Chest pain syndrome in women: a diagnostic dilemma

by Josh C. Leonard, MD; John R. Hoyle, MD; Killian Robinson, MD; and William Ntim, MD

A forward from Imaging Section Editor Tasneem Z. Naqvi, MD
The ability to diagnose coronary artery disease (CAD) in women may be limited by the sensitivity and specificity of symptoms as well as of noninvasive testing. The choice of which test should be performed to evaluate the presence of CAD in women remains controversial. Currently American Heart Association/American College of Cardiology guidelines recommend initial evaluation with exercise electrocardiogram (ECG) testing. In a meta-analysis of 3721 women, however, exercise ECG had a sensitivity of 61% and a specificity of 70%¹ as compared to 68% sensitivity and 77% specificity in men. Lower prevalence of CAD, particularly in younger women, higher prevalence of single-vessel disease, differences in exercise capacity, and the digoxin-like effects of estrogen are some factors accounting for this low diagnostic yield of exercise stress.² The addition of imaging to the evaluation of women with suspected CAD is most helpful in those women whose pretest likelihood of disease is intermediate (25%-75%). Stress echocardiography and myocardial perfusion imaging both allow for improved sensitivity and specificity in the diagnosis of obstructive CAD in women. Stress echocardiography has been shown to have a sensitivity of 85% to 86% and specificity of 77% to 79%.³Although the ability to detect new wall motion abnormalities as evidence of obstructive CAD is limited by body habitus, the advent of harmonic imaging⁴ and contrast echo⁵ have improved diagnostic accuracy.

Recent studies show that a combined perfusion and delayed enhancement cardiovascular magnetic resonance (CMR) examination can accurately diagnose CAD in the clinical setting with a sensitivity, specificity, and accuracy of 89%, 87%, and 88%, respectively. In a recent study including 92 men and 37 women, the accuracy was shown to be high both in single-vessel and multivessel disease and independent of CAD location.⁶ This case illustrates improved detection of single vessel CAD in a woman when stress echocardiography provided suboptimal information due to body habitus.

References
1. Kwok Y, Kim C, Grady D, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol. 1999; 83:660-666.

2. Vaitkevicus P, Wright JG, Fleg JL. Effect of estrogen replacement therapy on the ST segment response to postural and hyperventilation stimuli. Am J Cardiol. 1989; 64:1076-1077.

3. Fleischmann KE, Hunink MG, Kuntz KM, et al. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA. 1998;280:913-920.

4. Skolnick DG, Sawada SG, Feigenbaum H, et al. Enhanced endocardial visualization with non-contrast harmonic imaging during stress echocardiography. J Am Soc Echocardiogr. 1999; 12:559-563.

5. Moir S, Haluska BA, Jenkins C, et al. Incremental benefit of myocardial contrast to combined dipyridamole-exercise stress echocardiography for the assessment of coronary artery disease. Circulation. 2004; 110(9): 1108-1113.

6. Klem I, Heitner JF, Shah DJ, et al. Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol. 2006; 47(8): 1630-1638.

From Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

Cardiovascular diseases are the leading cause of death in women in the United States, and the obesity epidemic has paralleled this disturbing trend. Atypical symptoms contribute in part to the diagnostic challenge posed when evaluating acute chest pain syndromes in women. For obese women, ischemia workup by such established modalities as echocardiography and radionuclide imaging is limited by poor acoustic windows and attenuation due to body habitus. Cardiovascular magnetic resonance (CMR), with its superior temporal and spatial resolution, obviates these limitations. Cardiovascular magnetic resonance may enhance the diagnostic accuracy of ischemia evaluation in obese female patients.

Presentation and evaluation
A 51-year-old African American female with a history of hypertensive heart disease, non-insulin requiring diabetes mellitus, morbid obesity with hypoventilation syndrome, and mild pulmonary hypertension presented with a recurrent atypical chest pain syndrome. Patient had a previous nondiagnostic stress echocardiogram partly due to poor acoustic windows (Figure 1). Evaluation for pulmonary embolism was unremarkable. Initial workup revealed no biochemical evidence of evolving myocardial infarction and no dynamic ST/T changes on electrocardiogram. In view of coronary risk factors, further evaluation with adenosine stress perfusion magnetic resonance imaging (MRI) was pursued.

Diagnosis
Adenosine MRI stress perfusion study demonstrated inducible ischemia in the lateral wall (Figure 2A) with no evidence of transmural infarction (Figure 2B). Coronary angiography showed subtotal obstruction of the obtuse marginal branch of the left circumflex artery (Figure 3).

Patient management
Successful angioplasty and stenting of culprit lesion was performed.

Outcome
Patient tolerated procedure well, was discharged, and has had no subsequent admissions for chest pain syndrome.

Conclusions
Traditional cardiovascular imaging modalities, such as echocardiography and radionuclide imaging, have diagnostic limitations in a number of patients, including those with lung disease or obesity. Cardiovascular MRI may provide a novel utility in the evaluation of chest pain syndrome in women.

Imaging

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