1. Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010 FEDERICA ETTORI SPEDALI CIVILI EMODINAMICA BRESCIA Symptoms and coronary artery disease diagnosis: the preminent role of imaging techniques

2. MEN / WOMEN : SYMPTOMS DYSPNEA = CHEST PAIN LEFT ARM PAIN DIAPHORESIS NAUSEA DIAPHORESIS NAUSEA AFTER BINARY LOGISTIC REGRESSION = M = F ACS REGISTRY MICHIGAN AJC 2006

3. CRUSADE : NSTE ACS 35875 PTS – 41% female ( 2000-02) JACC 2005

4. NSTE ACS: biomarkers TIMI TACTICS 18 –TIMI 11 - OPUS TIMI 16 F FF WIVIOTT CIRC 2004

5. AHA STATEMENT algorithm for evaluation of sympomatic women Mieres circ.2005

6. SYMPTOMATIC WOMEN

7. NON INVASIVE TESTING AND PRETEST PROBABILITY

8. MYOCARDIAL PERFUSION IMAGE: APPROPRIATENESS SPECT : 6315 PTS INAPPROPRIATE USE = 14,4% HENDEL JACC 2010

9. Exercise ECG : diagnosis Exerctional symptoms of low predictable value Shorter exercise duration Lower CAD prevalence Reported high rate of false positives  Heart rate recovery  Functional capacity  Integrative test scores

10. Prognostic value of functional capacity

11. Stress echocardiography in women Diagnosis  No ionization radiation  Systolic and diastolic Ventricular dysfunction  Valvular disease  Extent of infarction and stress induced ischemia  Minimal added cost  More cost effective than exercise ECG  Exercise test or pharmacological test  Reduced image quality (obese,smokers) NO SEX EFFECT

12. RISK ASSESSMENT 5yr survival 4234 women exercise and dobutamine stress Shaw EUR HEART J 2005

13. CARDIAC RADIONUCLIDE IMAGING Perfusion defect Global and regional left ventricular function Left ventricular volumes Lung uptake of 201 Tl Exercise test or pharmacological test

14. STRESS SPECT RISK ASSESSMENT MARWICK AJM 1999 Continuum of risk

15. CT CORONARY CALCIFICATION DIAGNOSIS NEGATIVE PREDICTIVE VALUE = 100% LOW SPECIFICITY (Modest relationship between CAC and obstructive coronary artery disease) AHA STATEMENT IN NON INVASIVE TESTING (2005 ) “Coronary artery calcium testing for CAD risk detection should be limitated to clinically selected women at intermediate risk”

16. RISK ADJUSTED SURVIVAL BY CAC 35388 pts Raggi JACC 2010

17. Magnetic resonance myocardial perfusion imaging META- ANALYSIS PI = DYNAMIC FIRST-PASS PERFUSION IMAGING IWMA = STRESS INDUCED WALL MOTION ABNORMALITIES IMAGINES SENSITIVITY=91% SPECIFICITY=81% NANDALUM JACC 2007 X X ACC 2006 THE STRESS MRI IS INDICATED IN SYMPTOMATIC PATIENTS WITH INTERMEDIATE PRETEST PROBABILITY

18. COMPUTED TOMOGRAPHY ANGIOGRAPHY PROMISE trial ongoing Anatomic Functional Strategy test CTA strategy CAD SEVERITY TOTAL PLAQUE SCORE LVEF ? CHOW JACC 2010

19. GRAZIE

20. Clinical reason for symptoms alternative hypothesis Non obstructive atherosclerosis Endotelial dysfunction Microvascular disease and Subendocardial ischemia PLAQUE MORPHOLOGY Carotid IMT ACETYCHOLINE TEST CORONARY FLOW RESERVE IVUS - OCT - CT

21. Vulnerable Plaque E.Braunwald

22. Missed diagnoses of acute cardiac ischemia in the emergency departement Pope NEJM 2000

23. Role of non invasive testing in the clinical evaluation of women with suspected CAD Asymptomatic women Low risk in premenopausal women except High risk : diabetes, periferal arterial disease, chronic kidney disease Framingham risk score intermediate (controversial recommendation)