive
evaluation and management of patients with suspected coronary
artery disease.
Shaw LJ, Miller DD, Romeis JC, Kargl D, Younis LT, Chaitman
BR.
St. Louis University School of Medicine, Missouri.
OBJECTIVE: To determine if gender-based differences exist in the post-test
management and clinical outcome of patients with clinically suspected coronary
artery disease who have stress electrocardiographic or myocardial perfusion
imaging evaluation. DESIGN: Retrospective cohort study. SETTING: University
medical center. PATIENTS: From a cohort of 3975 middle-aged patients referred
for outpatient stress testing, 840 (47% women) were evaluated noninvasively
for clinically suspected coronary artery disease. MEASUREMENTS: The rates
of subsequent diagnostic procedures and the incidence of subsequent coronary
revascularization, myocardial infarction, or cardiac death were determined
for women and men. RESULTS: Pretest cardiac risk profiles were similar, except
hypertension and hypercholesterolemia were more frequent in women. Atypical
angina was more common in women than in men (57.5% compared with 44.5%, respectively;
P < 0.001). Rates of initial test positivity (defined as exercise-induced
horizontal or downsloping ST-segment depression > or = 1.0 mm or > or
= 1 reversible thallium-201 defect) were similar in women and men. Compared
with men, most women with an initial positive test result had no additional
coronary artery disease evaluation (62.3% compared with 38.0%; P = 0.002).
Coronary revascularization procedures were done more frequently in men (4.9%
[22 of 449] compared with 2.0% [8 of 391]; P = 0.03). Cardiac death or myocardial
infarction occurred more often in women during 2 years of follow-up (6.9%
[27 of 391] compared with 2.4% [11 of 449]; P = 0.002). CONCLUSIONS: Women
with suspected coronary artery disease have fewer additional diagnostic tests
than men after an initial abnormal noninvasive stress test result, even though
the incidence of typical angina, cardiac risk factors, and initial diagnostic
test positivity rates are similar.
PMID: 8116993 [PubMed - indexed for MEDLINE
-
-
Prognostic value of treadmill exercise
testing: a population-based study in Olmsted County, Minnesota.
Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey
KR, Gersh BJ.
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and
Mayo Foundation, Rochester, Minn 55905, USA.
BACKGROUND: The prognostic value of treadmill exercise testing (TMET) has
been studied in selected populations. The generalizability of these data
to different populations and to women is uncertain. METHODS AND RESULTS:
A retrospective, population-based cohort study of all persons (1452 men and
741 women) who underwent TMET in years 1987 to 1989 in Olmsted County, Minnesota,
was undertaken. Individuals were followed up for all-cause mortality and
cardiac events (cardiac deaths, nonfatal myocardial infarction, or congestive
heart failure). Sex-specific analyses were performed to determine whether
the predictors of outcome and the magnitude of the associations were similar
in both sexes. In men, 77 deaths and 106 cardiac events occurred during 8956
person-years of observation; in women, 46 deaths and 54 cardiac events occurred
during 4801 person-years of follow-up. Exercise-induced angina, ECG changes,
and workload achieved on the TMET were strongly associated with all-cause
mortality and cardiac events in both sexes, and the strength of the association
was similar. After adjustment, workload was the only TMET variable associated
with outcome. A higher workload was associated with a reduction in the risk
of cardiac events and of all-cause mortality; the protective effect of exercise
capacity was strong and was similar in both sexes. CONCLUSIONS: In this population-based
cohort, exercise capacity was the TMET variable that exhibited the strongest
association with all-cause mortality and cardiac events. This protective
effect of exercise capacity was observed in both sexes.
PMID: 9860784 [PubMed - indexed for MEDLINE]
-
Incremental value of exercise electrocardiography
and thallium-201 testing in men and women for the presence
and extent of coronary artery disease.
Morise AP, Diamond GA, Detrano R, Bobbio M.
Department of Medicine, West Virginia University School of Medicine, Morgantown
26506, USA.
Our goal was to assess the incremental value of exercise testing in men and
women for the diagnosis and extent of coronary artery disease. With data
from one center, incremental logistic algorithms were developed and evaluated
in a separate set of 865 patients from four centers. Variables included were
pretest (age, sex, symptoms, diabetes, smoking, and cholesterol concentration);
exercise electrocardiogram (ECG) (ST-segment depression [millimeters], ST-segment
slope, peak heart rate, and change in systolic blood pressure); and thallium-201
scintigram (defect presence, reversibility, and intensity of hypoperfusion).
End points were coronary disease presence (50% diameter stenosis) and extent
(multivessel disease). Accuracy and incremental value were assessed by receiver
operating characteristic (ROC) curve analysis. Incremental ROC curve areas
for disease presence were pretest 0.75 +/- 0.02, post-exercise ECG 0.82 +/-
0.01, and post-thallium scintigram 0.85 +/- 0.01 and for disease extent were
pretest 0.71 +/- 0.02, post-exercise ECG 0.76 +/- 0.02, and post-thallium
scintigram 0.78 +/- 0.02 (p < 0.005 for all increments). Incremental increases
in accuracy were similar for men and women. We conclude that when multivariable
algorithms derived from one center were applied to a separate group, there
was a significant incremental increase in accuracy associated with exercise
testing for the presence and extent of coronary disease. This increase in
accuracy was similar for men and women.
Publication Types:
PMID: 7631606 [PubMed - indexed for MEDLINE]
-
Factors affecting sensitivity and specificity
of a diagnostic test: the exercise thallium scintigram.
Detrano R, Janosi A, Lyons KP, Marcondes G, Abbassi
N, Froelicher VF.
Veterans Administration Medical Center, Long Beach, California 90822.
Technical and methodological factors might affect the reported accuracies
of diagnostic tests. To assess their influence on the accuracy of exercise
thallium scintigraphy, the medical literature (1977 to 1986) was non-selectively
searched and meta-analysis was applied to the 56 publications thus retrieved.
These were analyzed for year of publication, sex and mean age of patients,
percentage of patients with angina pectoris, percentage of patients with
prior myocardial infarction, percentage of patients taking beta-blocking
medications, and for angiographic referral (workup) bias, blinding of tests,
and technical factors. The percentage of patients with myocardial infarction
had the highest correlation with sensitivity (0.45, p = 0.0007). Only the
inclusion of subjects with prior infarction and the percentage of men in
the study group were independently and significantly (p less than 0.05) related
to test sensitivity. Both the presence of workup bias and publication year
adversely affected specificity (p less than 0.05). Of these two factors,
publication year had the strongest association by stepwise linear regression.
This analysis suggests that the reported sensitivity of thallium scintigraphy
is higher and the specificity lower than that expected in clinical practice
because of the presence of workup bias and the inappropriate inclusion of
post-infarct patients.
PMID: 3041808 [PubMed - indexed for MEDLINE]
-
Gender-related imaging issues in assessment
of coronary artery disease by nuclear techniques.
Grover-McKay M.
Division of Cardiovascular Diseases, University of Iowa, Iowa City 52242-1081,
USA.
