exercise testing in women with suspected...
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Exercise Testing in Women with Suspected Coronary Artery Disease
Anthony P. Morise, MD Professor of Medicine
WVU School of Medicine
ACCURACY OF EXERCISE TESTINGMeta-Analyses – ST Segment Depression
Sens Spec ▪ Gianrossi et al -
Men and women 67% 72% ▪ Kwok et al - Women 61% 69%
Circulation 1989;80: 87
AJC 1999;83:660
Positive=-5, Negative=5Total Score
Reason for stopping =15induced AnginaEstrogen Status
Occurred =9Exercise testYes=10Diabetes?Yes=10Smoking?
Non-cardiac pain =2
Probable/atypical =6
Definite/Typical = 10Angina History 50 to 65 yrs = 15
>65 yrs =25Age> 2mm =10Depression 1-2mm =6Exercise ST
190 to 220 bpm =4160 to 189 bpm =8
130 to 159 bpm =12
100 to 129 bpm = 16Rate Less than 100 bpm = 20Maximal Heart
SumChoose responseVariable Exercise Test Score
WomenChoose only one
per group<40=low
probability
40-60= intermediate probability
>60=high probability
AHJ 2002, 144:818
Validation of Exercise Score in Women
Prev
alen
ce o
f CA
D
0
25
50
75
100
Exercise Score Group1 2 3
71
39
7
Low Intermediate High
0102030405060708090
100P
reva
lenc
e %
<20 20-29 30-39 40-49 50-59 60-69 >70
Exercise Test Score
CAD
MVD
5
26
5681
49
32
7
Am Heart J 2002; 144:818
JACC 2003;42:842
Estrogen Status and Outcomes
ACC/AHA CONSENSUSDiagnostic Applications of EST for Obstructive CAD (2002)
• Class I - All with Intermediate pretest probability of CAD
• Class IIb - Low or High pretest probability
• Class III - WPW, Paced, LBBB, deep T invers, >1mm ST dep
PRETEST PROBABILITY Diamond-Forrester
Age Gender TA AA NA
30-39 M W
I I
I L
L L
40-49 M W
H I
I L
I L
50-59 M W
H I
I I
I L
60-69 M W
H H
I I
I I
H=>90% I=10-90% L=<10%
Circulation 2002;106:1883-1892
Total Score:
1Obesity? BMI>271Family Hx CAD? 1o
1Smoking? (Any)1Hypertension?1Hyperlipidemia?2Diabetes?
Non-anginal = 1Atypical = 3Diamond Method
Typical = 5Angina HistoryNegative = +3Women onlyPositive = -3Estrogen Status
9>55 >65640-54 50-643<40 <50
Age Men Women
SumChoose responseVariable PretestMedRules
Choose only one
per group
<8=low probability
9-15= intermediate probability
>16=high probability
Am J Med 1997;102:350Am Heart J 1999;138:740http://pbrain.hypermart.net/medrules.html
PRETEST PROBABILITY
Sign CADSev CAD
Low
Intermediate
High
Am J Med 1997;102:350
JACC 2003; 42: 842
Exercise
% C
ardi
ac D
eath
/MI
0
1,8
3,5
5,3
7
Pretest Score1 2 3 4 5 6 7 8 9 10 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 >17
0 253
6 575 3
781
6 763
8 801
14 680
15 522
13 324
6 199
B
Heart 2007; 93:200-204
Low
High
Interm
Pretest Score – WISE Cohort
PRETEST PROBABILITY Frequency of Groups Presenting
for Exercise Testing
All Men Women
Low 47% 30% 64%
Int 45% 64% 27%
High 7% 6% 9%
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score0 8 15 23 30
HighLow Intermediate
Death CD/MI CMRev
0.8 0.8 1.3
4.3 2.6 4.9
7.8 4.8 7.0
Outcomes By Pretest Score Group
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score0 8 15 23 30
Suspected CAD – Test Selection
EST Cath, Imaging, EST
EST or Imaging
HighIntermediateLow
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score0 8 15 23 30
High
HighLow
Int
Int
0%
46%
1%
<1%
5%
1%
30%
15%
1%
Frequency Group by Both Scores
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score0 2 4 6 8
Outcomes Within Low Pretest Subgroups
Low
Int
High
Death CDMI CMRev
3.3 3.3 8.1
0.7 0.7 1.1
0 0 0
FU Imaging
No further CV testing
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score16 17 18 19 20 21 22 23 24
Outcomes Within High Pretest Subgroups
Low
Int
HighDeath CDMI CMRev 12.5 5.6 8.3
7.4 5.1 7.0
0 0 3.6 Med Rx CAD
FU Imaging
Exer
cise
Tes
t Sco
re
0
23
45
68
90
Pretest Score9 10 11 12 13 14 15
Outcomes Within Intermediate Pretest Subgroups
Low
Int
HighDeath CDMI CMRev 13.3 6.7 15.6
7.9 3.8 7.5
2.3 1.9 3.3
FU Imaging
No further CV testing unless other EST abnormality present (Imaging).
EXERCISE TESTINGOther EST Abnormalities
No more CV tests >Average Ex Capacity Low Duke Score HR responses NL BP response NL No Arrhythmias
FU Imaging < Fair Ex Capacity > Low Duke Score HR responses ABNL Chronotropic Recovery BP response ABNL Arrhythmias