Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease—state-of-the-evidence and clinical recommendations

Abstract

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

Understanding Sex Differences in Coronary Artery Disease Risk

“…9, 10 The finding that women in this cohort were more likely than men to be symptomatic, including with typical angina, is consistent with a greater likelihood of ischemia, and possibly, a greater risk of events. Anatomical/functional “mismatch” has been reported both in visually assessed obstructive angiographic stenoses that are not hemodynamically significant, as well as in apparently nonobstructive intermediate angiographic stenoses that are ischemia-inducing; 11 it is plausible that some LM lesions <50% may have been functionally flow-limiting.…”

Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC

“…There is much debate in the literature 132,133 over optimal strategies for evaluation of known or suspected CAD in women. An important consideration is that a sizeable proportion of symptomatic women may have no evidence of obstructive CAD but are nonetheless at increased risk of cardiac complications.…”

Sex Differences in Ischemic Heart Disease

“…include detecting the extent and severity of myocardial ischemia resulting from obstructive coronary artery disease, visualizing the nonobstructive plaque burden on coronary computed tomography, and evaluating small vessel disease by use of myocardial perfusion coronary flow reserve (positron emission tomography and stress magnetic resonance imaging). 36 Guidelines for diagnosis and management of symptomatic women with suspected IHD comprise both the determination of a woman's risk status for IHD (including a pretest evaluation based on AHA guidelines) and shared decision-making regarding the need for and choice of diagnostic testing.…”