- Chest pain in women is frequent
- Chest pain in women is not benign even when coronary angiography appears normal.
- Assessment of ischemic heart disease is challenging in women.
- Non-invasive and multi-modality imaging facilitates optimal risk management and targeted therapies.
Diagnosing coronary heart disease in women remains challenging. This excellent session nicely illustrated the issues of diagnosing coronary disease in women by several case presentations, which were followed by a panel discussion on how to address this problem in clinical practice.
Bernhard GERBER (Brussels, Belgium) introduced the session and pointed out the importance of ischemic artery disease in women, which remains the first cause of mortality in women. He explained why the diagnosis of ischemic heart disease is more difficult in women than in men. Indeed, women frequently present chest pain, but as demonstrated by the WISE and DALLAS Heart studies, the prevalence of obstructive epicardial coronary disease is lower than in men. Also, exercise ECG is less accurate in women than in men. While non-invasive imaging techniques have similar accuracy in both sexes, because of a lower pre-test probability, women will have lower post-test probability of disease and thus, more false positive results. New imaging techniques such as CT and MRI could be useful to diagnose CAD in women. Indeed, CT has high negative predictive value, and the CE-Mark study demonstrated higher accuracy of perfusion CMR than SPECT in women. There are currently only few studies indicating the optimal approach to diagnose coronary disease relative to outcome.
Leslee SHAW (Atlanta, US) showed a case of a premenstrual young woman with chest pain and positive exercise ECG. She discussed that premenstrual women generally have low risk. She defended the use of exercise ECG as a first line test, despite lower diagnostic accuracy, because this strategy was associated with lower cost and similar outcome in the Women trial.
Udo SECHTEM (Stuttgart, Germany) showed a case of an elderly woman with chest pain and normal coronary arteries on coronary angiography. He discussed the importance of endothelial and microvascular dysfunction in the pathogenesis of chest pain in women. He also stated that many women undergo unnecessary coronary angiograms demonstrating normal coronary arteries, while they could benefit from better medical treatment of risk factors.
Chiara BUCCIARELLI-DUCCI (Bristol, UK) presented a challenging case of a woman with rheumatic arthritis and abnormal LV function on echocardiography. She illustrated the usefulness of cardiac MRI to demonstrate the nature of dysfunction, showing myocardial infarction and evaluation of the microvasculature in this setting.
Prof. Sophie MAVROGENI (Athens, Greece) pointed out the importance of inflammation in rheumatic disease and stated that rheumatic disease is a risk factor as important as diabetes for coronary disease in women.
Leyla Elif SADE (Ankara, Turkey) summarized the session and presented the take home messages. She showed the guidelines for diagnosing coronary artery disease based on risk stratification, and menstrual status in women. In intermediate and high risk women, non-invasive imaging techniques such as stress-echo, SPECT (both class I indication) or cMR (class IIa indication) should be used to evaluate ischemic burden. If ischemia is present, cardiac catheterization should be performed. Coronary CT could be an alternative with high negative predictive value to rule out coronary artery disease, but the approach was not superior to functional testing in the Promise trial.
Overall, this was an excellent and well attended session, clarifying the approach to evaluation of coronary artery disease in women.