Current evidence on diagnostic testing in women with suspected coronary artery disease: choosing the appropriate test.

Marked reductions in cardiovascular mortality have been reported over the last 2 decades as a result of therapeutic advances in ischemic heart disease. Despite medical advances, case fatality rates are higher for women than men. A critical step toward improving outcomes is early diagnosis of coronary artery disease by noninvasive evaluation. The use of noninvasive testing in women has been controversial because of a perception of diminished accuracy, limited female representation, and compromise of efficacy of testing because of technical limitations (eg, thallium-201 breast artifact). Recent meta analysis and large observational series report marked improvements in the accuracy of results for women undergoing exercise treadmill, echocardiography, and nuclear testing. Exercise treadmill testing has an improved accuracy when multiple risk parameters (eg, ST deviation, chest pain, exercise time) are included in the test interpretation. For women, a low-risk Duke treadmill score is associated with a 97% 5-year survival, with 80% of these patients having no obstructive disease. Multivessel disease (70%) is common for those with a high-risk treadmill score with a 5-year survival of 90%. The diagnostic accuracy of electron beam computed tomography reveals a sensitivity and specificity of 88% and 49%. For exercise echocardiography, test diagnostic sensitivity and specificity are 86% and 79%. For nuclear imaging, 3-year cardiac survival ranged from 99% to 85% for 0 to 3 vascular territories with perfusion abnormalities. A sufficient body of evidence supports the use of noninvasive testing for intermediate-risk, symptomatic women. Diagnostic certainty may be effectively guided by the evaluation of global and regional wall motion, eg, with echocardiography. Risk assessment may be more precise with the evaluation of myocardial perfusion, eg, with stress nuclear imaging. With the use of updated evidence, informed test selection for women may result in improved diagnostic and therapeutic decision-making, with the use of available noninvasive testing modalities.