Heart disease is a major threat to women's health. However, noninvasive evaluation
of women for the presence of significant heart disease is often problematic.
Cardiovascular nuclear tests interrogate different consequences of physiologically
significant coronary artery disease (CAD). Myocardial perfusion imaging supplies
information about regional myocardial blood flow. Radionuclide angiocardiography
provides information about ejection fraction and regional wall motion. Infarct
and metabolic imaging yield information about myocardial viability. This
article briefly discusses the concepts and radionuclides involved in cardiovascular
nuclear testing and reviews published studies as they relate to assessment
of coronary artery disease in women. Myocardial perfusion imaging is a reasonable
test for detection of coronary artery disease in women, especially when attenuation
artifacts from breast tissue are taken into account. Intravenous dipyridamole
stress provides comparable overall accuracy in women and men although women
reportedly have a higher incidence of side effects; gender-specific data
have not been reported for adenosine. Sufficient gender-specific data are
also not currently available for either 99mTc or positron-emitting perfusion
tracers. Exercise radionuclide angiography can help determine the probability
of significant left main or severe three vessel disease but provides only
limited prognostic information in women with CAD. Thus in women, although
choice of testing using nuclear techniques depends in part on local experience
and expertise, myocardial perfusion imaging appears preferable to radionuclide
angiocardiography for detection of significant CAD. To determine the most
accurate methods to evaluate women for the presence of significant CAD, all
current and future studies of diagnostic testing for CAD should analyze data
separately for women and men.
Publication Types:
PMID: 8680134 [PubMed - indexed for MEDLINE]
-
-
Effective risk stratification using exercise
myocardial perfusion SPECT in women: gender-related differences
in prognostic nuclear testing.
Hachamovitch R, Berman DS, Kiat H, Bairey CN, Cohen
I, Cabico A, Friedman J, Germano G, Van Train KF, Diamond
GA.
Department of Imaging (Division of Nuclear Medicine), Cedars-Sinai Medical
Center, Los Angeles, California 90048, USA.
OBJECTIVES: This study was designed to evaluate the incremental prognostic
value over clinical and exercise variables of rest thallium-201/exercise
technetium-99m sestamibi single-photon emission computed tomography (SPECT)
in women compared with men and to determine whether this test can be used
to effectively risk stratify patients of both genders. BACKGROUND: To minimize
the previously described gender-related bias in the evaluation of coronary
artery disease in women, there is a need to identify a noninvasive testing
strategy that is able to accurately and effectively risk stratify women.
METHODS: We identified 4,136 consecutive patients (2,742 men, 1,394 women)
who underwent dual-isotope SPECT. The incremental value of nuclear testing
was determined using both a stepwise Cox proportional hazards model and Kaplan-Meier
survival analysis. Receiver operating characteristic curve analysis was performed
to determine test discrimination for high risk patients in men and women.
RESULTS: The patient population was followed up for 20 +/- 5 months for events
(cardiac death or nonfatal myocardial infarction). During this time, 63 myocardial
infarctions and 32 cardiac deaths occurred in the men, and 31 myocardial
infarctions and 14 cardiac deaths occurred in the women. Nuclear testing
significantly stratified both men and women irrespective of their rest electrocardiogram.
Cox proportional hazards analysis revealed that nuclear testing added incremental
prognostic value in both men and women after inclusion of the most predictive
clinical exercise variables (overall chi-square 89 in men vs. 120 in women,
p < 0.005). Kaplan-Meier survival analysis demonstrated that nuclear testing
further stratified men and women with both intermediate to high and low prescan
likelihoods of coronary artery disease (p < 0.005 for all). Receiver operating
characteristic curve analysis demonstrated superior discrimination for the
nuclear scan results in identifying high risk women than men (area under
the curve: 0.84 +/- 0.03 vs 0.71 +/- 0.03 in men, p < 0005). The odds
ratio comparing event rates in patients with women than in men, suggesting
superior stratification using nuclear testing in women. CONCLUSIONS: Dual-isotope
myocardial perfusion imaging yields incremental prognostic value in both
men and women. This modality identifies low risk women and men equally well
but relatively high risk women more accurately than relatively high risk
men and, thus, is able to stratify women more effectively than men.
PMID: 8752792 [PubMed - indexed for MEDLINE]
-
-
Comparative diagnostic accuracy of Tl-201
and Tc-99m sestamibi SPECT imaging (perfusion and ECG-gated
SPECT) in detecting coronary artery disease in women.
Taillefer R, DePuey EG, Udelson JE, Beller GA, Latour
Y, Reeves F.
Department of Nuclear Medicine, Hotel-Dieu De Montreal, Quebec, Canada.
OBJECTIVES: This prospective study was conducted in 115 women to directly
compare the sensitivity and specificity of thallium-201 (Tl-201), technetium-99m
(Tc-99m) sestamibi perfusion and Tc-99m sestamibi electrocardiographic (ECG)-gated
single-photon emission computed tomographic (SPECT) studies for detection
of coronary artery disease (CAD). BACKGROUND: Data on the comparative diagnostic
accuracy of Tl-201 and Tc-99m sestamibi perfusion imaging for the detection
of CAD, specifically in women, are very limited. METHODS: Eighty-five patients
with suspected CAD, scheduled for coronary angiography, and 30 volunteers
with a pretest likelihood of < or = 5% for CAD were evaluated. Within
1 week, each patient underwent Tl-201 and Tc-99m sestamibi SPECT imaging
procedures (both perfusion and gated SPECT imaging). Treadmill stress testing
was used in 78 patients and dipyridamole in the remaining 37 patients. All
images were interpreted by three observers in a blinded manner (consensus
reading). Technetium-99m sestamibi SPECT studies were read without and then
with ECG gating. Technetium-99m sestamibi gated SPECT studies were used to
differentiate scar tissue from soft tissue attenuation artifact. RESULTS:
The overall sensitivities for detecting > or = 50% and > or = 70% stenoses
were 75.0% and 84.3%, respectively, for Tl-201, and 71.9% and 80.4%, respectively,
for Tc-99m sestamibi perfusion studies (p = 0.48). The specificity for lesions > or
= 50% was 61.9% for Tl-201 and 85.7% for Tc-99m sestamibi perfusion (p =
0.07), whereas for lesions > or = 70% it was 58.8% for Tl-201 and 82.4%
for Tc-99m sestamibi perfusion (p = 0.01). When the 34 patients with a normal
coronary angiogram were added to the group of 30 normal volunteers, the "specificity" for
lesions > or = 70% was 67.2% for Tl-201, 84.4% for Tc-99m sestamibi SPECT
perfusion (p = 0.02) and 92.2% for Tc-99m sestamibi gated SPECT (p = 0.0004).
CONCLUSIONS: Both Tl-201 SPECT and Tc-99m sestamibi SPECT perfusion studies
had a similar sensitivity for the detection of CAD in women. However, Tc-99m
sestamibi SPECT perfusion imaging shows a significantly better specificity,
which is further enhanced by the use of ECG gating.
