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Noninvasive Technologies for Diagnosing Coronary Artery Disease in Women: Comparative Effectiveness

Clinician Summary – Oct. 11, 2012

Noninvasive Technologies for Diagnosing Coronary Artery Disease in Women: Comparative Effectiveness

Formats

Table of Contents

Research Focus for Clinicians

In response to a request from the public regarding the accuracy and harms of noninvasive technologies for diagnosing coronary artery disease (CAD) in adult women with symptoms suggestive of CAD, a systematic review of comparative studies was undertaken to evaluate the evidence. The review included 1 randomized clinical trial, 79 prospective observational studies, and 24 retrospective observational studies published from August 1975 through September 12, 2011. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/diagnosecad.cfm. This summary is provided to inform clinicians and to assist in decisionmaking along with consideration of a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Background

The diagnosis of CAD in women is challenging. Women with chest pain demonstrate a lower prevalence of obstructive epicardial CAD. Symptoms of CAD in women are less predictive and more often atypical when compared with those of men. The American Heart Association (AHA) reports that women at risk of CAD are less often referred for an appropriate diagnostic test than men. Coronary angiography, the gold standard for diagnosing CAD, is indicated in patients with chest pain and a high likelihood of CAD; however, it is associated with risks that make noninvasive modalities attractive for women in whom angiography is not indicated.

In 2005, the AHA developed a consensus statement on the role of noninvasive technologies (NITs) in diagnosing CAD in women. The statement recommended noninvasive tests for women with atypical chest pain and a low risk of CAD who might require evidence that their symptoms are not cardiac in origin and for symptomatic women with intermediate pretest probability of CAD.

The NITs used to diagnose CAD may be categorized as "functional" or "anatomic" tests. Functional NITs include:

Anatomic NITs include:

Although the 2005 AHA consensus statement was a thorough synopsis of the literature and included expert recommendations for the diagnostic evaluation of symptomatic women, it did not include a comparative effectiveness review of the accuracy of the various NITs. A better understanding of the accuracy of the many different NITs for CAD may help in clinical decisionmaking.

* Cardiac magnetic resonance imaging can be used as an anatomic or a functional modality.

Conclusions

Overall, within a given modality, the summary sensitivities and specificities were similar for all studies when compared with good-quality studies alone. When considering only the good-quality studies, the diagnostic accuracy of detecting CAD in women presenting with anginal chest pain but with no known CAD appeared to be better (in descending order) for coronary CTA, SPECT, ECHO, CMR, and ECG. However, the confidence intervals were wide, especially for CTA and CMR. Analysis for statistical differences between the diagnostic accuracies of NITs in women revealed that the sensitivities of ECHO and SPECT were significantly higher than that of ECG. Statistical analysis also revealed that the specificities of CMR and ECHO were significantly higher than that of ECG (when considering only good-quality studies). From comparator trials, there is limited or insufficient evidence on the predictors of the diagnostic accuracy of NITs; on the role of NITs in improving risk stratification, decisionmaking, and clinical outcomes; and on potential harms associated with NITs.

Clinical Bottom Line: Accuracy of Noninvasive Technologies for Diagnosing CAD in Symptomatic Women With No Known CAD

Modality Quality of Studies Number of Studies Number of Patients Summary Sensitivity (95% CI) Summary Specificity (95% CI) Strength of Evidence
Total Women
Analysis for a statistical difference between the accuracies of NITs for diagnosing CAD in women with no known CAD revealed that:
95% CI = 95-percent confidence interval; CMR = cardiac magnetic resonance imaging; CTA = computed tomography angiography; ECG = electrocardiography; ECHO = exercise/stress echocardiography; SPECT = single photon emission computed tomography
ECG All 29 8,825 3,392 0.62 (0.55–0.68) 0.68 (0.63–0.73) evidence high
Good 10 3,821 1,410 0.70 (0.58–0.79) 0.62 (0.53–0.69)
ECHO All 14 2,538 1,286 0.79 (0.74–0.83) 0.83 (0.74–0.89) evidence high
Good 5 1,227 561 0.79 (0.69–0.87) 0.85 (0.68–0.94)
SPECT All 14 1,340 1,000 0.81 (0.76–0.86) 0.78 (0.69–0.84) evidence high
Good 4 484 394 0.83 (0.52–0.95) 0.72 (0.37–0.92)
CMR All 5 580 501 0.72 (0.55–0.85) 0.84 (0.69–0.93) evidence low
Good 5 580 501 0.72 (0.55–0.85) 0.84 (0.69–0.93)
Coronary CTA All 5 1,298 474 0.93 (0.69–0.99) 0.77 (0.54–0.91) evidence low
Good 3 312 124 0.85 (0.26–0.99) 0.73 (0.17–0.97)
Strength of Evidence Scale

evidence high

High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.

evidence medium

Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.

evidence low

Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

evidence insufficient

Evidence either is unavailable or does not permit a conclusion.

Additional Findings

Gaps in Knowledge and Future Research Needs

What To Discuss With Your Patients

  • Their risk for developing CAD and factors that might increase their risk such as smoking, obesity, and a sedentary lifestyle
  • The importance of early detection and management of CAD
  • The relative accuracy of the NITs available for diagnosing CAD
  • The physical status, health conditions, or medication use that might preclude the use of a certain procedure for diagnosing CAD
  • The relative safety of the NITs available for diagnosing CAD, particularly the risk of radiation exposure for younger women
  • Coexisting conditions such as diabetes and the metabolic syndrome that have an impact on the risk of CAD
  • The possible consequences of an abnormal test result

Source

The information in this summary is based on Noninvasive Technologies for the Diagnosis of Coronary Artery Disease (CAD) in Women: Comparative Effectiveness, Comparative Effectiveness Review No. 58, prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I for the Agency for Healthcare Research and Quality, June 2012. Available at www.effectivehealthcare.ahrq.gov/diagnosecad.cfm

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Geetha Achanta, Ph.D., Glenn Levine, M.D., and Michael Fordis, M.D.

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