Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease

Abstract

Declines in cardiovascular deaths have been dramatic for men but occur significantly less in women. Among patients with symptomatic ischemic heart disease (IHD), women experience relatively worse outcomes compared with their male counterparts. Evidence to date has failed to adequately explore unique female imaging targets and their correlative signs and symptoms of IHD as major determinants of IHD risk. We highlight sex-specific anatomic and functional differences in contemporary imaging and introduce imaging approaches that leverage refined targets that may improve IHD risk prediction and identify potential therapeutic strategies for symptomatic women.

Keywords: imaging; prognosis; sex; women.

Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1. Invasive Angiogram With Nonobstructive CAD

Analysis using QCA. (Left) Coronary computed tomography angiography (CTA) evidence of high-risk plaque including positive remodeling, spotty calcification, and low-attenuation plaque; Hounsfield units (HU) <30. (Right) The invasive angiography reveals mild CAD, whereas coronary CTA identifies high-risk plaque features in the same patient with mild CAD. CAD = coronary artery disease; QCA = quantitative coronary angiography.

FIGURE 2. Unadjusted 3-Year Survival for Women Versus Men by the Extent of CAD by Coronary CTA

Comparative all-cause survival estimates from the CONFIRM (COronary CT EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry in women and men. In women and men, nonobstructive CAD was associated with worsening survival. Reprinted with permission from Min et al. (51).

FIGURE 3. Myocardial Inflammation and Impaired Myocardial Perfusion Reserve by CMR

A 37-year-old female was admitted with visual changes. Serologic testing and neuroimaging yielded a diagnosis of lupus cerebritis. Significant resting tachycardia (heart rate 120 to 130 beats/min) raised concern of lupus myocarditis, confirmed by CMR examination that showed significantly elevated myocardial T2 values (A). Immunomodulatory therapy was initiated, with both improvement visual symptoms and normalization of heart rate. She returned to the hospital approximately 5 months later with chest pain and lack of inflammatory markers with a resting heart rate of 75 beats/min. ECG and serial troponin-I measurements were negative for myocardial injury. CMR showed normalized T2 values (B); vasodilator stress adenosine infusion produced severe chest pain, and concomitant first-pass perfusion imaging showed diffuse subendocardial hypoperfusion (C). Minimal residual chest pain was present upon termination of adenosine, with near-complete normalization of perfusion (D). Chest pain attributed to impaired myocardial perfusion reserve has reduced with angiotensin converting enzyme inhibitor therapy.

FIGURE 4. Cumulative Cardiac Mortality Rates by the Percentage of Abnormal Stress Myocardium With Rubidium-82 PET Imaging

Comparative CAD mortality estimates from the PET Prognosis Registry in women and men. In women and men, the percentage of the myocardium that was abnormal was associated with a graded increase in CAD mortality. CAD = coronary artery disease; PET = positron emission tomography.

CENTRAL ILLUSTRATION. A Working Model of Imaging Targets Identifying Ischemic Heart Disease Risk in Women

Potential influential factors contributing to high rates of nonobstructive coronary artery disease (CAD) in women. Investigations have implicated altered flow reserve and provocative ischemia as determinants of risk, even in women with nonobstructive CAD. Other factors may further refine risk including scarring and unrecognized myocardial infarction. Each of these proposed parameters may differentially affect short- or long-term outcomes in women.