Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Discuss the need for the 2014 update to the American Heart Association’s consensus statement on the use of coronary artery disease imaging for evaluating symptomatic women with suspected myocardial ischemia.
- Cite key recommendations made in the American Heart Association’s consensus statement on the use of coronary artery disease imaging for evaluating symptomatic women with suspected myocardial ischemia.
- Describe several caveats to consider in regard to the risks and benefits of diagnostic test use in women suspected of ischemic heart disease.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwmay2. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Christopher Cole- Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
In recent decades, physicians have used the male model of testing to identify coronary artery disease (CAD) in women, but studies show that there are gender-specific differences in the pathophysiology of coronary atherosclerosis. “These differences are multifactorial and include obstructive and non-obstructive CAD as well as dysfunction of the coronary microvasculature and endothelium,” explains Jennifer H. Mieres, MD, FACC, FASNC, FAHA. “As such, the term ischemic heart disease (IHD) best describes the varied pathophysiology in women. Women with IHD are at increased risk for coronary events.”
Using the male model approach has led to under-diagnosis and under-treatment of IHD for women, which in turn has led to higher case fatality rates and greater morbidity. More recently, efforts have been made to ensure gender equality in the quantity and quality of research by better representing women in clinical trials and registries. These efforts were made to optimize management strategies for women with suspected and known IHD.
A New Consensus on Coronary Artery Disease in Women
In 2005, the American Heart Association (AHA) published a consensus statement on the use of CAD imaging for evaluating symptomatic women with suspected myocardial ischemia. Since that time, many reports have provided additional high-quality evidence, including data on coronary CT angiography (CCTA) and cardiac MRI (CMR). In 2014, the AHA updated this statement and published it in Circulation. The update provides sex-specific data on the diagnostic and prognostic accuracy for exercise treadmill testing (ETT) with electrocardiography, stress echocardiography, stress myocardial perfusion imaging (MPI) with single-photon emission CT or positron emission tomography, stress CMR, and CCTA.
“In the past, clinicians didn’t recognize the importance of non-obstructive CAD in women,” says Dr. Mieres, who was co-chair of both the 2005 and 2014 AHA consensus statements. “This led to false-positive stress tests and a lack of appropriate treatment. We now recognize that women experience a broader range of IHD symptoms than men and have a different pattern and distribution of pain symptoms. Women may present with the classic symptoms of left-sided chest pain or pressure, but other symptoms that aren’t localized to the chest may also present. These include jaw pain, upper back pain, and widespread indigestion. In addition, women’s symptoms are frequently associated with mental or emotional stress, whereas men’s symptoms are more likely to result from physical exertion.”
Key Recommendations from the AHA Consensus
The most recent AHA consensus statement provides helpful diagnostic recommendations for women presenting with suspected IHD symptoms and for establishing the level of IHD risk (Figure). “Healthcare providers should determine whether a woman is at low, intermediate, or high risk for IHD and discuss the available options,” Dr. Mieres says. “The level of risk should help steer these conversations on which diagnostic tests to use.”
According to the consensus statement, low-risk women are not candidates for diagnostic testing in most cases. Women at low and intermediate IHD risk are recommended to first undergo a treadmill exercise electrocardiogram (ECG). For symptomatic women with functional disability, an indeterminate ETT, or an abnormal rest ECG, the AHA recommends echocardiography or MPI; CMR may be considered a reasonable test option. CCTA may also be considered reasonable for women at intermediate IHD risk. The AHA writing group developed a summary of recommendations for IHD imaging in women with ischemic symptoms (Table).
Ischemic Heart Disease: Important Caveats
According to the AHA, there are several caveats to consider when discussing the risks and benefits of diagnostic tests with women suspected of IHD. For example, women of childbearing age may want to avoid tests that require exposure to radiation. “We must also consider a woman’s functional ability when determining the type of diagnostic testing to use,” says Dr. Mieres. “Women with low functional disability are at higher risk for heart attacks.”
Premenopausal women at intermediate IHD risk who are functionally disabled generally are recommended to undergo echocardiography or CMR. However, they may also be candidates to undergo MPI or CCTA if an effective radiation dose of less than 3 mSv is possible. When stratifying risk, clinicians are urged to base their decisions on the extent and severity of inducible abnormalities noted on the stress examination.
Dr. Mieres says that the most recent AHA consensus statement update allows clinicians to better determine the risks and treatment strategies for IHD in symptomatic women who were previously undiagnosed. However, she notes that more research is still warranted. “We need additional comparative effectiveness studies to further improve and guide testing,” she says. “The treatment of women presenting with ischemic symptoms is an important aim for future research.”
Readings & Resources (click to view)
Mieres JH, Gulati M, Merz NB, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation. 2014 Jun 16 [Epub ahead of print]. Available at: http://circ.ahajournals.org/content/early/2014/06/16/CIR.0000000000000061.full.pdf+html.
Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.
Mosca L, Barrett-Connor E, Wenger NK. Sex/gender differences in cardiovascular disease prevention: what a difference a decade makes. Circulation. 2011;124:2145-2154.
Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association [published corrections appear in Circulation. 2011;123:e624 and Circulation. 2011;124:e427]. Circulation. 2011;123:1243-1262.