Early and Appropriate Diagnosis of Coronary Artery Disease in Women: The Role

Cardiac Stress Imaging

Release and Expiration Dates: July 15, 2011 - July 14, 2012

Your peers recently submitted questions about coronary artery disease. See responses from Dr. Mieres
below.

Faculty Bio:
Jennifer H. Mieres, MD
Hofstra North Shore LIJ
School of Medicine
North Shore–LIJ Health System
Long Island, New York

How do you identify subclinical atherosclerotic changes in asymptomatic women?

The identification of subclinical atherosclerosis using noninvasive imaging techniques offers the
opportunity to identify asymptomatic women at risk of cardiovascular events due to coronary
artery disease (CAD). Cardiac CT, using electron beam tomography or multidetector CT, allows
a noninvasive anatomic quantification of coronary artery calcification (CAC), noncalcified
coronary artery plaque, and degree of coronary artery stenosis. The presence of calcification
signifies the presence of atherosclerosis since calcification does not occur in a normal vessel
wall. Therefore, the CAC score, which gives an estimate of the total atherosclerotic plaque
burden, provides information regarding cardiac risk. Recent data reveal an evolving role of
contemporary low radiation techniques with cardiac CT in the identification and risk assessment
in asymptomatic women at risk for CAD (Shaw LJ et al. J Am Coll Cardiol. 2009;54:1561-1575;
Fuster V et al. Nat Rev Cardiol. 2010;7:327-333). CAC detection adds incremental prognostic
value to traditional risk factors in asymptomatic women at risk for ischemic heart disease (Shaw
LJ et al. J Am Coll Cardiol. 2009;54:1561-1575; Michos ED et al. Atherosclerosis.
2006;184:201-206; Pasternak RC et al. J Am Coll Cardiol. 2003;41:1863-1874).

Other methods for the identification of subclinical atherosclerosis include an abnormal ankle
brachial index and abnormal carotid intima-media thickness.

Does the presence of a high level of fitness on a treadmill test preclude the presence of other
abnormalities such as hypertensive response or impaired heart rate recovery?

The diagnostic and prognostic accuracy of exercise testing in women can be improved by
incorporating additional independent parameters such as exercise capacity, chronotropic
response, heart rate recovery, blood pressure response, and the Duke Treadmill score, in addition
to ST-segment depression with exercise. Therefore, despite the fact that exercise capacity
(functional capacity) has strong prognostic implications in asymptomatic and symptomatic
women, the presence of a high level of fitness on a treadmill test does not preclude the presence
of other abnormalities such as hypertensive response or impaired heart rate recovery (Kohli P,
Gulati M. Circulation. 2010;122:2570-2580; Kligfield P, Lauer MS. Circulation.
2006;114:2070-2082).

There are limited data regarding sex differences in the response to the commonly used agents for
pharmacologic stress: adenosine, dipyridamole, regadenoson, and dobutamine.
Slight differences between men and women have been noted in hemodynamic responses to
adenosine stress and have been described in small populations. Women have been shown to have
a greater decrease in systolic blood pressure and a greater reflex tachycardia than men. This
change might be explained by a relatively greater volume of distribution of the infused
vasodilator in women compared with men attributable to a higher fat-to-muscle ratio (Johnston
DL et al. Mayo Clin Proc. 1998;73:314-320). Rest and peak heart rate, and systolic blood
pressure were higher in women than in men who underwent stress testing with adenosine.
Women also demonstrated greater increase in heart rate and decrease in systolic blood pressure
during adenosine infusion, resulting in higher peak/rest heart rate ratio and minimally lower
peak/rest systolic blood pressure ratio (Abidov A et al. Circulation. 2003;107:2894-2899).

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http://www.peerviewpress.com/early-and-appropriate-diagnosis-coronary-artery-
disease-women-role-cardiac-stress-imaging?person_id=3201022

This CME activity is jointly sponsored by Albert Einstein College of Medicine of Yeshiva University, Montefio
Medical Center and PVI, PeerView Institute for Medical Education.

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the
Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Eins
College of Medicine of Yeshiva University, Montefiore Medical Center and PVI, PeerView Institute for Medic
Education. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical educ
for physicians.

Albert Einstein College of Medicine of Yeshiva University designates this enduring material for a maximum of 

AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of the
participation

This activity is supported through an independent educational grant from Astellas Pharma Global Developmen
in the activity.