PMID: 8996297 [PubMed - indexed for MEDLINE]
-
Comment in:
Exercise echocardiography or exercise SPECT imaging?
A meta-analysis of diagnostic test performance.
Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS.
Cardiology Division, University of California, Medical Center, San Francisco
94143-0214, USA. Fleischm@cardio.ucsf.edu
CONTEXT: Cardiac imaging has advanced rapidly, providing clinicians with
several choices for evaluating patients with suspected coronary artery disease,
but few studies compare modalities directly. OBJECTIVES: To review the contemporary
literature and to compare the diagnostic performance of exercise echocardiography
(ECHO) and exercise single-photon emission computed tomography (SPECT) imaging
in the diagnosis of coronary artery disease. DATA SOURCES: Studies published
between January 1990 and October 1997 identified from MEDLINE search; bibliographies
of reviews and original articles; and suggestions from experts in each area.
STUDY SELECTION: Articles were included if they discussed exercise ECHO and/or
exercise SPECT imaging with thallous chloride TI 201 (thallium) or technetium
Tc 99m sestamibi for detection and/or evaluation of coronary artery disease,
if data on coronary angiography were presented as the reference test, and
if the absolute numbers of true-positive, false-negative, true-negative,
and false-positive observations were available or derivable from the data
presented. Studies performed exclusively in patients after myocardial infarction,
after percutaneous transluminal coronary angioplasty, after coronary artery
bypass grafting, or with recent unstable coronary syndromes were excluded.
DATA EXTRACTION: Clinical variables, technical factors, and test performance
were independently extracted by 2 reviewers on a standardized spreadsheet.
Discrepancies were resolved by consensus. RESULTS: Forty-four articles met
inclusion criteria. In pooled data weighted by the sample size of each study,
exercise ECHO had a sensitivity of 85% (95% confidence interval [CI], 83%-87%)
with a specificity of 77% (95% CI, 74%-80%). Exercise SPECT yielded a similar
sensitivity of 87% (95% CI, 86%-88%) but a lower specificity of 64% (95%
CI, 60%-68%). In a summary receiver operating characteristic model comparing
exercise ECHO performance to exercise SPECT, exercise ECHO was associated
with significantly better discriminatory power (parameter estimate, 1.18;
95% CI, 0.71-1.65), when adjusted for age, publication year, and a setting
including known coronary artery disease for SPECT studies. In models comparing
the discriminatory abilities of exercise ECHO and exercise SPECT vs exercise
testing without imaging, both ECHO and SPECT performed significantly better
than exercise testing. The incremental improvement in performance was greater
for ECHO (3.43; 95% CI, 2.74-4.11) than for SPECT (1.49; 95% CI, 0.91-2.08).
CONCLUSIONS: Exercise ECHO and exercise SPECT have similar sensitivities
for the detection of coronary artery disease, but exercise ECHO has better
specificity and, therefore, higher overall discriminatory capabilities as
used in contemporary practice.
Publication Types:
PMID: 9739977 [PubMed - indexed for MEDLINE]
-
Stress echocardiography in women.
Tong AT, Douglas PS.
Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts,
USA.
The diagnosis of coronary heart disease in women has been thought to be more
difficult than in men, owing to the overall lower prevalence and severity
of disease in women, as well as more subtle clinical presentations. Exercise
electrocardiography is associated with a high rate of false-positive results.
In contrast, exercise and pharmacologic stress echocardiography have been
shown to have high sensitivity, specificity, and prognostic value in women,
comparable to that obtained in a male population. Although exercise thallium
provides high f disease accuracy, due to its cost, availability, and radiation
exposure, it may not be the ideal initial test in women. Thus, compared with
other modalities, the advantages of stress echocardiography include its lower
cost, availability, and high diagnostic accuracy. In the evaluation of women
with chest pain, the initial step should involve clinical stratification
into low, moderate, or high-probability groups based on symptoms, age, and
cardiovascular risk factors. In women with atypical chest pain and a low
probability of coronary heart disease, further testing should be avoided
because any positive result is likely to be falsely positive. In those women
with a moderate likelihood of disease, the most efficient and cost-effective
strategy includes stress echocardiography as the initial test. This approach
avoids the high rate of false-positive results with subsequent unnecessary
angiography generated by exercise electrocardiography, as well as minimalizing
false-negative results, which would lead to delays and potential increase
in morbidity and mortality from untreated coronary heart disease. The optimal
strategy for women at high clinical risk may be either exercise echocardiography
or cardiac catheterization as the initial test. Although the diagnosis of
CAD in women is different than in men, it is not necessarily more difficult.
Astute clinical evaluation, in conjunction with judicious use of diagnostic
testing, yields excellent results.
Publication Types:
PMID: 10453299 [PubMed - indexed for MEDLINE]
-
-
Influence of gender on physiologic response
and accuracy of dobutamine echocardiography.
Secknus MA, Marwick TH.
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Dobutamine echocardiography (DE) has been shown to be safe, feasible, and
accurate for identification of coronary artery disease (CAD) in mixed populations.
The purpose of this study was to examine gender differences in physiologic
response and accuracy of DE. We studied 2,886 consecutive DEs, performed
in 2,748 patients, 1,209 of whom (44%) were women. A standard incremental
protocol (5 to 40 microg/kg/min in 3-minute stages) was followed by atropine
and/or an additional stage with 50 microg/kg/min, if the heart rate response
was inadequate. Hemodynamic and echocardiographic findings were recorded
at each stage. Three hundred sixty-nine patients without previous cardiac
intervention (including 135 women) also underwent cardiac catheterization
within 1 year of DE. Significant coronary stenoses (defined angiographically
as >50% diameter) were present in 67% of women and 65% of men, of whom
55% and 65%, respectively, had multivessel disease. Women had a higher baseline
heart rate (76 +/- 13 vs 73 +/- 14 beats/min, p <0.0001), and showed a
more rapid increase in heart rate at low dose, with a higher age-predicted
maximum heart rate at peak. This led to test termination at target heart
rate but a submaximum dose in 22% of women versus 15% of men (p <0.0001)
and less frequent administration of atropine (29% vs 34%, p <0.01). Dose-limiting
side effects (8% vs 7%) and submaximum heart rate responses (14% vs 17%)
were comparable in men and women. Even after the exclusion of negative DE
at submaximal heart rate responses, the overall sensitivity was significantly
lower in women than men (78% vs 88%, p <0.05), both for single (72% vs
78%, p <0.05) and for multivessel disease (82% vs 93%, p <0.05). The
low specificity in both genders (55% vs 46%) probably reflected post-test
referral bias. Thus, physiologic responses to dobutamine stress are comparable
in men and women, except for a more rapid heart rate response in women, but
the accuracy of DE for diagnosis of CAD in women is less than in men.
Publication Types:
PMID: 9315576 [PubMed - indexed for MEDLINE]
-
-
Gender differences in the accuracy of
dobutamine stress echocardiography for the diagnosis of coronary
artery disease.
