The role of cardiovascular ultrasound for the assessment of coronary artery disease in women
File(s)
Author(s)
Gurunathan, Sothinathan
Type
Thesis
Abstract
Background
Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in women.
Guidelines advocate Exercise ECG in intermediate risk women who are able to exercise to diagnose obstructive coronary artery disease (CAD), which is controversial. Due to the low prevalence of obstructive CAD in women, functional testing has a relatively low predictive value for this. Carotid ultrasound can be used to identify carotid plaque and increased carotid intimal-media thickness which are markers of atherosclerosis. Carotid disease has been shown to predict obstructive CAD on coronary angiography.
Methods and Results
I randomised 416 women with suspected CAD, to undergo either exercise electrocardiography (Ex-ECG) or Exercise stress echocardiography (ESE). The positive predictive value (PPV) for both tests was similar, and during follow up there was no difference in cardiac events. Ex-ECG was marginally more cost-effective than ESE. For the second part of this thesis, I prospectively performed carotid ultrasonography on 415 women attending for stress echocardiography. In women with inducible ischaemia and carotid plaque versus no carotid plaque, the prevalence of significant CAD was 71% and 13% respectively (p< 0.001). A high proportion of women classified as low cardiovascular risk were found to have carotid plaque, potentially benefiting from aggressive primary prevention.
Conclusion
In intermediate-risk women, I have shown that a diagnostic strategy that used Ex-ECG had similar efficacy to an ESE strategy. Ex-ECG may be considered a useful initial diagnostic strategy in the absence of ESE, in symptomatic women with suspected CAD. Carotid ultrasound is a useful adjunct to women undergoing stress echocardiography (SE), acting as a superior gatekeeper to invasive coronary angiography over SE alone. It also identifies high risk women, where conventional cardiovascular risk scores underestimate risk.
Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in women.
Guidelines advocate Exercise ECG in intermediate risk women who are able to exercise to diagnose obstructive coronary artery disease (CAD), which is controversial. Due to the low prevalence of obstructive CAD in women, functional testing has a relatively low predictive value for this. Carotid ultrasound can be used to identify carotid plaque and increased carotid intimal-media thickness which are markers of atherosclerosis. Carotid disease has been shown to predict obstructive CAD on coronary angiography.
Methods and Results
I randomised 416 women with suspected CAD, to undergo either exercise electrocardiography (Ex-ECG) or Exercise stress echocardiography (ESE). The positive predictive value (PPV) for both tests was similar, and during follow up there was no difference in cardiac events. Ex-ECG was marginally more cost-effective than ESE. For the second part of this thesis, I prospectively performed carotid ultrasonography on 415 women attending for stress echocardiography. In women with inducible ischaemia and carotid plaque versus no carotid plaque, the prevalence of significant CAD was 71% and 13% respectively (p< 0.001). A high proportion of women classified as low cardiovascular risk were found to have carotid plaque, potentially benefiting from aggressive primary prevention.
Conclusion
In intermediate-risk women, I have shown that a diagnostic strategy that used Ex-ECG had similar efficacy to an ESE strategy. Ex-ECG may be considered a useful initial diagnostic strategy in the absence of ESE, in symptomatic women with suspected CAD. Carotid ultrasound is a useful adjunct to women undergoing stress echocardiography (SE), acting as a superior gatekeeper to invasive coronary angiography over SE alone. It also identifies high risk women, where conventional cardiovascular risk scores underestimate risk.
Version
Open Access
Date Issued
2023-01-01
Date Awarded
06/01/2025
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Senior, Roxy
Publisher Department
National Heart and Lung Institute, Imperial College London
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)