Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain

Abstract

I n industrialized countries, coronary artery disease (CAD) is the leading cause of death among women and associated with a worse outcome compared with men.1,2 Because of a frequently different presentation of complaints, ischemic heart disease is thought to be under-recognized in women. 3,4 The prevalence of vasospasm and microvascular angina is higher in women, which may partly explain the differences in symptoms between women and men. 4 Conventional first-line noninvasive diagnostic tests are thought to be less accurate in women, further contributing to underdiagnosis and potentially undertreatment. 5,6 On the other hand, women have higher rates of indeterminate exercise ECG results but also more falsepositive results because of nonspecific ST-T segment changes. The lower sensitivity of nuclear imaging is thought to result from the smaller size of the female heart, although falsepositive diagnoses may be introduced by breast attenuation artifacts. 7,8 Paradoxically, there seems to be a relative overuseBackground-Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency. Methods and Results-The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to FunctionalTesting for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097). Conclusions-Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028. Cardiac computed tomography (CT) is a noninvasive imaging modality with an excellent diagnostic accuracy for the detection of CAD in both men and women.11 Recently, 3 multicenter randomized trials showed that cardi...

Prognostic value of combined coronary CT angiography and myocardial perfusion imaging in women and men

“…Our results are in line with recent studies showing that among patients evaluated for suspected CAD, men have more coronary atherosclerosis, a higher prevalence of obstructive CAD, and lower event-free survival than women. 4 , 5 , 6 Unlike some recent analyses, 4 , 16 our results do not show differences in referral for ICA or early invasive management between women and men with myocardial ischaemia. The observed revascularization rate is in line with previous studies.…”

Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis

“…The recent randomised CRESCENT trial highlighted that CCTA is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. This is largely attributed to an increase in prognostic information obtained for women on CCTA, while men fare similarly in anatomical and functional testing [ 23 , 24 ]. Comparable results were found in the randomised ROMICAT-II trial, which recommended an early CCTA strategy in the evaluation of chest pain, reporting safe application with a lower cumulative radiation dose and shorter hospital stay [ 17 ].…”

Advances in Cardiac Computed Tomography Functional Imaging Technology

“…Hence, patients with severe calcification of the coronary artery, as well as patients with suspected coronary artery disease and negative invasive angiography results, stress dynamic CT myocardial perfusion imaging should be the first choice. At present, Lubbers et al [30] conducted a multicenter study named CRESCENT-II, where the process of one-stop stress myocardial perfusion imaging was optimized. For patients with suspected stable chest pain, the first scanning was performed to calculate the coronary artery calcium score.…”