Cardiovascular Disease in Women: What the Radiologist Needs to Know

Abstract

Background Sex-specific disparities are well documented for cardiovascular disease (CVD). There are differences in physiology and pathophysiology, pain perception, spectrum of disease, risk, therapeutic aspects, prognosis, and outcome. CVD represents a broad spectrum of disorders. This review focuses on cardiovascular and cardiac pathology.

Method This review summarizes the current state of the literature on cardiovascular disease in women from a radiological viewpoint. It aims to provide a deeper understanding of these differences and thereby alerts the reader to the potential of CT and MRI for diagnosing CVD in women. Special attention is paid to disparities in the underlying physiological and pathophysiological processes, clinical presentation, and the quality of care to provide a deep understanding of the topic. Cardiovascular and cardiac pathologies with a sex-specific pattern of disease are presented and typical CT and MRI findings are arranged and illustrated with imaging findings.

Results and Conclusion Sex-specific differences are not only sex hormonal in nature but are rooted in the epigenome and encompass a multitude of physiological systems. In fact, cardiovascular disease shows sex-specific characteristics spanning from incidence to clinical presentation, course of disease, and prognosis. This is of significance regarding pretest probabilities, the power of tests, imaging strategies, and interpretation of imaging results. Key sex-specific issues encompass obstructive and non-obstructive coronary artery disease (CAD), microvascular angina, myocardial infarction with non-obstructive CAD, and coronary artery dissection. Sex-specific patterns are also noted in myocardial disease and heart failure such as pregnancy-related heart disease, Takotsubo syndrome, and anthracycline-induced cardiotoxicity.

Key points: 

• Cardiovascular diseases have sex-specific characteristics.

• Imaging strategies and interpretation of imaging results should be adjusted for women.

• Imaging helps in the improvement of the sex-specific management of cardiovascular disease.

Zusammenfassung

Hintergrund Geschlechtsspezifische Unterschiede sind bei kardiovaskulären Erkrankungen gut dokumentiert. Sie beziehen sich auf Physiologie, Pathophysiologie, Schmerzwahrnehmung, Krankheitsspektrum, