Transcript Document

Chest pain in Women
Deborah B. Diercks, MD, MSc
Professor of Emergency Medicine
University of California, Davis Medical Center
Disclosures: Grant and Research Support: GE Health Care
Speaker’s Bureau: Astellas Pharma US, Inc.
Women and Heart Disease Advisory Board: CVT
Objective
Case based presentation
– Symptoms
– Diagnosis
– Risk stratification
The Scope of the Problem
Treating heart disease topped a list of the 10
most costly conditions for American women.
– This from a new study by AHRQ. The study, based on
medical care that was provided in 2008, says treating
women for heart disease cost nearly $44 billion.
The Scope of the Problem
In 2007, CVD still caused 1 death per minute
among women in the United States
Women and Heart Disease:
Keys to Improving Outcomes
Keys to reducing mortality from CHD:
Early recognition of symptoms
Accurate diagnosis of CAD
Treatment
Case Study
39-Year-Old African-American Woman
with Atypical Chest Pain
Case Study
39-year-old African-American woman with recent
onset of exertional jaw pain and heart burn
Height: 5’4”
Weight: 170 lb
Waist: 45”
Labs: fasting glucose: 135; TG: 200; TC: 260;
HDL: 45
BP: 165/92 mm Hg
Case Study
Discharged from ED after 10 hours with negative
cardiac enzymes and told to see a GI specialist
Admitted to hospital with continued episodes of
chest pain
Meds: none
Medical history:
– Mother: CAD at age 50, diabetes at age 35
– Father: died of MI at age 55
Was there an error made at the time of
the initial presentation?
At what time in the evaluation was it
made?
Are there gender differences in
presentation?
Clinical Presentation of AMI in Women
Compared to Men, Women Have:
– Women with AMI had lower odds and a lower rate of
presenting with chest pain than men
• risk ratio .93; 95% confidence interval, .91-.95
– Women were significantly more likely than men to
present with fatigue, neck pain, syncope, nausea,
right arm pain, dizziness, and jaw pain.
Heart Lung. 2011 Nov-Dec;40(6):477-91
Compared to Men, Women:
– Are Older with More Comorbidities (HTN, Diabetes,
CHF)
– Have Higher Rates of “Silent MI
– Have Smaller Cardiac Enzyme Elevations
Presentation
85-90% of Women with AMI present
with the complaint of chest pain
Presentation-ACS
Euro Heart Survey of ACS
– STEMI
• 85% vs 90% typical angina
– NSTEMI/UA
• 85% vs 87% typical angina
– No difference in outcomes
Hasdai Am J Cardiol 2003;91: 1466-1469
MONICA/KORA Myocardial Infarction Registry
– No significant gender differences were found in
chest pain, feelings of pressure or tightness,
diaphoresis, pain in the right shoulder/arm/hand,
and syncope.
Canto Am J Cardiol 2002;90:248-253.
Am J Cardiol. 2011 Jun 1;107(11):1585-9.
Are EKG and cardiac markers enough?
Historically
Newer generation of troponins
Are There Gender Differences in
Noninvasive Diagnostic Tests?
Some Noninvasive Testing Options
Stress ECG
Stress MPI/PET
EBCT/CTA
Stress ECHO
MRI
Progressive Manifestations of Myocardial
Ischemia as Illustrated by the Ischemic Cascade
Progressive Manifestations of Demand Ischemia
Symptomatic Manifestations
Chest Pain
Asymptomatic Manifestations
ST-T Wave Changes
Systolic Dysfunction
Diastolic Dysfunction
Metabolic Changes
Commonly Applied
Noninvasive Testing
Correlates of Ischemia
Invasive Disease
States Where Ischemia
is Manifested
ECG
Gated SPECT, ECHO
Severe Stenosis
ECHO
PET, CMR
Moderate Stenosis
Decreased Perfusion
Exposure Time of Mismatch in Myocardial Oxygen Supply / Demand
Near Term
Prolonged
ECG = electrocardiogram; SPECT = single-photon emission computed tomography; PET = positron-emission tomography;
ECHO = echocardiogram; CMR = cardiovascular magnetic resonance imaging.
Adapted from Mieres et al. Am Fam Physician. 2006. In press.
PET, SPECT, CMR
Endothelial
Dysfunction/
Microvascular Disease
ECG Testing in Women: Sensitivity and
Specificity of ≥1 mm ST Segment Depression
Comparison of AHRQ Results to Prior Studies in Women*
Ex ECG
Fleischmann 1998
Kwok 1999
ECHO
SPECT
Sn
Sp
Sn
Sp
Sn
Sp
-
-
85%
77%
87%
64%
61%
70%
86%
79%
78%
64%
81%
73%
77%
69%
Grady (AHRQ) 2003
Sn = Diagnostic sensitivity (true positive / CAD)
Sp = Diagnostic specificity (true negative / no CAD)
*AHRQ = Agency for Healthcare Research and Quality.
Fleischmann et al. JAMA 1998;280:913-920.
Kwok et al. Am J Cardiol. 1999;83:660-666.
Grady et al. AHRQ Publication No. 03-E037. May 2003. Available at:
http://www.ahrq.gov/downloads/pub/evidence/pdf/chdwomtop/chdwmtop.pdf.
.
Diagnostic Accuracy of Exercise ECG
Testing in Women
Altered prevalence of disease1,2
Reduced predictive accuracy in younger women2
Potential factors affecting diagnostic accuracy1:
– Hormonal influences
– Reduced functional capacity
– Resting ST-T wave abnormalities
– Comorbidities
1. Isaac D, et al. Can J Cardiol. 2001;17(suppl D):38D-48D.
2. Shaw LJ, et al. In: Charney P, ed. Coronary Artery Disease in Women: What All Physicians
Need to Know. Philadelphia, Pa: American College of Physicians. 1999:327-350.
