Imaging of heart disease in women: review and case presentation

Heart matters: the unique landscape of cardiovascular health in women

Cardiovascular disease (CVD) remains the leading cause of death globally, despite significant public health efforts. The identification and targeting of modifiable risk factors - including hypertension, dyslipidemia, diabetes mellitus, smoking and obesity - have led to significant improvements in patient outcomes over the past 60 years. However, current strategies based on this model have been shown to underestimate CVD risk in women and they are less frequently targeted compared to men. In addition, female-specific biological differences known to contribute to CVD are frequently understudied or excluded from risk stratification efforts. This review explores the unique epidemiological burden, pathobiology and outcomes of CVD in women; the influence of traditional and sex-specific risk factors; and both diagnostic and therapeutic strategies that may improve clinical outcomes in the future.

Age- and sex-specific differences in myocardial sympathetic tone and left ventricular remodeling following myocardial injury

BACKGROUND

Presentations and outcomes of acute myocardial infarction (MI) differ between women and men, with the worst outcomes being reported in younger women. Mental stress induced ischemia and sympathetic activation have been suggested to play a prominent role in the pathogenesis of MI in younger women, however, the impact of sex hormones on these parameters remains unknown.

METHODS

The effect of sex hormones and age on myocardial infarct size and myocardial sympathetic activity (MSA) was assessed in male and female, as well as young (4-6 months) and aged (20-22 months) FVB/N mice (n = 106, 60 gonadectomized and 46 sham-operated animals) who underwent in vivo [11C]meta-hydroxyephedrine ([11C]mHED) positron emission tomography (PET) and cardiac magnetic resonance (CMR) imaging 24 h after a 30 min myocardial ischemic injury.

RESULTS

MSA and catecholamine levels following myocardial injury were highest in young males (p = 0.008 and p = 0.043 vs. young females, respectively) and were reduced by orchiectomy. Accordingly, testosterone serum levels correlated positively with MSA (r = 0.66, p < 0.001). Males had a larger average infarct size and lower left ventricular contractility following myocardial injury than females (p < 0.05 vs. females). These sex differences were no longer evident in gonadectomized animals (p = NS vs. females). In female animals, estrogen depletion did not affect MSA (ovariectomy effect, p = 0.892). Female animals showed an age-dependent increase in MSA (p = 0.011), which was absent in males.

CONCLUSION

Testosterone associates with an increase in sympathetic tone, contributing to adverse cardiac remodeling following MI. Conversely, females maintain sympathetic integrity, independent of sex hormones. Our results suggest a biological advantage of female sex in post MI recovery. Further research is warranted to confirm these findings in humans.

The value and accuracy of intracoronary electrocardiogram in the diagnosis of myocardial ischemia in coronary heart disease

BACKGROUND

Although intracoronary electrocardiography (IC-ECG) offers direct electrophysiological insights into myocardial ischemia caused by insufficient coronary blood supply, compared to common diagnostic methods like electrocardiography (ECG), it lacks widespread adoption and robust clinical research.

OBJECTIVE

To analyze the value and accuracy of intracoronary electrocardiogram in myocardial ischemia diagnosis in coronary heart disease patients.

METHODS

Three hundred patients treated at our hospital were included in the study. Patients were categorized into non-ischemic group A (Fraction Flow Reserve [FFR] > 0.8) and ischemic group B (FFR < 0.75) based on FFR examination results. Both groups underwent IC-ECG examination. The ischemic group received percutaneous coronary intervention (PCI) treatment followed by another FFR examination, dividing them into non-ischemic subgroup B1 (FFR > 0.8) and ischemic subgroup B2 (FFR < 0.75). Both subgroups underwent IC-ECG examination. Receiver operating curves were constructed using FFR to assess the clinical utility of different IC-ECG parameters.

