Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Ischemic Heart Disease A Consensus Statement From the American Heart Association
Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Ischemic Heart Disease A Consensus Statement From the American Heart Association
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DOI：
10.1161/cir.0000000000000061
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发表时间：
2014-07-22
期刊：
影响因子：
37.8
通讯作者：
Shaw, Leslee J.
中科院分区：
文献类型：
--
作者：
Mieres, Jennifer H.;Gulati, Martha;Shaw, Leslee J.
从历史上看，对有症状的女性和男性进行诊断评价的重点是检测需要血运重建的阻塞性冠状动脉狭窄（如适用）。对这种方法的两个挑战导致了对这种评估算法的修订，并为女性动脉粥样硬化的负担和IHD事件的总体危害提供了更多的见解。首先，最近的临床试验数据显示，及时的基于指南的医疗管理是安全的，对于患有稳定IHD（SIHD）的女性和男性，血运重建可能会推迟。7，8无论是采用最佳药物治疗的血运重建策略，还是仅采用最佳药物管理策略，都能有效减轻SIHD患者的心绞痛负担。9第二，有证据表明血管内超声或CCTA检测到的非梗阻性CAD的临床和预后意义。10-18尽管非梗阻性CAD对女性和男性都有影响，但非梗阻性CAD的负担不成比例地使高危女性处于不利地位，在冠状动脉造影中，女性的非梗阻性CAD患病率更高（定义为1%-49%狭窄）。19，20有一个普遍的模式，即具有稳定缺血症状的女性，尽管非梗阻性CAD的患病率较高，但与普通人群相比，冠状动脉事件的风险较高，20-22，并且这种风险在< 75岁的女性中尤其增加。[23]此外，心肌缺血与有症状的女性IHD死亡率高于男性相关。[23]在动脉扩张性重塑和非阻塞性斑块的情况下，女性症状与冠状动脉血管功能障碍相关，这一概念是理解女性特异性症状表现模式和IHD风险升高的关键组成部分。21，24，25因此，当代观点强调了记录的心肌缺血的重要性以及女性非梗阻性和梗阻性CAD的负担对于确定IHD风险和指导治疗决策的重要性。因此，本声明重点关注临床表现和相关疾病负担的2种一般模式：（1）阻塞性CAD狭窄引起的诱导性缺血（即诊断准确性）和（2）在非阻塞性CAD背景下识别冠状动脉血管功能障碍导致的心肌缺血的范围和严重程度，以及随后有症状女性IHD风险的升高（即主要不良IHD事件的预后准确性）。因此，患有非梗阻性CAD和负荷试验异常的女性不再被定义为具有假阳性试验，但其试验被归类为异常，并且他们被指出处于IHD风险升高。还讨论了与更广泛和严重的室壁运动或灌注异常或CTA定义的阻塞性CAD相关的预后估计。
Historically, the focus of the diagnostic evaluation for symptomatic women and men has been the detection of an obstructive coronary stenosis requiring revascularization (as appropriate). Two challenges to this approach have resulted in revision of this evaluation algorithm and provided added insight into the burden of atherosclerosis and overall hazard for IHD events in women. First, recent clinical trial data have revealed that prompt guideline-based medical management is safe and that revascularization may be deferred for women and men with stable IHD (SIHD). 7, 8 Strategies of either revascularization with optimal medical therapy or optimal medical management alone are effective at reducing the burden of angina for SIHD patients. 9 Second, there is unfolding evidence of the clinical and prognostic significance of nonobstructive CAD, detected by intravascular ultrasound or CCTA. 10–18 Although it affects both women and men, the burden of nonobstructive CAD disproportionately disadvantages at-risk females, who have a higher prevalence of nonobstructive CAD (defined as 1%–49% stenosis) at coronary angiography. 19, 20 There is a general pattern that women with stable ischemic symptoms, despite having a higher prevalence of nonobstructive CAD, have an elevated hazard for coronary events compared with the general population, 20–22 and this risk is particularly increased for women< 75 years of age. 23 Moreover, myocardial ischemia is associated with higher IHD mortality among symptomatic women than among men. 23 The concept that symptoms in women are correlated with coronary vascular dysfunction in the setting of arterial expansive remodeling and nonobstructive plaque is a critical component for understanding female-specific patterns in symptom presentation and elevated IHD risk. 21, 24, 25 Thus, the contemporary perspective highlights the importance of documented myocardial ischemia and the burden of nonobstructive and obstructive CAD in women as being fundamental to determining IHD risk and guiding therapeutic decisions. Accordingly, the present statement focuses on 2 general patterns of clinical presentation and correlative disease burden:(1) inducible ischemia caused by an obstructive CAD stenosis (ie, the diagnostic accuracy) and (2) the identification of the extent and severity of myocardial ischemia that results from coronary vascular dysfunction in the setting of nonobstructive CAD and the ensuing elevation of IHD risk (ie, prognostic accuracy for major adverse IHD events) in symptomatic women. Consequently, women with nonobstructive CAD and stress test abnormalities are no longer defined as having a false-positive test, but their test is classified as abnormal, and they are noted as being at an elevated IHD risk. Prognostic estimates relative to more extensive and severe wall-motion or perfusion abnormalities or CCTA-defined obstructive CAD are also addressed.