Chest pain in WomenChest 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 CareSpeaker’s Bureau: Astellas Pharma US, Inc.

Women and Heart Disease Advisory Board: CVT

ObjectiveObjective

Case based presentation– Symptoms– Diagnosis– Risk stratification

The Scope of the ProblemThe 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 ProblemThe 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 OutcomesWomen and Heart Disease: Keys to Improving Outcomes

Early recognition of symptoms Accurate diagnosis of CAD Treatment

Keys to reducing mortality from CHD:

Case StudyCase Study39-Year-Old African-American Woman

with Atypical Chest Pain

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 StudyCase Study

Case StudyCase 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?

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?

Are there gender differences in presentation?

Clinical Presentation of AMI in WomenClinical 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

PresentationPresentation

85-90% of Women with AMI present with the complaint of chest pain

Presentation-ACSPresentation-ACS

Euro Heart Survey of ACS

– STEMI• 85% vs 90% typical angina

– NSTEMI/UA• 85% vs 87% typical angina

– No difference in outcomesHasdai 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?Are EKG and cardiac markers enough?

Historically

Newer generation of troponins

Are There Gender Differences in Noninvasive Diagnostic Tests?

Are There Gender Differences in Noninvasive Diagnostic Tests?

Stress ECG

Some Noninvasive Testing Options Some Noninvasive Testing Options

Stress ECHOStress MPI/PET

EBCT/CTA MRI

Progressive Manifestations of Myocardial Ischemia as Illustrated by the Ischemic Cascade

Progressive Manifestations of Myocardial Ischemia as Illustrated by the Ischemic Cascade

Exposure Time of Mismatch in Myocardial Oxygen Supply / DemandNear Term Prolonged

Asymptomatic Manifestations

Chest Pain

Prog

ress

ive

Man

ifest

atio

ns o

f Dem

and

Isch

emia

Decreased Perfusion

Metabolic Changes

Diastolic Dysfunction

Systolic Dysfunction

Symptomatic Manifestations

ST-T Wave Changes

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.

Commonly AppliedNoninvasive Testing

Correlates of Ischemia

ECG

Gated SPECT, ECHO

ECHO

PET, CMR

PET, SPECT, CMR

Invasive DiseaseStates Where Ischemia

is Manifested

Moderate Stenosis

Severe Stenosis

Endothelial Dysfunction/

Microvascular Disease

ECG Testing in Women: Sensitivity and Specificity of ≥1 mm ST Segment Depression

ECG Testing in Women: Sensitivity and Specificity of ≥1 mm ST Segment Depression

Sn = Diagnostic sensitivity (true positive / CAD)Sp = Diagnostic specificity (true negative / no CAD)

Comparison of AHRQ Results to Prior Studies in Women

Ex ECG ECHO SPECT

Sn Sp Sn Sp Sn Sp

Fleischmann 1998 - - 85% 77% 87% 64%

Kwok 1999 61% 70% 86% 79% 78% 64%

Grady (AHRQ) 2003 81% 73% 77% 69%

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..

*

*AHRQ = Agency for Healthcare Research and Quality.

Diagnostic Accuracy of Exercise ECG Testing in Women

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 TestChoosing a Cardiac Stress Test

Stress ECHO

Stress MPI

Stress ECHO Stress ECHO

Courtesy of Howard Lewin, MD, of San Vicente Cardiac Imaging Center.

Ultrasound performed both at rest and during peak stress

Exercise or other stress

Ischemia defined by development of wall-motion abnormalities

Stress MPI Stress MPI

Courtesy of Jennifer H. Mieres, MD, NYU Medical Center.

Exercise or pharmacologic stress vs rest

Myocardial accumulation of radioactivity in proportion to blood flow

Ischemia defined by diminished perfusion during stress vs rest

Stress

Rest

Stress

Rest

Stress

Rest

Stress

Rest

PROGNOSTIC CAPABILITY OF NONINVASIVE TESTS IN WOMEN: IMPORTANT FOR MANAGEMENT

PROGNOSTIC CAPABILITY OF NONINVASIVE TESTS IN WOMEN: IMPORTANT FOR MANAGEMENT

Exercise ECG

Stress ECHO

Myocardial Perfusion Imaging

What Is the Warranty of a Normal Test?

What Is the Warranty of a Normal Test?

Risk Stratification With Stress SPECTRisk Stratification With Stress SPECT

Perfusion Imaging Correlates With Cardiac Mortality in Women as a Function of Reversible Perfusion Defects

Economics of Noninvasive Diagnosis (END) Study Group

0 0.5 1 1.5 2 2.5 3Years

0.6

0.7

0.8

0.9

1.0

Car

dia

c S

urv

ival

Women(n=3,402)

0 0.5 1 1.5 2 2.5 3Years

0.6

0.7

0.8

0.9

1.0

Men

(n=4,500)

012

3

012

3

Number of Vascular Territories With Ischemia

Marwick et al. Am J Med. 1999;106:172-178.

Do Test Results Have the Same Meaning in High-Risk Patients (eg,

Diabetics) as in Other Patients?

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

3-Year Survival by Gender, Diabetic Status, and Extent of Myocardial Ischemia

*P < 0.05%.

Giri et al. Circulation. 2002;105:32-40.

77.5%85%95.5%Nondiabetic Women

60%*72.5%*96.5%Diabetic Women

85%88%93.8% Nondiabetic Men

79%77%86.3%Diabetic Men

≥2-Vessel Ischemia

1-Vessel Ischemia

No Ischemia

Follow-up (Years)

3.02.52.01.51.0.50.0

Cu

mu

lati

ve S

urv

ival

1.00

.95

.90

.85

.80

Nondiabetics

Diabetics

P<.00001

Giri S, et al. Circulation. 2002;105:32-40.

Significance of Normal Stress SPECT: Diabetic vs Nondiabetic Patients

Significance of Normal Stress SPECT: Diabetic vs Nondiabetic Patients

Re-Test@ ~1-1.5 years

When Do You Refer for Cardiac Imaging vs Exercise ECG?

When Do You Refer for Cardiac Imaging vs Exercise ECG?

What’s the evidence?

Algorithm for Evaluation of Symptomatic Women Using Cardiac Imaging

Algorithm for Evaluation of Symptomatic Women Using Cardiac Imaging

Intermediate-High Likelihood Women With Atypical or Typical Chest Pain Symptoms

Low Post-ETT LK

EX OR PHARMACOLOGIC STRESS IMAGING

Cardiac Cath

Risk FactorModification +/-

Anti-Ischemic Rx

Pharmacologic Stress

ExerciseStress

Moderate-SeverelyAbnormal or

Depressed EF

Exercise TMTest

Normal or MildlyAbnormal w/ NormalLV Function

Good Ex Tolerance+ Normal 12-L ECG

Diabetes, Abnormal 12-L ECG, or Questionable Ex Capacity

Int Risk TM

Able to Ex Unable to Ex

Adapted from Mieres et al. Circulation. 2005;111:682-696.

39-year-old African-American woman with recent onset of exertional jaw pain and heart burn

Case StudyCase Study

Myocardial Perfusion Scintigraphy (MPS)Myocardial Perfusion Scintigraphy (MPS)

Images courtesy of Dr. Frans J. Wackers © Yale University.

Infero-septum

AnteriorAntero-septum

Inferior

Lateral

StressStress

RestRest

Normal Short Axis Normal Short Axis Image*Image*

InferiorApex

Anterior

Normal Vertical-Long Normal Vertical-Long Axis*Axis*

Infero-apical

StressStress

RestRest

Cardiac CatheterizationCardiac Catheterization

SummarySummary

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?

Are There Gender Differences in Invasive Diagnostic Tests?

Can Cardiac Catheterization Identify Coronary Artery Disease in Women?

Decisive Findings From the WISE Study 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

Women and Heart Disease: Making a Difference—A Call To Action

The National Coalition for Women with Heart Diseasewww.womenheart.org

www.herheartcommunity.com

Hospital Strategies and the Power of Partnership

Women and Heart Disease: Making a Difference—A Call To Action for EM

Physicians

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