Cardiac imaging plays an important role in the cardiac care continuum, and choosing the right test can mean all the difference in quality care for both women and men.
Cardiovascular disease remains the leading cause of morbidity and mortality in women, and a potent killer of women and men alike. Although there have been recent decreases in cardiovascular mortality, gains have been far less for women than men. This seeming lack of progress suggests opportunities for new diagnostic strategies to improve disease detection and clinical outcomes for women with heart disease.
Meanwhile, payment systems are continuing to evolve into quality- and performance-based systems across all payers covering commercial and elderly populations, making it increasingly important that cardiology practices use the available tools in an appropriate and effective manner to diagnose and manage heart disease in women.
One of these imaging tools is myocardial perfusion imaging (MPI). A new consensus statement from the American Society of Nuclear Cardiology (ASNC) highlights three themes for the effective use of MPI in women (J Nucl Cardiol, online June 5, 2017).
Gatekeeper to quality
First, MPI can serve as a gatekeeper to quality testing and treatment patterns aimed at reducing the cardiovascular disease burden in women. While the clinical evaluation of symptomatic women can be challenging due to their varying clinical presentation, substantial evidence suggests that both SPECT and PET MPI can effectively risk-stratify women with stable ischemic heart disease. The appropriate selection of patients for testing can markedly reduce the need for additional testing, and potentially lead to improvements in overall value by optimizing test efficiency, cost-effectiveness and radiation dose reduction.
Updated technology & test protocols
Second, contemporary standards of care necessitate the uniform application of targeted radiation dose–reduction strategies whenever possible to all women (and men) undergoing MPI. These include the use of high-sensitivity solid-state cadmium zinc telluride detector SPECT, and the use of PET, which allows for enhanced image quality while limiting patient exposure to ionizing radiation due to the short half-lives of radiopharmaceuticals. Imaging laboratories are encouraged to continually review practices to implement dose-reduction strategies, such as stress-first perfusion imaging when appropriate, for decreasing radiation doses to levels that are as low as reasonably achievable. Thallium-based and dual-isotope SPECT protocols should be avoided.
New tools in the toolbox
Third, new tools, such as PET to assess coronary blood flow reserve, are becoming available to better probe ischemic heart disease in women, which may be more commonly associated with coronary microvascular dysfunction and non-obstructive coronary artery disease. Quantitative MPI with PET represents a promising way to improve risk detection in symptomatic women.
Appropriate use of imaging requires in-depth understanding of the specifics of the population being evaluated. As such, more investment in cardiovascular imaging research, including clinical trials of imaging with outcomes in women with heart disease, is needed. Judicious use of emerging imaging technologies in at-risk women may prove useful to better interrogate their relevant disease processes while limiting radiation exposure and decreasing the need for unnecessary or potentially harmful downstream procedures.
Viviany R. Taqueti, MD, MPH, is an associate cardiologist in the Cardiovascular Imaging Program, Departments of Medicine and Radiology, at Brigham and Women’s Hospital, and assistant professor at Harvard Medical School in Boston. She is the lead author of the 2017 ASNC Consensus Statement on Myocardial Perfusion Imaging in Women for the Evaluation of Stable Ischemic Heart Disease.