Exercise Stress Testing in Women

Abstract

Marked reductions in cardiovascular mortality in women have occurred for the first time this decade as a result of advances in medical treatment, improvement in medical technology, and a greater focus on women and their cardiovascular risk. 1 Nonetheless, cardiovascular disease remains the No. 1 cause of death for women in the United States, and more women die from cardiovascular disease than men every year. 2 In addition, women with coronary artery disease (CAD) are more likely to have a poorer prognosis than men. 1,3,4 Women who have an acute myocardial infarction have a higher mortality than their male counterparts, and women who have symptoms of angina or an abnormal stress test are less likely to be referred for further diagnostic testing. 2,[5][6][7] Given these gender differences in the evaluation of possible CAD symptoms and the higher mortality due to CAD in women, critical steps should be taken to identify women at the earliest stage of presentation so that appropriate therapeutic strategies can be implemented. Nonetheless, identifying women with coronary disease can be a diagnostic challenge. The prevalence of CAD in younger women is low, and women tend to present with symptoms and CAD at older ages as compared with men. In addition, women may present with more atypical symptoms. 8 Women also have a lower prevalence of obstructive coronary disease, making diagnostic testing designed to detect focal areas of coronary stenosis less sensitive and specific in this population. 9 Currently, exercise stress testing is the most commonly used method of diagnosing CAD in women, 10 -12 Historically, exercise stress testing in women has been thought to have a decreased diagnostic accuracy because of a lower prevalence of CAD in women, but most early studies evaluating stress testing as a diagnostic tool were performed in almost exclusively male cohorts. [15][16][17][18][19][20][21][22][23][24][25] Until recently, the representation of women in published studies was too small to determine any gender differences in test accuracy. The underrepresentation of women, as well as the bias in selection of women when included, may be the reason for the misconceptions regarding the value of exercise stress testing in women. Nonetheless, research on exercise stress testing in women has increased in the past decade, improving our understanding of the diagnostic and prognostic value of this modality in women.The purpose of this article is to review the literature regarding exercise stress testing in women, with a focus beyond ST-segment depression alone. It addition to interpretation of ECG changes with exercise, evaluation of exercise capacity, chronotropic index, heart rate (HR) recovery (HRR), blood pressure response, and Duke Treadmill Score (DTS) can be used to enhance the utility of exercise testing. The diagnostic and prognostic value of these non-ECG variables in women is reviewed, with a goal of highlighting the importance of exercise stress testing in women on the basis of the research available to date. ST-Segment...

Clinical Characteristics, Sex Differences, and Outcomes in Patients With Normal or Near‐Normal Coronary Arteries, Non‐Obstructive or Obstructive Coronary Artery Disease

“…This finding is not surprising, given that recent studies have shown that women present with more atypical symptoms than men and have less‐obstructive CAD at angiography 19, 20, 22. It is likely that microvascular dysfunction was the pathophysiological mechanism for angina in many of the women without obstructive CAD.…”

Noninvasive Diagnostic Techniques for Coronary Disease in Women

“…12,13 Although historic evidence suggests lower sensitivity and specificity of ETT for the detection of obstructive CAD in women compared to men, recent research on ETT in women has improved our understanding of the diagnostic and prognostic value of this modality in women. 17 The use of the traditional criteria for a positive stress test of ≥1-mm horizontal or downsloping reversible STsegment depressions, in addition to the lower prevalence of obstructive CAD in women and lower exercise tolerance, frequently results in an underdiagnosis of obstructive CAD. In a meta-analysis of 3721 women being evaluated for obstructive CAD with an exercise ECG, positive ECG changes were shown to have a sensitivity and specificity in women of 61% and 70%, respectively, 18 as compared with men, in whom the sensitivity and specificity have been found to be approximately 10% higher.…”

“…26 The diagnostic and prognostic accuracy of exercise testing in women can be improved by incorporating parameters such as exercise capacity, chronotropic response, heart rate recovery, blood pressure response, and the DTS, in addition to ST-segment depression with exercise. 17 The Role of Stress Echocardiography Contemporary stress echocardiography utilizing exercise or dobutamine can be used to identify stress-induced ischemia based on the development of regional wall-motion abnormalities in the area of a decrease in myocardial blood flow. Its role in symptomatic women at risk for CAD has been well established.…”

Cardiac Diagnostic Testing: What Bedside Nurses Need to Know

“…13 The mean sensitivity of exercise stress testing for detection of coronary artery disease is 68%, and the specificity is 77% (in a meta-analysis of a findings obtained predominantly in men). 15,19 If echocardiography is added, stress testing has a sensitivity of 81% and a specificity of 92%, and if nuclear imaging is added, it has a sensitivity of 88% and a specificity of 90%. 19 Compared with men, women have an increased risk for false-positives, with a sensitivity of 31% to 71% and a specificity of 66% to 78%.…”

“…15,19 If echocardiography is added, stress testing has a sensitivity of 81% and a specificity of 92%, and if nuclear imaging is added, it has a sensitivity of 88% and a specificity of 90%. 19 Compared with men, women have an increased risk for false-positives, with a sensitivity of 31% to 71% and a specificity of 66% to 78%. 19 The difference between the sexes may be due to more frequent ST-T wave changes in women at rest, lower ECG voltage, and hormone-related factors.…”