A multidisciplinary panel tackled the challenge of testing for coronary artery disease (CAD) in women. Their roundtable discussion touched on the current evidence, appropriate use and new approaches.
While there have been advances in sex-specific health research during the past few decades, CAD, MI and heart failure continue to be the world’s leading causes of morbidity and mortality in women, according to the American Heart Association. As a major public health challenge, CAD accounts for more than $195 billion in direct and indirect medical costs, based on a Centers for Disease Control and Prevention analysis. With such an impact on our healthcare system, it is important for all healthcare stakeholders to understand the latest advances in CAD.
CAD manifests differently in men and women. Symptoms women may experience tend to be general and highly variable, making it difficult to easily identify CAD as a likely culprit or rule it out to move on and find the real cause of patients’ symptoms. Diagnostic challenges in the evaluation of women with symptoms suggestive of obstructive CAD are largely due to the “atypical” nature of these symptoms, lower probability of disease compared with men, fatty tissue and breast tissue attenuation on cardiac imaging that lead to false positive findings and the presence of microvascular CAD.
This leads to both over-testing—meaning multiple and sometimes unnecessary repeat tests—and under-testing in women. Each end of the curve is fraught with its own issues. Over-testing can increase risks associated with radiation or contrast agent use. Under-testing may lead to a delayed diagnosis of a potentially serious condition. Overall, we need more and better understanding of the basic mechanisms and pathophysiology of the sex differences in cardiovascular disease to optimize the use of testing for CAD in women.
With this mind, I participated in a roundtable of national experts interested in cardiovascular disease and the unmet need in the diagnosis of women with CAD, with the proceedings now published (Popul Health Manag 2015;18:86-92). We convened the multidisciplinary panel with representatives from cardiology, medical technology innovation, women’s health research and policy analysis, personalized medicine, managed care, patient advocacy and health economics. Our discussion centered on:
- The current evidence pertaining to sex differences in obstructive CAD
- The appropriate use, risks and benefits of noninvasive and invasive testing for obstructive CAD
- The exploration of incorporating an age, sex, and gene expression test score in evaluating patients, specifically women, into care guidelines
From the roundtable proceedings, the most important takeaway was the need to develop better diagnostic testing to evaluate women for CAD. Future endeavors should focus on increasing awareness of sex-specific differences between men and women in the pathophysiology of CAD. Our discussion made it clear that the current diagnostic pathway presented challenges and barriers to optimal patient care. A majority of clinicians favored rule-out CAD testing strategies when developing a diagnostic management plan for patients.
Age, sex, and gene expression tests, for instance, might allow clinicians to more quickly and accurately identify patients as being at low- and high-risk of obstructive CAD. This might decrease unnecessary testing on low-risk CAD patients or, combined with other clinical information, help determine whether further cardiac testing is necessary. With this approach, clinicians may be able to more accurately assess patients presenting with symptoms suggestive of obstructive CAD and avoid healthcare inefficiencies and unnecessary costs to our healthcare system.
Through increased awareness of these issues and diagnostic pathways, professional organizations can consider personalized approaches to cardiac evaluation that will lead to better patient health.
Dr. Nash is dean of the Jefferson School of Population Health in Philadelphia.