Ischemic heart disease in women Contemporary diagnostic assessment
Amalia Peix, MD, PhD Full Professor & Senior Researcher Department of Nuclear Medicine Institute of Cardiology La Habana, Cuba
[email protected]
Classification of risk for cardiovascular disease in women Other high risk markers: Chronic obstructive lung disease TIA or Cerebrovascular accident Functional disability
Mosca L et al. Circulation 2011;123:1243
Emerging risk factors in women • • • • •
Metabolic syndrome Obesity hs-CRP Autoimmune disease Polycystic ovary syndrome • Functional Hypothalamic Amenorrhea
• Preeclampsia and pregnancy-associated hypertension • Gestational Diabetes • Breast cancer therapy • Hormone replacement therapy
Ischemic heart disease in women. Why? Diagnosis and Management • Clinical picture & diagnosis • Differences according to sex: In 66% of women (vs. 56% of men) SCD is the first manifestation Absence of chest pain in ACS in 37% women vs. 27% men Younger women had higher mortality rates compared to men Diabetic women have a 3-7 fold higher risk to develop a coronary disease (vs. a two-fold risk in men) 33% women vs. 25% men die during the first year after AMI Higher mortality after CABG (4.5% vs. 2.5% in men) Women’s ischemic symptoms are more often precipitated by mental or emotional stress than by physical stress Atypical chest pain: epigastric discomfort and associated nausea, dyspnea and fatigue
Mosca L, et al. Circulation 1999;99:2480 Canto RG et al. Arch Intern Med 2007;167:2405
Diagnosis of IHD in women. Problems to face Higher prevalence of nonobstructive CAD and 1-vessel disease in women reduces the diagnostic accuracy of noninvasive tests
Complex pathophysiology of coronary atherosclerosis in women: Abnormal coronary reactivity Microvascular dysfunction Plaque erosion / distal microembolization
Physiopathology – Some lessons from the WISE study Death or AMI
% 16 14 12 10 8 6 4 2 0
13.6 6.9 2.5 Nonobstructive
Minimal obstructive disease
20-49% obstruction
At 4 years: 9.4% absolute risk of death or AMI in those with nonobstructive or minimal obstructive coronary disease
Obstructive disease 50% obstruction
Wise Study Group. JACC 2006;47:1S
Contemporary evaluation of women with suspected IHD • Focus in the past: to detect obstructive coronary stenosis / revascularization • Focus in the present: to document myocardial ischemia & burden of nonobstructive and obstructive CAD To determine IHD risk and guide therapeutic decisions
Pretest CAD likelihood in women and men across age deciles
Fihn SD et al. Circulation 2012;126:e354
Categorization of IHD risk in symptomatic women
High Risk Equivalents PAD Longstanding, poorly controlled DM Mieres J et al. Circulation 2014;130:350
Mieres J et al. Circulation 2014;130:350
Nomogram for exercise capacity in women - Activities for daily living: 4-5 METS (threshold for defining functional disability) Pharmacological stress - More than 9 METS, low expected event rate - ≥10 METS: 0.4% incidence of provocative ischemia
Gulati M et al. NEJM 2005;353:468 Bourque JM et al. JACC 2009;54:538
Stress Testing Sensitivity
Specificity
100%
80% 60%
79%
83% 81%
78%
68% 62%
40% 20% 0%
Ex ECG
Echo
Nuclear
Fihn SD et al. JACC 2012;60:e44
Exercise Testing % 80
72
61
77
Men (n=1 977)
70
Women (n=3 721)
70 60
PPV (47% in women vs. 77% in men, p8 METS 5–8 METS