Choosing a Cardiac Stress Test
Stress ECHO
Stress MPI
Stress ECHO
Ultrasound performed both
at rest and during peak
stress
Exercise or other stress
Ischemia defined by
development of wall-motion
abnormalities
Courtesy of Howard Lewin, MD, of San Vicente Cardiac Imaging Center.
Stress MPI
Exercise or pharmacologic
stress vs rest
Stress
Rest
Stress
Myocardial accumulation of
radioactivity in proportion to
blood flow
Rest
Stress
Rest
Ischemia defined by
diminished perfusion during
stress vs rest
Stress
Rest
Courtesy of Jennifer H. Mieres, MD, NYU Medical Center.
PROGNOSTIC CAPABILITY OF
NONINVASIVE TESTS IN WOMEN:
IMPORTANT FOR MANAGEMENT
What Is the Warranty
of a Normal Test?
Exercise ECG
Stress ECHO
Myocardial Perfusion Imaging
Risk Stratification With Stress SPECT
Cardiac Survival
Perfusion Imaging Correlates With Cardiac Mortality in Women as a
Function of Reversible Perfusion Defects
1.0
Number of Vascular Territories With Ischemia
1.0
0.9
0.9
0
1
2
0
1
2
3
0.8
0.8
0.7
0.6
Women
(n=3,402)
0 0.5 1 1.5 2 2.5 3
Years
Marwick et al. Am J Med. 1999;106:172-178.
3
0.7
Men
(n=4,500)
0.6
0
0.5
1
1.5
2
2.5
3
Years
Economics of Noninvasive Diagnosis (END) Study Group
Do Test Results Have the Same
Meaning in High-Risk Patients (eg,
Diabetics) as in Other Patients?
3-Year Survival by Gender, Diabetic Status,
and Extent of Myocardial Ischemia
No Ischemia
1-Vessel
Ischemia
≥2-Vessel
Ischemia
Diabetic Men
86.3%
77%
79%
Nondiabetic
Men
93.8%
88%
85%
Diabetic
Women
96.5%
72.5%*
60%*
Nondiabetic
Women
95.5%
85%
77.5%
*P < 0.05%.
Giri et al. Circulation. 2002;105:32-40.
Significance of Normal Stress SPECT:
Diabetic vs Nondiabetic Patients
Cumulative Survival
1.00
Nondiabetics
Diabetics
.95
.90
Re-Test
@ ~1-1.5 years
.85
P<.00001
.80
0.0
.5
1.0
1.5
2.0
Follow-up (Years)
Giri S, et al. Circulation. 2002;105:32-40.
2.5
3.0
When Do You Refer for Cardiac
Imaging vs Exercise ECG?
What’s the evidence?
Algorithm for Evaluation of Symptomatic
Women Using Cardiac Imaging
Intermediate-High Likelihood Women With Atypical or Typical Chest Pain Symptoms
Risk Factor
Modification +/Anti-Ischemic Rx
Good Ex Tolerance
+ Normal 12-L ECG
Exercise TM
Test
Low
Post-ETT
LK
Int Risk
TM
Normal or Mildly
Abnormal w/ Normal
LV Function
Adapted from Mieres et al. Circulation. 2005;111:682-696.
Diabetes, Abnormal 12-L ECG, or
Questionable Ex Capacity
EX OR PHARMACOLOGIC STRESS IMAGING
Able to Ex
Exercise
Stress
Unable to Ex
Pharmacologic
Stress
Moderate-Severely
Abnormal or
Depressed EF
Cardiac
Cath
Case Study
39-year-old African-American woman with recent
onset of exertional jaw pain and heart burn
Myocardial Perfusion Scintigraphy (MPS)
Normal Short Axis
Image*
Stress
Normal Vertical-Long
Axis*
Stress
Rest
Anteroseptum
Anterior
Lateral
Rest
Inferoseptum
Inferior
Inferior
Images courtesy of Dr. Frans J. Wackers © Yale University.
Anterior
Apex
Infero-apical
Cardiac Catheterization
Summary
39 y/o African-American woman with recent
onset of exertional jaw pain and heart burn
Cardiac catheterization findings:
– Severe coronary artery disease (70% stenosis) in left
anterior descending artery and right coronary artery
– Moderate disease (65% stenosis) in left circumflex
artery
Ventricular function: ejection fraction of 55%
Management: Referral to coronary artery bypass
graft surgery
Are There Gender Differences in
Invasive Diagnostic Tests?
Can Cardiac Catheterization Identify
Coronary Artery Disease in Women?
Decisive Findings From the WISE Study
Approximately 50% of women referred for evaluation of
ischemia do not have obstructive coronary disease
– Prognosis for these women is intermediate for future
adverse cardiac events and persistent symptoms
Practitioners should no longer ignore nonobstructive
coronary angiograms in women
Practitioners should not call evidence of clear ischemia in
this setting, such as a positive troponin or an abnormal
stress perfusion test, a false positive
Lerman et al. J Am Coll Cardiol. 2006;47:59S-62S.
Women and Heart Disease: Making a
Difference—A Call To Action
Hospital Strategies and the Power of Partnership
www.herheartcommunity.com
The National Coalition for Women with Heart Disease
www.womenheart.org
Women and Heart Disease: Making a
Difference—A Call To Action for EM
Physicians
Negative troponin may not mean no disease
No significant disease does not mean no disease
Use risk stratification to determine prognosis
Integrate preventive measures into observation
unit strategies
More research is needed
– How will the newer generation troponins change the
game