ACC: Gender disparities exist in screening for heart disease

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ATLANTA--“Within the past decade, our focus on women at risk has led to a clarification of understanding of the sex-specific factors that can influence our decisions and testing when it comes to women at risk or with symptoms of heart disease,” said Jennifer Mieres, MD, associate professor of medicine and director of nuclear cardiology at New York University School of Medicine, during a presentation at the 59th annual American College of Cardiology (ACC) conference.

Mieres’ presentation focused on tests that physicians can employ in the detection and risk assessment of women with suspected CAD.

Noting that CAD can present differently in women than in men, Mieres said, “I think when we are dealing with women in our daily practice, the first important thing to do when you suspect CAD is to do a risk assessment.”

During her presentation, Mieres noted a case study of a 54-year-old woman who had been admitted to NYU two years ago. Mieres and colleagues noted that the woman had risk factors for CAD, including mild hypertension and obesity and had a slightly elevated LDL. Prior to her treatment at NYU, the woman had been prescribed a statin and at the time of admittance her blood pressure was 144 over 90.  She was referred for stress testing following her exam.

Noting the ACC guidelines, Mieres said the patient was considered to be an intermediate to high likelihood of CAD risk and fit “the perfect criteria” for stress testing.

At this point, Mieres and colleagues had to determine which type of stress test to employ. “She had good exercise tolerance, as she worked out twice a week, but had shortness of breath brought on by exertion, so we learned that her exercise tolerance should be fine,” said Mieres. For this case, exercise treadmill electrocardiogram (ECG) testing was selected for diagnosis.

While the sensitivity of exercise stress testing is 61 percent for women and 70 percent for men, and specificity is 70 percent for women and 77 percent for men, Mieres said that there is still value in using this diagnosis method on women.

“I think the evidence is still such that an exercise ECG is useful for the first test in assessing symptomatic women with suspected CAD,” explained Mieres. “You are able to get information about functionality, and you also can get information about whether symptoms recur as well as what the blood pressure response will be like with exercise.”

In terms of prognosis for women presenting with suspected CAD, Mieres suggested that physicians use the Duke Activity Status Index (DASI), a 12-point questionnaire the patient fills out based on her activities, she noted.

“When you are faced with a female patient and you are trying to figure out her functional capacity, doing a quick 12-point assessment dealing with her daily life can help determine whether you should use any other imaging tests rather than stress testing, Mieres said.

Mieres explained that the stress test proved that the woman in her case study did not require any further testing. “From a diagnostic point of view, she falls into the category of having a good prognosis,” explained Mieres, noting that her blood pressure could be managed without medication.

Paying attention to exercise duration during testing is key, and false positives could be a force to be reckoned with, noted Mieres. “If there are positives on the ECG, [the patient] would go on for cardiac imaging.”