Elhendy A, Geleijnse ML, van Domburg RT, Nierop PR,
Poldermans D, Bax JJ, TenCate FJ, Nosir YF, Ibrahim MM,
Roelandt JR.
Thoraxcenter, University Hospital-Dijkzigt, Erasmus University, Rotterdam,
The Netherlands.
The accuracy of dobutamine stress echocardiography (DSE) for the diagnosis
of coronary artery disease (CAD) has not been yet evaluated in women. We
studied the effect of gender on the accuracy of DSE for the diagnosis of
CAD in 306 consecutive patients (210 men and 96 women) with limited exercise
capacity and suspected myocardial ischemia who underwent coronary angiography
within 3 months of DSE. There were no serious complications during DSE. Men
had a higher prevalence of nonsustained ventricular tachycardia (7% vs 0.03%,
p <0.05) and supraventricular tachycardia (9% vs 0.03%, p <0.05) during
the test compared with women. Peak stress rate-pressure product was not different
in men and women (18,140 +/- 4,187 vs 18,543 +/- 4,223). Significant CAD
(> or =50% luminal diameter stenosis) was present in 171 men (81%) and
in 62 women (65%, p <0.005). The sensitivity, specificity, and accuracy
of ischemic pattern at DSE for the diagnosis of significant CAD were 76%
(confidence interval [CI] 67 to 84), 94% (CI 89 to 99), and 82% (CI 75 to
90) in women and 73% (CI 67 to 79), 77% (CI 71 to 83), and 74% (CI 68 to
80) in men, respectively. Overall specificity was higher in women than in
men (p <0.05). Regional accuracy of DSE was significantly higher in women
than in men in the 3 arterial regions (84% [CI 79 to 88] vs 75% [CI 72 to
79], p <0.005). It is concluded that DSE is a safe and feasible method
for the diagnosis of CAD in women. The overall specificity and the regional
accuracy of DSE are higher in women than in men. Further studies are required
to evaluate the functional significance of these findings and their reproducibility
in different patient populations.
PMID: 9399713 [PubMed - indexed for MEDLINE]
-
-
Dobutamine stress echocardiography in
women with chest pain. Pilot phase data from the National
Heart, Lung and Blood Institute Women's Ischemia Syndrome
Evaluation (WISE).
Lewis JF, Lin L, McGorray S, Pepine CJ, Doyle M, Edmundowicz
D, Holubkov R, Pohost G, Reichek N, Rogers W, Sharaf BL,
Sopko G, Merz CN.
WISE Clinical Centers, Division of Cardiology, University of Florida, Gainesville,
USA.
OBJECTIVES: The aim of this project was to assess the utility of dobutamine
stress echocardiography (DSE) for evaluation of women with suspected ischemic
heart disease. BACKGROUND: Most investigations addressing efficacy of diagnosis
and treatment of coronary artery disease (CAD) have been performed in predominantly
male populations. As part of the Women's Ischemia Syndrome Evaluation (WISE)
study, DSE was assessed in women participating at the University of Florida
clinical site. METHODS: Women with chest pain or other symptoms suggestive
of myocardial ischemia and clinically indicated coronary angiography were
eligible for the WISE study. Enrolled subjects underwent DSE using a modified
protocol. Coronary stenosis was assessed by core laboratory quantitative
coronary angiography (QCA). RESULTS: The 92 women studied ranged in age from
34 to 82 years (mean 57.5). All women had > or = 1 major risk for CAD,
and most (89, 97%) had > or = 2 risk factors. In 78 women (85%), left
ventricular wall motion was normal at baseline and during peak infusion.
The remaining 14 women had wall motion abnormalities during DSE. By QCA,
25 women (27%) had > or = 50% coronary stenosis, including 10 with single-vessel
obstruction. Dobutamine stress echocardiography was abnormal in 10 of these
25 women, yielding overall sensitivity of 40%, and 60% for multivessel stenosis.
Exclusion of women with inadequate heart rate response yielded overall sensitivity
of 50%, and 81.8% for multivessel stenosis. Dobutamine stress echocardiography
was normal in 54 of the 67 women with < 50% coronary narrowing, specificity
80.6%. CONCLUSIONS: Dobutamine stress echocardiography reliably detects multivessel
stenosis in women with suspected CAD. However, DSE is usually negative in
women with single-vessel stenosis, and in the larger subset without coronary
stenosis. Ongoing protocols of the WISE study are expected to improve diagnostic
accuracy in women with single-vessel disease, as well as provide important
data in the substantial number of women with chest pain but without epicardial
coronary artery stenosis.
PMID: 10334409 [PubMed - indexed for MEDLINE]
-
Left ventricular cavity obliteration during
dobutamine stress echocardiography is associated with female
sex and left ventricular size and function.
Khanal S, Daggubati R, Gaalla A, Shah PM, Pai RG.
Section of Cardiology, Loma Linda University Medical Center, California,
USA.
We investigated 568 consecutive patients undergoing dobutamine stress echocardiography
to elucidate the mechanism of left ventricular (LV) obliteration. Baseline
clinical and echocardiographic variables were related to dobutamine-induced
LV cavity obliteration defined as approximation of LV endocardium associated
with an intracavitary flow acceleration of at least 2 m/s in the absence
of a distal residual cavity. The LV cavity obliteration was observed in 89
(16%) of the 568 patients and was more frequent in women and those with smaller
LV dimensions, increased LV wall thickness, and higher resting ejection fractions.
Despite similar peak stress levels, the cavity obliterators were less likely
to have chest pain and detectable stress-induced wall motion abnormalities.
We conclude that LV cavity obliteration during dobutamine stress is common
and is associated with female sex, smaller LV size, presence of LV hypertrophy,
and higher LV ejection fraction. Despite similar stress levels, chest pain
and reversible wall motion abnormalities are observed less frequently in
patients with cavity obliteration, raising the possibility of lower prevalence
of coronary artery disease or masking of ischemia in this patient population.
PMID: 9804100 [PubMed - indexed for MEDLINE]
-
-
Diagnostic and prognostic implications
of left ventricular cavity obliteration response to dobutamine
echocardiography.
Secknus MA, Niedermaier ON, Lauer MS, Marwick TH.
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Left ventricular (LV) cavity obliteration during dobutamine echocardiography
(DE) indicates a vigorous inotropic response to stress. Such a response may
suggest the absence of coronary artery disease (CAD), but a small LV cavity
may also preclude recognition of wall motion abnormalities. We sought to
determine the frequency, correlates, accuracy, and prognostic value of the
LV cavity obliteration response in 336 consecutive patients who underwent
coronary angiography within 1 year of DE. Cavity obliteration was defined
by contact of the opposite walls in the apical views during DE, and ischemia
by detection of a new or worsening wall motion abnormality. Sensitivity was
based on comparison with coronary anatomy in 220 patients without prior revascularization.
The prognostic implications of cavity obliteration were examined by follow-up
of 324 patients (96%) over 23 +/- 9 months for death, myocardial infarction,
and late revascularization. Cavity obliteration was present in 86 of the
336 DE studies (26%). Baseline and stress hemodynamics were not predictive
of cavity obliteration, which was associated with LV hypertrophy and female
gender (p <0.0001), and inversely related to LV systolic dysfunction and
use of angiotensin-converting enzyme inhibitors or diuretics (p <0.02).