RESULTS

Group A patients showed a significant decrease in ST-segment shift at J-point, ST-segment integral, T-peak, T-wave integral, and T-peak to end-time, while the Corrected Q-T interval (QTc-time) was significantly higher in the B group (p< 0.05). The parameters, including ST-segment shift at J-point, ST-segment integral, T-wave integral, T-peak, T-peak to end-time, and QTc-time, were found to have clinical significance in predicting the occurrence of myocardial ischemia (p< 0.05).

CONCLUSION

Intracoronary electrocardiogram QT interval dispersion and Q-T peak (QTp) interval dispersion have a high diagnostic accuracy for myocardial ischemia in coronary heart disease.

Advancing the access to cardiovascular diagnosis and treatment among women with cardiovascular disease: a joint British Cardiovascular Societies' consensus document

Despite significant progress in cardiovascular pharmacotherapy and interventional strategies, cardiovascular disease (CVD), in particular ischaemic heart disease, remains the leading cause of morbidity and mortality among women in the UK and worldwide. Women are underdiagnosed, undertreated and under-represented in clinical trials directed at management strategies for CVD, making their results less applicable to this subset. Women have additional sex-specific risk factors that put them at higher risk of future cardiovascular events. Psychosocial risk factors, socioeconomic deprivation and environmental factors have an augmented impact on women's cardiovascular health, highlighting the need for a holistic approach to care that considers risk factors specifically related to female biology alongside the traditional risk factors. Importantly, in the UK, even in the context of a National Health Service, there exist significant regional variations in age-standardised mortality rates among patients with CVD. Given most CVDs are preventable, concerted efforts are necessary to address the unmet needs and ensure parity of care for women with CVD. The present consensus document, put together by the British Cardiovascular Society (BCS)'s affiliated societies, specifically portrays the current status on the sex-related differences in the diagnosis and treatment of each of the major CVD areas and proposes strategies to overcome the barriers in accessing diagnoses and treatments among women. This document aims at raising awareness of the scale of the current problem and hopes to stimulate a multifaceted approach to address sex disparities and enable future comprehensive sex- and gender-based research through collaboration across different affiliated societies within the BCS.

The essential role of dual-energy x-ray absorptiometry in the prediction of subclinical cardiovascular disease

Subclinical cardiovascular disease (Sub-CVD) is an early stage of cardiovascular disease and is often asymptomatic. Risk factors, including hypertension, diabetes, obesity, and lifestyle, significantly affect Sub-CVD. Progress in imaging technology has facilitated the timely identification of disease phenotypes and risk categorization. The critical function of dual-energy x-ray absorptiometry (DXA) in predicting Sub-CVD was the subject of this research. Initially used to evaluate bone mineral density, DXA has now evolved into an indispensable tool for assessing body composition, which is a pivotal determinant in estimating cardiovascular risk. DXA offers precise measurements of body fat, lean muscle mass, bone density, and abdominal aortic calcification, rendering it an essential tool for Sub-CVD evaluation. This study examined the efficacy of DXA in integrating various risk factors into a comprehensive assessment and how the application of machine learning could enhance the early discovery and control of cardiovascular risks. DXA exhibits distinct advantages and constraints compared to alternative imaging modalities such as ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. This review advocates DXA incorporation into cardiovascular health assessments, emphasizing its crucial role in the early identification and management of Sub-CVD.

Cardiovascular Imaging in Women

Multimodality cardiovascular imaging is a cornerstone diagnostic tool in the diagnosis, risk stratification, and management of cardiovascular diseases, whether those involving the coronary tree, myocardial, or pericardial diseases in general and particularly in women. This manuscript aims to shed some light and summarize the very features of cardiovascular disease in women, explore their unique characteristics and discuss the role of cardiovascular imaging in ischemic heart disease and cardiomyopathies. The role of four imaging modalities will be discussed including nuclear medicine, echocardiography, noninvasive coronary angiography, and cardiac magnetic resonance.

