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Assessment of the presence and extent of coronary artery disease in postmenopausal women after an episode of unstable coronary artery disease: incremental value of exercise electrocardiography and thallium-201 SPECT
Linköping University, Department of Medicine and Care, Cardiology. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Care, Clinical Physiology. Linköping University, Faculty of Health Sciences.
Östergötlands Läns Landsting, Heart Centre, Department of Cardiology Thoracic Radiology. Linköping University, Faculty of Health Sciences.
Östergötlands Läns Landsting, Heart Centre, Department of Cardiology Thoracic Radiology. Linköping University, Faculty of Health Sciences.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims To compare the incremental diagnostic properties of Thallium-201 (201TI) SPECT perfusion imaging with clinical and exercise test variables in a female population with a suspected high prevalence of coronary artery disease.

Methods and Results We prospectively studied 121 postmenopausal women admitted to the coronary care unit with symptoms of unstable coronary artery disease and ECG changes suggestive of ischaemia. Incremental diagnostic logistic algorithms were developed. These included pretest variables (age; body mass index; previous myocardial infarction; myocardial markers at inclusion and type of anginal symptoms); exercise test (maximum workload; occurrence of ST-depression ≥ 0.1mV and peak heart rate); and 201TI scintigram (extent of thallium uptake abnormalities during exercise and presence of reversibility). End points were presence of coronary artery disease (250% diameter stenosis) and extent ('severe coronary artery disease' defined as left main, three vessel disease and two vessel disease involving proximal left anterior descending). Diagnostic accuracy and incremental value were assessed by receiver operating characteristic curve analysis. Incremental curve areas for disease presence were pretest 0.76 ±0.04, post-exercise ECG 0.83 ±0.04 (p<0.02 for the increment), and post-thallium scintigraphy 0.89 ±0.03 (p<0.02) and for disease extent were pretest 0.82 ±0.04, post-exercise ECG 0.89 ±0.03 (p<0.01 for the increment), and post thallium scintigraphy 0.92 ±0.02 (p = ns).

Conclusion In postmenopausal women, stable after an episode of unstable coronary artery disease, there is an incremental value of adding 201TI SPECT to clinical parameters and exercise testing in the determination of coronary artery disease. In women with severe coronary artery disease there was no significant additive value of myocardial scintigraphy.

National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-79932OAI: oai:DiVA.org:liu-79932DiVA: diva2:544729
Available from: 2012-08-15 Created: 2012-08-15 Last updated: 2013-09-11Bibliographically approved
In thesis
1. Diagnostic and Prognostic Evaluation in Postmenopausal Women with Signs and Symptoms of Unstable Coronary Artery Disease
Open this publication in new window or tab >>Diagnostic and Prognostic Evaluation in Postmenopausal Women with Signs and Symptoms of Unstable Coronary Artery Disease
2000 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Coronary artery disease (CAD) is the major cause of death in both men and women in the western world. The majority of studies undertaken to evaluate diagnostic methods, risk stratification and treatment of CAD, have been performed on men. Although there are studies reporting gender differences in the presentation of symptoms, prognosis and response to treatment, current recommendations for practice are based on a model of the disease in men.

The diagnostic information from basic clinical data, ECG and an early symptomlimited exercise test was evaluated in a prospective study on 200 postmenopausal women with unstable CAD. The prevalence of atherosclerosis was high (85%). A patient history and markers of myocardial injury were good predictors of significant CAD and the exercise test was as valuable for the assessment of this diagnosis in women as that reported in men.

The incremental diagnostic values of basic clinical data, the exercise test and 201TI SPECT were assessed in 121 postmenopausal women after an episode of unstable CAD. There was an incremental diagnostic value of 201TI SPECT compared to basic data and the exercise test when diagnosing significant CAD, but not regarding the identification of extensive CAD.

Evaluation of symptom-limited exercise test for risk stratification in postmenopausal women with unstable CAD was carried out on a population of 395 women in the "FRagmin during InStability in CAD" (FRISC I) Study. The exercise test was a good predictor of future cardiac death and myocardial infarction (MI) if parameters reflecting cardiac performance also were taken under consideration and not only chest pain and ST-segment depression, two parameters reflecting ischaemia and often used in studies on men. However, the patients who, after admission, did not become stable enough to perform the exercise test, had the highest risk of adverse future events.

Comparison of symptom limited exercise test and troponin T measurements for risk stratification in women and men was performed in the FRISC I study population. It was concluded that the early symptom-limited exercise test and troponin T are at least as useful as prognostic risk indicators in women as they are in men.

The gender differences in outcome after early revascularisation compared to noninvasive management was assessed in 749 women and 1708 men in the "Fast Revascularisation during InStability in CAD" (FRISC II) Study. Women were older, had less severe CAD and a better prognosis than men. Men had a more favourable outcome if randomised to early revascularisation, whereas there was an opposite trend in women, although not significant. The different outcome in women may partly be explained by A high procedure-related event rate in the invasive group compared to the non-invasive group, and an overall low event rate during follow-up. Further research is needed in this area, and in the mean time, a more conservative approach to revascularisation in women, guided by risk stratification seems reasonable.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2000. 110 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 647
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-27546 (URN)12207 (Local ID)91-7219-748-X (ISBN)12207 (Archive number)12207 (OAI)
Public defence
2000-11-10, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-08-15Bibliographically approved

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Säfström, KågeNylander, EvaNielsen, Niels ErikSwahn, Eva

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