The sensitivity of DE was less in patients with cavity obliteration than
the remainder, especially in single vessel (46% vs 92%, p <0.001) but
also in multivessel CAD (73% vs 95%, p = 0.01). Irrespective of DE and angiographic
results, cavity obliteration was a negative predictor for cardiac events
(RR 0.42, 95% confidence interval [CI] 0.21 to 0.87, p = 0.02) and death
(RR 0.14, 95% CI 0.02 to 1.09, p = 0.06). Even after exclusion of patients
with LV dysfunction, cavity obliteration was an independent predictor of
freedom from events (RR 0.41, 95% CI 0.19 to 0.88, p = 0.02). Thus, LV cavity
obliteration is a frequent response to DE, which compromises the sensitivity
of DE but is correlated paradoxically with a favorable clinical outcome.
PMID: 9631970 [PubMed - indexed for MEDLINE]
-
Influence of gender in the therapeutic
management of patients with acute myocardial infarction in
Israel. The Israeli Thrombolytic Survey Group.
Behar S, Gottlieb S, Hod H, Narinsky R, Benari B, Rechavia
E, Pauzner H, Rougin N, Kracoff OH, Katz A, et al.
Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel.
A national study was performed in early 1992 in the 25 operating coronary
care units in Israel, which enabled the assessment of whether the therapeutic
management of patients with acute myocardial infarction was affected by patient
gender. During a 2-month period, 1,014 consecutive patients with acute myocardial
infarction were hospitalized. Thrombolytic therapy was given to 47% of men
(362 of 769), and 43% of women (106 of 245) (p = NS). After adjustment for
age, no gender differences in the administration of thrombolytic therapy
were noted (odds ratio 0.95; 95% confidence interval 0.73-1.23). Coronary
angiography was more frequently performed in men (22%) than in women (16%)
(p < 0.05). However, no gender differences in the use of angioplasty or
coronary bypass surgery performed during the index hospitalization were found
(10% in men, and 8% in women). The main reasons for ineligibility for thrombolytic
therapy were: late hospital arrival, absence of qualifying ST-T changes on
admission electrocardiogram, and contraindications to thrombolytic therapy.
Hospital death was significantly lower in patients receiving thrombolytic
therapy (37 of 456; 8%) than in those excluded from thrombolysis (70 of 540;13%)
(p < 0.01). This difference was significant for men, but not for women.
The 1-year postdischarge mortality was 4% in patients treated compared with
12% in those ineligible for thrombolysis (p < 0.01). This significant
difference persisted among men and women.
Publication Types:
PMID: 8141083 [PubMed - indexed for MEDLINE]
-
Race and sex differences in rates of invasive
cardiac procedures in US hospitals. Data from the National
Hospital Discharge Survey.
Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA.
Cardiovascular Health Studies Branch, Centers for Disease Control and Prevention,
Atlanta, Ga.
BACKGROUND: Lower rates of invasive cardiac procedures have been reported
for blacks and women than for white men. However, few studies have adjusted
for differences in the type of hospital of admission, insurance status, and
disease severity. SETTING, DESIGN, AND PARTICIPANTS: Data from the National
Hospital Discharge Survey were used to investigate race and sex differences
in rates of cardiac catheterization, percutaneous transluminal coronary angioplasty,
and coronary artery bypass surgery among 10,348 persons hospitalized for
acute myocardial infarction. RESULTS: White men consistently had the highest
procedure rates, followed by white women, black men, and black women. After
matching for the hospital of admission and adjusting for age, in-hospital
mortality, health insurance, and hospital transfer rates (with white men
as the referent), the odds ratios for cardiac catheterization were 0.067
(95% confidence interval [CI], 0.51 to 0.87) for black men, 0.72 (95% CI,
0.63 to 0.83) for white women, and 0.50 (95% CI, 0.37 to 0.68) for black
women. Similar race-sex differences were noted for percutaneous transluminal
coronary angioplasty and coronary artery bypass surgery. CONCLUSIONS: Race
and sex differentials in the rates of invasive cardiac procedures remained
despite matching for the hospital of admission and controlling for other
factors that influence procedure rates, suggesting that the race and sex
of the patient influence the use of these procedures.
PMID: 7832604 [PubMed - indexed for MEDLINE]
-
Comment in:
Selection of patients for coronary angiography and coronary
revascularization early after myocardial infarction: is there evidence
for a gender bias?
Krumholz HM, Douglas PS, Lauer MS, Pasternak RC.
Cardiovascular Division, Beth Israel Hospital, Boston, MA 02215.
OBJECTIVE: To determine whether a gender bias exists in the selection of
patients for diagnostic and therapeutic cardiovascular procedures early after
myocardial infarction. DESIGN: A retrospective cohort study. SETTING: A community-based
tertiary care teaching hospital. PATIENTS: A total of 2473 consecutive patients
with a principal discharge diagnosis of acute myocardial infarction and a
peak creatine kinase MB fraction of at least 4%. MEASUREMENTS: Comparison
of men and women regarding the frequency with which they underwent various
cardiac procedures. RESULTS: Women had coronary angiography during hospitalization
for myocardial infarction much less frequently than men (odds ratio, 0.55;
95% Cl, 0.46 to 0.65), but the age-adjusted rates were similar in women and
men (odds ratio, 0.91; Cl, 0.75 to 1.12). An abnormal ejection fraction (less
than 50%) was equally frequent in women and men who underwent left ventriculography
(odds ratio, 0.85; Cl, 0.56 to 1.30). Among patients who had coronary angiography,
women had a significantly lower rate of severe coronary artery disease, defined
as either a left main stenosis of more than 50%, three-vessel disease, or
two-vessel disease with a proximal left anterior descending stenosis of more
than 70% (odds ratio, 0.67; Cl, 0.48 to 0.93). When adjustments were made
for age, women had percutaneous transluminal coronary angioplasty as often
as men (odds ratio, 1.16; Cl, 0.83 to 1.62) but had coronary artery bypass
graft surgery significantly less frequently (odds ratio, 0.58; Cl, 0.37 to
0.91). When adjustments were made for age and the severity of coronary artery
disease, the difference in rates was of borderline significance (odds ratio,
0.65; Cl, 0.41 to 1.01). CONCLUSIONS: No evidence of a difference in the
rate of coronary angiography early after myocardial infarction between women
and men was found after age adjustment. Among patients who have cardiac catheterization
early after myocardial infarction, women and men are equally likely to have
angioplasty, but women are less likely than men to have coronary artery bypass
surgery.
PMID: 1567092 [PubMed - indexed for MEDLINE]
-
Influence of sex on the use of cardiac
procedures in patients presenting to the emergency department.
A prospective multicenter study.
Maynard C, Beshansky JR, Griffith JL, Selker HP.