Machine Learning and Bias in Medical Imaging: Opportunities and Challenges

Bias in health care has been well documented and results in disparate and worsened outcomes for at-risk groups. Medical imaging plays a critical role in facilitating patient diagnoses but involves multiple sources of bias including factors related to access to imaging modalities, acquisition of images, and assessment (ie, interpretation) of imaging data. Machine learning (ML) applied to diagnostic imaging has demonstrated the potential to improve the quality of imaging-based diagnosis and the precision of measuring imaging-based traits. Algorithms can leverage subtle information not visible to the human eye to detect underdiagnosed conditions or derive new disease phenotypes by linking imaging features with clinical outcomes, all while mitigating cognitive bias in interpretation. Importantly, however, the application of ML to diagnostic imaging has the potential to either reduce or propagate bias. Understanding the potential gain as well as the potential risks requires an understanding of how and what ML models learn. Common risks of propagating bias can arise from unbalanced training, suboptimal architecture design or selection, and uneven application of models. Notwithstanding these risks, ML may yet be applied to improve gain from imaging across all 3A's (access, acquisition, and assessment) for all patients. In this review, we present a framework for understanding the balance of opportunities and challenges for minimizing bias in medical imaging, how ML may improve current approaches to imaging, and what specific design considerations should be made as part of efforts to maximize the quality of health care for all.

Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring

Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.

Sex-Related Differences in Heart Failure Diagnosis

PURPOSE OF REVIEW

The literature on the importance of sex in heart failure diagnosis is scarce. This review aims to summarize current knowledge on sex differences regarding the diagnosis of heart failure.

RECENT FINDINGS

Comorbidities are frequent in patients with heart failure, and their prevalence differs between sexes; some differences in symptomatology and diagnostic imaging techniques were also found. Biomarkers also usually show differences between sexes but are not significant enough to establish sex-specific ranges. This article outlines current information related to sex differences in HF diagnosis. Research in this field remains to be done. Maintaining a high diagnostic suspicion, actively searching for the disease, and considering the sex is relevant for early diagnosis and better prognosis. In addition, more studies with equal representation are needed.

[Gender-specific differences in cardiology]

BACKGROUND

Evidence in cardiovascular patient care is currently skewed to the disadvantage of women. This article provides a summary of the current state of knowledge on gender differences with a special focus on the epidemiology, pathophysiology, risk factors and treatment of the most frequent cardiovascular diseases.

MATERIAL AND METHODS

Evaluation and discussion of background research and expert recommendations.

RESULTS

The necessity for a gender-specific analysis of results is a relatively recent development in clinical trials. There is increasing evidence for pathogenic mechanisms specific for women as well as pharmacodynamic and pharmacokinetic differences between women and men. Women are currently less likely to receive treatment for cardiac diseases according to medical guidelines than men.

CONCLUSION

For improvement of the treatment options and effective disease prevention, it is pivotal to investigate pathogenetic mechanisms specific to women.

Approach to Imaging Ischemia in Women

Approach to imaging ischemia in women Coronary artery disease in women tends to have a worse short- and long-term prognosis relative to men and remains the leading cause of mortality worldwide. Both clinical symptoms and diagnostic approach remain challenging in women due to lesser likelihood of women presenting with classic anginal symptoms on one hand and underperformance of conventional exercise treadmill testing in women on the other. Moreover, a higher proportion of women with signs and symptoms suggestive of ischemia are more likely to have nonobstructive coronary artery disease (CAD) that requires additional imaging and therapeutic considerations. New imaging techniques such as coronary computed tomography (CT) angiography, CT myocardial perfusion imaging, CT functional flow reserve assessment, and cardiac magnetic resonance imaging carry substantially better sensitivity and specificity for the detection of ischemia and coronary artery disease in women. Familiarity with various clinical subtypes of ischemic heart disease in women and with the major advantages and disadvantages of advanced imaging tests to ensure the decision to select one modality over another is one of the keys to successful diagnosis of CAD in women. This review compares the 2 major types of ischemic heart disease in women - obstructive and nonobstructive, while focusing on sex-specific elements of its pathophysiology.

Cardiac Imaging in Women with Ischemic Heart Disease

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.