Noninvasive diagnostic evaluation for chest pain in women

Abstract

UpdateWomen are eight times less likely to develop myocardial infarction than men are; nonetheless, when myocardial ischemic disease is present, it has a worse evolution 1,2 . No explanations for this fact are available, although speculations exist about the inadequate manner of diagnosis.It is worth emphasizing that in studies about coronary disease, women are either a minority or excluded from the study protocols. Therefore, most of the information regarding coronary disease in women comes from studies conducted in men. In fact, invasive cardiovascular procedures -either diagnostic or therapeutic -are frequently less indicated for women who bear confirmed coronary disease. However, it is not yet clearly established whether this difference is due to a larger use of such procedures in men or to a smaller indication in women.Typical angina is more prevalent in women, although angiographic studies have revealed that all forms of angina, including the typical type, are associated on a smaller scale with coronary disease in women when compared with that men. The CASS 3 study reveals that 62% of women with defined angina had ischemic disease compared with 40% of those with probable angina and 4% with nonischemic pain.We propose to critically evaluate the main noninvasive diagnostic methods for chronic coronary disease in women.Electrocardiogram -The association between electrocardiographic abnormalities at rest and a higher incidence of cardiovascular diseases is well documented in men but not in women. When ranking different levels of rest electrocardiographic abnormalities in men and women aged 40 to 64 years and with higher risk of cardiovascular disease-induced death, De Bacquer et al 4 observed higher relative risk for men. High-degree abnormalities were directly associated with mortality in both sexes, but low-degree abnormalities were not. The abnormalities considered as high degree were the presence of depression of the ST segment, T-wave inversion, complete or 2 nd degree atrioventricular block, branch (left or right) block, frequent extrasystoles and atrial fibrillation or flutter; low-degree abnormalities were a deviated QRS axis complex with high or low voltage and other alterations in ventricular repolarization. De Bacquer et al 4 demonstrated that depression of the ST segment in the rest electrocardiogram was associated with higher cardiovascular mortality, and was equally important in both sexes. The T-wave abnormalities were also more predictive for men, whereas arrythmias were more predictive for women. It is worth emphasizing that low-degree abnormalities did not have predictive values for either sex.Stress test -Several studies 3-7 have revealed a reduced amount of noninvasive diagnostic interventions for coronary disease in women. This is so because of the lower prevalence of ischemic disease in women, in addition to a higher number of false-positives 8 , ie, the specificity of the conventional effort test is lower in women, compared with that observed in men. It is important to consider the proba...