Diagnosing Cardiac Ischemia in Women: Key Imaging Considerations

Not only do women have higher prevalence and mortality rates with ischemic heart disease (IHD) than men, they also have more atypical symptoms of the disease, according to researchers from the Beth Israel Deaconess Medical Center (BIDMC).

In a video interview, Diana Litmanovich, MD, chief of the cardiothoracic imaging section at BIDMC, and Rokas Liubauskas, a clinical research fellow in the radiology department of BIDMC, discussed their recent poster presentation at the American Roentgen Ray Society (ARRS) conference, which focused on the impact of sex-based differences with risk factors, imaging, and the diagnostic workup of suspected IHD in women.

While diabetes mellitus and hypertension are well-established risk factors for myocardial infarction (MI), Dr. Liubauskas noted that they are higher risk factors in women than men. The authors also said that fewer women symptomatic for IHD present with typical symptoms such as chest pain. Common atypical symptoms in women who could have IHD may include nausea, vomiting and epigastric pain. Other complaints in women with possible IHD may include dyspnea, jaw pain, loss of appetite or lightheadedness.

When assessing women for potential coronary artery disease (CAD), Dr. Litmanovich explained that clinical predictive factors are reliable but less reliable in women compared to men. However, she maintained that predictability of an acute coronary event in women via imaging is better than that of men.

There are also key differences with imaging findings in this patient population. They pointed out that the smaller coronary artery diameter in women plays a key role with interpretation of imaging. Drs. Litmanovich and Liubauskas also discussed a lack of flow-limiting stenosis in over 50 percent of women symptomatic for IHD.

Other considerations impact the use of imaging devices for women with suspected IHD. While coronary computed tomography angiography (CCTA) has been recognized for its ability to help stratify risk in patients with CAD, the use of some medications to mitigate anxiety-related tachycardia in women may warrant heart rate monitoring, according to Dr. Liubauskas. When microvascular dysfunction is part of the equation for cardiac ischemia, Dr. Liubauskas says this requires functional tests for diagnosis.

When it comes to CAD, Dr. Litmanovich said women with preserved myocardium and ejection fraction may still have heart failure. In these cases, she said the use of magnetic resonance imaging (MRI) with delayed gadolinium enhancement may be warranted as “what looks normal on echocardiography or CT might actually correlate with abnormal MRI findings.”

For additional insights on the imaging and diagnosis of IHD in women, watch the video below: