Gender and Stress Echocardiography

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Med Klin. 2002 Sep 15;97(9):513-21.
The current status of noninvasive cardiac diagnosis in women with suspected coronary heart disease
Schannwell CM, Lazica D, Plehn G, Leschke M, Strauer BE.
Medizinische Klinik und Poliklinik B Klinik fur Kardiologie, Pneumologie und Angiologie Heinrich-Heine-Universitat Dusseldorf Moorenstrasse 5 40225 Dusseldorf.

BACKGROUND AND OBJECTIVE: Coronary artery disease is the leading cause of mortality among women in the industrial countries. Unfortunately, the routinely available noninvasive tests used to screen the presence of coronary artery disease have been relatively insensitive and nonspecific for women. The aim of this study was to evaluate the importance of pretest coronary artery disease probability and to determine whether the evaluation of left ventricular diastolic parameters is a relevant diagnostic tool in women with suspected coronary artery disease. PATIENTS AND METHODS: Electrocardiography at rest and during exercise, echocardiography at rest with evaluation of systolic and diastolic functional parameters, dobutamine stress echocardiography, exercise thallium myocardial scintigraphy, and coronary angiography were performed in 180 consecutive patients with suspected coronary artery disease. RESULTS: Coronary angiography revealed significant coronary artery disease in 104 patients. Angina pectoris, resting and exercise electrocardiography had a very low pretest probability in women. Dobutamine stress echocardiography, myocardial scintigraphy and the evaluation of left ventricular diastolic function showed less relevant gender-related differences and had a significantly better pretest probability. CONCLUSION: Dobutamine stress echocardiography and exercise thallium myocardial scintigraphy are reliable methods of diagnosing coronary artery disease in women. Echocardiographic assessment of diastolic left ventricular function represents another screening test for the evaluation of suspected coronary artery disease in women. All three methods, however, are not able to discriminate between coronary macro- or microangiopathy.

Eur J Echocardiogr. 2001 Jun;2(2):132-8.
The stress echo prognostic gender gap.
Cortigiani L, Gigli G, Vallebona A, Mariani PR, Bigi R, Desideri A.
Cardiovascular Research Foundation, Castelfranco Veneto (Treviso), Italy.

AIMS: To investigate whether myocardial ischaemia elicitable during pharmacological stress echocardiography portends different prognosis in men and women.METHODS AND RESULTS: The study group was made by 1733 patients (941 men, 792 women) who underwent dipyridamole (n=1008) or dobutamine (n=725) stress echo for evaluation of known or suspected coronary artery disease. An ischaemic response was found in 460 patients (308 men, 152 women). Considering the whole ischaemic population, women were older (P<0.0001) and more likely to have hypertension (P=0.02) and hypercholesterolaemia (P=0.04) than men. No difference in age and risk factors was evidenced between the two sexes in the subset of 203 patients with ischaemia and suspected coronary artery disease. During follow-up (25 +/- 24 months for the ischaemic and 37 +/- 25 months for the non-ischaemic sample), there were 113 cardiac events (45 deaths and 68 infarctions) and 232 revascularizations. Revascularization rate in ischaemic population was similar in both sexes (P=0.36). Multivariate predictors of cardiac events in the whole ischaemic group were resting WMSI (HR=2.7, 95% CI 1.3--3.3;P=0.0050), female gender (HR=2.2, 95% CI 1.2--3.7; P=0.0062), age > or = l65 years (HR=1.9, 95% CI=1.0--3.6;P=0.0427), and Delta WMSI (HR=2.1, 95% CI=1.0--3.7;P=0.0447). Female gender (HR=2.7, 95% CI 1.1--6.3;P=0.0233) was the only independent prognostic predictor in patients with ischaemia and suspected coronary artery disease. Five-year infarction-free survival was 82% in men and 71% in women in the whole ischaemic population (P=0.0041) as well as in the ischaemic group with suspected coronary artery disease (CAD) (P=0.0175). In the non-ischaemic sample resting WMSI (HR=4.8), history of myocardial infarction (HR=2.5), and hypercholesterolaemia (HR=1.8) were independent predictors of outcome at multivariate analysis, whilst the gender had no prognostic importance. Conclusions: Our results show that female gender is an independent predictor of cardiac events in patients with myocardial ischaemia induced by pharmacological stress echocardiography.

J Am Coll Cardiol. 2002 Feb 20;39(4):625-31.
Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference?
Arruda-Olson AM, Juracan EM, Mahoney DW, McCully RB, Roger VL, Pellikka PA.
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.

OBJECTIVES: This study was designed to determine the effect of gender on the prognostic value of exercise echocardiography. BACKGROUND: Limited information exists regarding gender differences in prognostic value of exercise echocardiography. METHODS: We obtained follow-up (3.2 +/- 1.7 years) in 5,798 consecutive patients who underwent exercise echocardiography for evaluation of known or suspected coronary artery disease. RESULTS: There were 3,322 men (mean age 62 +/- 12 years) and 2,476 women (mean age 62 +/- 12 years) (p = 0.7). New or worsening wall motion abnormalities developed with exercise in 35% of men and 25% of women (p = 0.001). Cardiac events, including cardiac death (107 patients) and nonfatal myocardial infarction (148 patients), occurred in 5.3% of men and 3.1% of women (p = 0.001). Addition of the percentage of ischemic segments to the clinical and rest echocardiographic model provided incremental information in predicting cardiac events for both men (chi(2) = 137 to 143, p = 0.014) and women (chi(2) = 72 to 76, p = 0.046). By multivariate analysis, exercise electrocardiographic and exercise echocardiographic predictors of cardiac events in both men and women were workload and exercise wall motion score index. There was no significant interaction effect of rest echocardiography (p = 0.79), exercise electrocardiography (p = 0.38) or exercise echocardiography (p = 0.67) with gender. CONCLUSIONS: Although cardiac events occurred more frequently in men, the incremental value of exercise echocardiography was comparable in both genders. Of all exercise electrocardiographic and exercise echocardiographic variables, workload and exercise wall motion score index had the strongest association with outcome. The results of exercise echocardiography have comparable implications in both men and women.

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