Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Abstract-Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with Ͼ240 000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women; indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD. (Circulation. 2005;111:682-696.)Key Words: AHA Scientific Statements Ⅲ women Ⅲ coronary disease Ⅲ imaging Ⅲ exercise testing C ardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction (MI), acute coronary syndromes, and angina, is the largest subset of this mortality. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus document. Although US men have experienced a decline in CAD deaths, the number of coronary deaths in women, Ͼ240 000 annually, has remained stable or has increased, depending on the study referenced. 1,2 CAD, which increases with advancing age, also is a substantial cause of morbidity and disability for US women. 3 Women, in particular young women (Ͻ55 years), have a worse prognosis from acute MI than their male counterparts, with a greater recurrence of MI and higherThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that ma...

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A preliminary report on medical radiation exposures to the US population based on publicly available sources of data estimated that the collective dose received from medical uses of radiation has increased by Ͼ700% between 1980 and 2006. 1 Computed tomography (CT) has had an annual growth rate of Ͼ10% per year and accounted for Ϸ50% of the collective dose in 2006. Approximately 65% of the collective CT dose is from studies of chest, abdomen, and pelvis. In 2006, cardiac CT accounted for 1.5% of the collective CT dose; however, utilization of cardiac CT is expected to rise, with the potential to further increase exposure to the population. 1 Nuclear medicine studies in the United States have increased by 5% annually to 20 million in 2006 and accounted for Ϸ25% of the 2006 collective medical radiation dose. Among nuclear medicine studies, cardiac imaging represented 57% of the number of studies and Ϸ85% of the radiation dose. 1 A number of publications on imaging with CT, fluoroscopy, or radioisotopes have emphasized the risks that may be associated with exposure to ionizing radiation. [2][3][4] To make informed decisions concerning the use of medical radiation in imaging procedures, the following are important components: (1) A working knowledge of the principles and uncertainties of the estimation of patient dose and biological risk; (2) a comparison of the risks of radiation exposure with the risks of activities in daily life; and (3) recognition of the potential risk of failing to make important diagnoses or treatment decisions if imaging is not performed because of safety concerns.There is no federal regulation of patient radiation dose, with the exception of mammography. Most federal and state regulations are aimed at equipment performance or the handling of nuclear materials. Therefore, appropriate utilization of the equipment or nuclear material in cardiac imaging, to maintain the dose as low as reasonably achievable, is the responsibility of the imaging physician and facility. The purpose of this Science Advisory is to provide a conceptual framework and make general recommendations for the safe use of cardiac imaging that relies on ionizing radiation. Parameters of Dosimetry CT and FluoroscopyThe parameters by which ionizing radiation is quantified differ among imaging modalities. 4 The amount of radiation produced by an imaging device can be described using exposure, expressed in International System of Units (SI) units of coulombs per kilogram (C/kg), or air kerma, expressed in SI units of milligrays (mGy). This document will use the term exposure, which refers to the amount of ionization produced in air by photon irradiation. Exposure can be measured for CT and fluoroscopy with ionization chambers within test objects (phantoms) or at body surfaces with minimal difficulty. Measurable or easily derived parameters, such as entrance skin exposure in radiography and fluoroscopy and the weighted CT dose index (CTDI w ) in CT, are useful to establish diagnostic reference levels for radioThe American Heart Ass...

Hypertension accounts for 1 in 5 deaths among American women, posing a greater burden for women than men, and is among their most important risk factors for death and development of cardiovascular and other diseases. Hypertension affects women in all phases of life, with specific characteristics relating to risk factors and management for primary prevention of hypertension in teenage and young adult women; hypertension in pregnancy; hypertension during use of oral contraceptives and assisted reproductive technologies, lactation, menopause, or hormone replacement; hypertension in elderly women; and issues of race and ethnicity. All are detailed in this review, as is information relative to women in clinical trials of hypertension and medication issues. The overarching message is that effective treatment and control of hypertension improves cardiovascular outcomes. But many knowledge gaps persist, including the contribution of hypertensive disorders of pregnancy to cardiovascular disease risk, the role of hormone replacement, blood pressure targets for elderly women, and so on.

The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions.

for the WOMEN Trial InvestigatorsBackground-There is a paucity of randomized trials regarding diagnostic testing in women with suspected coronary artery disease (CAD). It remains unclear whether the addition of myocardial perfusion imaging (MPI) to the standard ECG exercise treadmill test (ETT) provides incremental information to improve clinical decision making in women with suspected CAD. Methods and Results-We randomized symptomatic women with suspected CAD, an interpretable ECG, and Ն5 metabolic equivalents on the Duke Activity Status Index to 1 of 2 diagnostic strategies: ETT or exercise MPI. The primary end point was 2-year incidence of major adverse cardiac events, defined as CAD death or hospitalization for an acute coronary syndrome or heart failure. A total of 824 women were randomized to ETT or exercise MPI. For women randomized to ETT, ECG results were normal in 64%, indeterminate in 16%, and abnormal in 20%. By comparison, the exercise MPI results were normal in 91%, mildly abnormal in 3%, and moderate to severely abnormal in 6%. At 2 years, there was no difference in major adverse cardiac events (98.0% for ETT and 97.7% for MPI; Pϭ0.59).Compared with ETT, index testing costs were higher for exercise MPI (PϽ0.001), whereas downstream procedural costs were slightly lower (Pϭ0.0008). Overall, the cumulative diagnostic cost savings was 48% for ETT compared with exercise MPI (PϽ0.001). Conclusions-In low-risk, exercising women, a diagnostic strategy that uses ETT versus exercise MPI yields similar 2-year posttest outcomes while providing significant diagnostic cost savings. The ETT with selective follow-up testing should be considered as the initial diagnostic strategy in symptomatic women with suspected CAD. Clinical Trial Registration-http://www.clinicaltrials.gov.