Department of Medicine, New England Medical Center, Tufts University School
of Medicine, Boston, Mass, USA.
BACKGROUND: Reports about the use of cardiac procedures have produced conflicting
results as to whether there is a sex bias in the use of thrombolytic therapy,
cardiac catheterization, or revascularization procedures. The present study
was undertaken with the hope of resolving some of these different findings
by examining the use of these therapies in women and men who presented to
the emergency department with symptoms suggestive of acute cardiac ischemia.
METHODS AND RESULTS: During 7 consecutive months in 1993, 10673 individuals > or
= 30 years old who presented with chest pain or other symptoms suggestive
of acute cardiac ischemia were enrolled in the Acute Cardiac Ischemia Time-Insensitive
Predictive Instrument Clinical Trial at 10 hospitals in the East and Midwest.
This study included 2542 patients (24% of all patients) who had confirmed
acute myocardial infarction or angina pectoris. There were significant sex
differences with respect to demographic and clinical characteristics and
the use of cardiac procedures. Among patients with acute myocardial infarction,
the use of thrombolytic therapy, cardiac catheterization, and revascularization
procedures was similar in women and men after multivariate adjustment. However,
in the group with angina pectoris, women were considerably less likely to
undergo these procedures, even after adjustment for significant baseline
covariates. CONCLUSIONS: Women with angina pectoris were less likely to undergo
cardiac catheterization or revascularization procedures, although unmeasured
factors could in part explain the observed differences.
Publication Types:
PMID: 8901726 [PubMed - indexed for MEDLINE]
-
-
Differences between men and women in the
management of unstable angina pectoris (The GUARANTEE Registry).
The GUARANTEE Investigators.
Scirica BM, Moliterno DJ, Every NR, Anderson HV, Aguirre
FV, Granger CB, Lambrew CT, Rabbani LE, Arnold A, Sapp
SK, Booth JE, Ferguson JJ, Cannon CP.
Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Few data are available in prospectively collected cohorts of patients with
unstable angina pectoris or on the use of appropriate medications or interventions.
Accordingly, we evaluated 2,948 consecutive patients with unstable angina
admitted to 35 hospitals in the United States in 1996, and comparing men
and women (39% of the patients were women). Differences were seen in coronary
risk profiles with a higher incidence of systemic hypertension, diabetes
mellitus, and a family history of coronary disease in women. Women were less
likely to receive Agency for Health Care Policy Research (AHCPR) recommended
pharmacologic treatment than men. Cardiac catheterization, coronary angioplasty,
and bypass was performed less often in women compared with men (44% vs. 53%,
p = 0.002; 12% vs. 18%, p = 0.02; 7% vs. 10%, p = 0.001, respectively). At
catheterization, women were more likely to have no significant coronary artery
disease (25% vs. 14%, p = 0.001). Although fewer women than men fulfilled
the AHCPR criteria for cardiac catheterization (54% vs. 64%, p = 0.001),
a similar rate of men and women with positive criteria underwent catheterization
and angioplasty. However, fewer women with positive criteria underwent bypass
surgery (36% vs. 46%, p = 0.03). More men "ruled-in" for a myocardial
infarction at admission (13% vs. 8%, p = 0.001), but there was no difference
in recurrent angina, in-hospital myocardial infarction, or death. Despite
different epidemiologic profiles and less evidence of coronary artery disease
by noninvasive and invasive tests, women and men had similar outcomes.
PMID: 10569321 [PubMed - indexed for MEDLINE]
-
Erratum in:
- N Engl J Med 1999 Apr 8;340(14):1130
Comment in:
The effect of race and sex on physicians' recommendations
for cardiac catheterization.
Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk
S, Gersh BJ, Dube R, Taleghani CK, Burke JE, Williams S,
Eisenberg JM, Escarce JJ.
Clinical Economics Research Unit, Georgetown University Medical Center, Washington,
DC 20007, USA.
BACKGROUND: Epidemiologic studies have reported differences in the use of
cardiovascular procedures according to the race and sex of the patient. Whether
the differences stem from differences in the recommendations of physicians
remains uncertain. METHODS: We developed a computerized survey instrument
to assess physicians' recommendations for managing chest pain. Actors portrayed
patients with particular characteristics in scripted interviews about their
symptoms. A total of 720 physicians at two national meetings of organizations
of primary care physicians participated in the survey. Each physician viewed
a recorded interview and was given other data about a hypothetical patient.
He or she then made recommendations about that patient's care. We used multivariate
logistic-regression analysis to assess the effects of the race and sex of
the patients on treatment recommendations, while controlling for the physicians'
assessment of the probability of coronary artery disease as well as for the
age of the patient, the level of coronary risk, the type of chest pain, and
the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD)
estimates of the probability of coronary artery disease were lower for women
(probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001),
younger patients (63.8+/-19.5 percent for patients who were 55 years old,
vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001),
and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent
for patients with possible angina and 77.1+/-14.0 percent for those with
definite angina; P=0.001). Logistic-regression analysis indicated that women
(odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and
blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02)
were less likely to be referred for cardiac catheterization than men and
whites, respectively. Analysis of race-sex interactions showed that black
women were significantly less likely to be referred for catheterization than
white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004).
CONCLUSIONS: Our findings suggest that the race and sex of a patient independently
influence how physicians manage chest pain.
PMID: 10029647 [PubMed - indexed for MEDLINE]
-
Chest pain in women: clinical, investigative,
and prognostic features.
Sullivan AK, Holdright DR, Wright CA, Sparrow JL, Cunningham
D, Fox KM.
Royal Brompton National Heart and Lung Hospital, London.
OBJECTIVE--To characterise clinical, investigative, and prognostic features
of women referred with chest pain who subsequently underwent coronary angiography.
DESIGN--Analysis of all women with angina referred to one consultant during
1987-91 who subsequently underwent coronary angiography, with follow up to
present day. SETTING--Cardiothoracic centre. SUBJECTS--Women with normal
coronary arteries; women with coronary artery disease shown on angiography;
men with coronary artery disease matched for age; men referred with chest
pain during the same period subsequently found to have normal coronary arteries.
MAIN OUTCOME MEASURES--Risk factor analysis; results of exercise testing
and coronary angiography; intervention; morbidity and mortality. RESULTS--Women
comprised 23% (202/886) of patients referred with chest pain who subsequently
underwent angiography. 83/202 women had normal coronary angiograms compared
with 55/684 men (41% v 8%, P < 0.01). Diabetes mellitus was the only risk
factor more frequently encountered in women with coronary artery disease
(P = 0.001). The specificity and positive predictive value of exercise testing
before angiography were significantly lower in women than men (71% v 93%,
P < 0.001 and 76% v 95%, P < 0.001, respectively). Revascularisation
procedures were as common in women with coronary artery disease as in men
(81 (68%) v 70 (59%)), and there was no difference in event rate during follow
up. Many patients with normal coronary arteries, irrespective of sex, had
symptoms during follow up (61 (73%) women, 36 (65%) men) and continued to
take antianginal drugs (27 (33%) women, 14 (28%) men); 14 (17%) women and
six (11%) men required hospital readmission for severe symptoms. CONCLUSIONS--In
this series, although women comprised the minority of patients referred with
chest pain, a diagnosis of normal coronary arteries was five times more common
in women than men. Risk factor analysis and exercise testing were of limited
value in predicting coronary artery disease in women. There was no sex bias
regarding revascularisation procedures, and outcome was similar. A diagnosis
of non-cardiac chest pain in patients with normal coronary arteries was of
little benefit to the patient with regard to morbidity.
PMID: 8173366 [PubMed - indexed for MEDLINE]
-
Comment in:
Cardiac syndrome X: clinical characteristics and left
ventricular function. Long-term follow-up study.
Kaski JC, Rosano GM, Collins P, Nihoyannopoulos P, Maseri
A, Poole-Wilson PA.
St. George's Hospital Medical School, London, United Kingdom.
OBJECTIVES. Our aim was to study the clinical characteristics and evolution
of symptoms and left ventricular function in a clinically homogeneous group
of patients with syndrome X (angina pectoris, positive exercise test results
and normal coronary arteriograms). BACKGROUND. The syndrome of angina with
normal coronary arteriograms is heterogeneous and encompasses different pathogenetic
entities. These characteristics may contribute to the existing controversy
concerning the cause of syndrome X. METHODS. We studied 99 patients with
syndrome X (78 women, 21 men; mean age +/- SD 48.5 +/- 8 years). All underwent
clinical characterization, ambulatory electrocardiographic (ECG) monitoring
and echocardiographic assessment of left ventricular function during a follow-up
period of 7 +/- 4 years. RESULTS. The syndrome was more common in women than
in men. Of the women, 61.5% were postmenopausal before the onset of chest
pain. All 99 patients had exertional angina, and 41 also had rest angina.
The average duration of episodes of chest pain was > 10 min in 53% of
patients. Sublingual nitrate was effective for relief of pain in 42% of patients.
Transient ST segment depression was observed during ambulatory ECG monitoring
in 64 patients and myocardial perfusion abnormalities in 22. During the first
stage of the exercise test, 32 patients had an increase > 20 mm Hg in
systolic blood pressure and showed an earlier onset of ST depression and
shorter exercise time than did patients whose blood pressure increased < or
= 20%. During follow-up, no deaths or myocardial infarctions occurred, ventricular
function was unchanged (shortening fraction 35.4 +/- 4% vs. 35.6 +/- 3%;
heart failure developed in only one patient), systemic hypertension occurred
in eight patients and conduction disturbances in four. Symptoms lessened
in 11 patients, were variable or unchanged in 64 and worsened in 24. CONCLUSIONS.
Syndrome X, as defined in this study, occurs predominantly in postmenopausal
women. Patients usually have chest pain typical for angina, but conventional
antianginal treatment is not often successful. Myocardial perfusion abnormalities
occur in a small proportion of patients. Long-term survival is not adversely
affected, and deterioration of cardiac function rarely occurs.
PMID: 7884081 [PubMed - indexed for MEDLINE]
-
-
Coronary flow velocity response to adenosine
characterizes coronary microvascular function in women with
chest pain and no obstructive coronary disease. Results from
the pilot phase of the Women's Ischemia Syndrome Evaluation
(WISE) study.
Reis SE, Holubkov R, Lee JS, Sharaf B, Reichek N, Rogers
WJ, Walsh EG, Fuisz AR, Kerensky R, Detre KM, Sopko G,
Pepine CJ.
Department of Medicine, University of Pittsburgh, Pennsylvania, USA. reisse@msx.upmc.edu
OBJECTIVES: We sought to develop and validate a definition of coronary microvascular
dysfunction in women with chest pain and no significant epicardial obstruction
based on adenosine-induced changes in coronary flow velocity (i.e., coronary
velocity reserve). BACKGROUND: Chest pain is frequently not caused by fixed
obstructive coronary artery disease (CAD) of large vessels in women. Coronary
microvascular dysfunction is an alternative mechanism of chest pain that
is more prevalent in women and is associated with attenuated coronary volumetric
flow augmentation in response to hyperemic stimuli (i.e., abnormal coronary
flow reserve). However, traditional assessment of coronary volumetric flow
reserve is time-consuming and not uniformly available. METHODS: As part of
the Women's Ischemia Syndrome Evaluation (WISE) study, 48 women with chest
pain and normal coronary arteries or minimal coronary luminal irregularities
(mean stenosis = 7%) underwent assessment of coronary blood flow reserve
and coronary flow velocity reserve. Blood flow responses to intracoronary
adenosine were measured using intracoronary Doppler ultrasonography and quantitative
angiography. RESULTS: Coronary volumetric flow reserve correlated with coronary
velocity reserve (Pearson correlation = 0.87, p < 0.001). In 29 (60%)
women with abnormal coronary microcirculation (mean coronary flow reserve
= 1.84), adenosine increased coronary velocity by 89% (p < 0.001) but
did not change coronary cross-sectional area. In 19 (40%) women with normal
microcirculation (mean flow reserve = 3.24), adenosine increased coronary
velocity and area by 179% (p < 0.001) and 17% (p < 0.001), respectively.
A coronary velocity reserve threshold of 2.24 provided the best balance between
sensitivity and specificity (90% and 89%, respectively) for the diagnosis
of microvascular dysfunction. In addition, failure of the epicardial coronary
to dilate at least 9% was found to be a sensitive (79%) and specific (79%)
surrogate marker of microvascular dysfunction. CONCLUSIONS: Coronary flow
velocity response to intracoronary adenosine characterizes coronary microvascular
function in women with chest pain in the absence of obstructive CAD. Attenuated
epicardial coronary dilation response to adenosine may be a surrogate marker
of microvascular dysfunction in women with chest pain and no obstructive
CAD.
PMID: 10334410 [PubMed - indexed for MEDLINE
-
Noninvasive imaging for the diagnosis
of coronary artery disease: focusing the development of new
diagnostic technology.
Hunink MG, Kuntz KM, Fleischmann KE, Brady TJ.
Erasmus Medical Center Rotterdam, The Netherlands. hunink@epib.fgg.eur.nl
BACKGROUND: New tests, such as magnetic resonance imaging (MRI) and electron-beam
computed tomography (CT), are being developed for the diagnosis of coronary
artery disease. OBJECTIVE: To determine the conditions that a new test must
meet to be a cost-effective alternative to established imaging tests. DESIGN:
Decision model and cost-effectiveness analysis. DATA SOURCES: Literature
review and meta-analysis. TARGET POPULATION: 55-year-old men and 65-year-old
women presenting with chest pain. TIME HORIZON: Lifetime of the patient.
PERSPECTIVE: Health care policy. INTERVENTIONS: MRI, electron-beam CT, exercise
echocardiography, exercise single-photon emission CT, and coronary angiography.
OUTCOME MEASURES: Target sensitivity and specificity values for a new noninvasive
test. RESULTS OF BASE-CASE ANALYSIS: Assuming that society is willing to
pay $75000 per quality-adjusted life-year (QALY) gained, a new test that
costs $1000 would need a sensitivity of 94% and a specificity of 90% to be
cost-effective. RESULTS OF SENSITIVITY ANALYSIS: Assuming that society is
willing to pay $50000 per QALY gained, a new test that costs $1000 or more
would never be cost-effective. For a test that costs $500, the sensitivity
and specificity must each be 95%. CONCLUSIONS: New imaging techniques, such
as MRI and electron-beam CT, must be relatively inexpensive and have excellent
sensitivity and specificity to be cost-effective compared with other techniques
for the diagnosis of coronary artery disease. Similar analyses in other areas
of health care may help to focus the development of new diagnostic technology.
Publication Types:
PMID: 10577330 [PubMed - indexed for MEDLINE]
-
Comment in:
Utility of fast cine magnetic resonance imaging and
display for the detection of myocardial ischemia in patients not well suited
for second harmonic stress echocardiography.
Hundley WG, Hamilton CA, Thomas MS, Herrington DM, Salido
TB, Kitzman DW, Little WC, Link KM.
Cardiology Section, Division of Radiological Sciences, The Wake Forest University
School of Medicine, Winston-Salem, NC, USA. ghundley@wfubmc.edu
BACKGROUND: Some patients referred for pharmacological stress testing with
transthoracic echocardiography (TTE) are unable to undergo testing owing
to poor acoustic windows. Fast cine MRI can be used to assess left ventricular
contraction, but its utility for detection of myocardial ischemia in patients
poorly suited for echocardiography is unknown. METHODS AND RESULTS: One hundred
fifty-three patients (86 men and 67 women aged 30 to 88 years) with poor
acoustic windows that prevented adequate second harmonic TTE imaging were
consecutively referred for MRI to diagnose inducible myocardial ischemia
during intravenous dobutamine and atropine. Diagnostic studies were completed
in an average of 53 minutes. No patients experienced myocardial infarction,
ventricular fibrillation, exacerbation of congestive heart failure, or death.
In patients who underwent computer-assisted quantitative coronary angiography,
the sensitivity and specificity for detecting a >50% luminal diameter
narrowing were 83% and 83%, respectively. In the 103 patients with a negative
MRI examination, the cardiovascular occurrence-free survival rate was 97%.
CONCLUSIONS: Fast cine cardiac MRI provides a mechanism to assess left ventricular
contraction and diagnose inducible myocardial ischemia in patients not well
suited for stress echocardiography.
Publication Types:
PMID: 10525488 [PubMed - indexed for MEDLINE]
-
-
Noninvasive prediction of coronary atherosclerosis
by quantification of coronary artery calcification using
electron beam computed tomography: comparison with electrocardiographic
and thallium exercise stress test results.
Kajinami K, Seki H, Takekoshi N, Mabuchi H.
Second Department of Internal Medicine, School of Medicine, Kanazawa University,
Japan.
OBJECTIVES. This study was designed to compare the usefulness of electron
beam computed tomography for prediction of coronary stenosis with that of
electrocardiographic (ECG) and thallium exercise tests. BACKGROUND. Electron
beam computed tomography can quantify coronary calcifications; however, its
clinical value has yet to be established. METHODS. Using the volume mode
of electron beam computed tomography, we studied 251 consecutive patients
who underwent elective coronary angiography because of suspected coronary
artery disease and compared the results with those of ECG and thallium exercise
tests. The total coronary calcification score was calculated by multiplying
the area ( > or = 2 pixels) of calcification (peak density > or = 130
Hounsfield units) by an arbitrarily weighted density score (0 to 4) based
on its peak density. The mean of two scans was log transformed. RESULTS.
Calcification was first noted in women in the 4th decade of life, approximately
10 years later than its occurrence in men. Among patients with advanced atherosclerosis
(two- and three-vessel disease), calcification scores were uniformly high
in women but ranged widely in men. Nine percent of patients with significant
stenoses ( > or = 75% by densitometry) had no calcification. The calcification
scores of patients with significant stenosis in at least one vessel were
significantly higher than those of patients without significant stenosis
in the study group as a whole and in most patient subgroups classified according
to age and gender. A cutoff calcification score for prediction of significant
stenosis, determined by receiver operating characteristic curve analysis,
showed high sensitivity (0.77) and specificity (0.86) in all study patients;
sensitivity was similarly high even in older patients ( > or = 70 years)
and was enhanced in middle-aged patients (40 to < or = 60 years). The
difference in specificity between calcification scores and ECG exercise test
results had borderline significance (p = 0.058) and that between calcification
scores and thallium test results was significant (p = 0.001). The latter
difference became small but remained significant (p = 0.01) even after the
reevaluation of thallium test results in light of each subject's clinical
data. CONCLUSIONS. Quantification of coronary artery calcification with electron
beam computed tomography noninvasively predicted angiographically confirmed
coronary stenosis. Results obtained with this method were at least as useful
and potentially better in some patient groups than those obtained with thallium
and ECG exercise testing.
PMID: 7594034 [PubMed - indexed for MEDLINE
-
-
Cost-effectiveness of diagnostic strategies
for patients with chest pain.
Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS.
Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts,
USA. kmk@hsph.harvard.edu
BACKGROUND: Many noninvasive tests exist to determine whether patients should
undergo coronary angiography. The routine use of coronary angiography without
previous noninvasive testing is typically not advocated. OBJECTIVE: To determine
the cost-effectiveness of diagnostic strategies for patients with chest pain.
DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published data. TARGET
POPULATION: Patients who present with chest pain, have no history of myocardial
infarction, and are able to perform an exercise stress test. TIME HORIZON:
Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: No testing, exercise electrocardiography,
exercise echocardiography, exercise single-photon emission computed tomography
(SPECT), and coronary angiography alone. OUTCOME MEASURES: Quality-adjusted
life expectancy, lifetime cost, and incremental cost-effectiveness. RESULTS
OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio of routine
coronary angiography compared with exercise echocardiography was $36,400
per quality-adjusted life-year (QALY) saved for 55-year-old men with typical
angina. For 55-year-old men with atypical angina, exercise echocardiography
compared with exercise electrocardiography cost $41,900 per QALY saved. If
adequate exercise echocardiography was not available, exercise SPECT cost
$54,800 per QALY saved compared with exercise electrocardiography for these
patients. For 55-year-old men with nonspecific chest pain, the incremental
cost-effectiveness ratio of exercise electrocardiography compared with no
testing was $57,700 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS: On the
basis of a probabilistic sensitivity analysis, there is a 75% chance that
exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old
men with atypical angina. CONCLUSIONS: Exercise electrocardiography or exercise
echocardiography resulted in reasonable cost-effectiveness ratios for patients
at mild to moderate risk for coronary artery disease in terms of age, sex,
and type of chest pain. Coronary angiography without previous noninvasive
testing resulted in reasonable cost-effectiveness ratios for patients with
a high pretest probability of coronary artery disease.
PMID: 10357689 [PubMed - indexed for MEDLINE]
|
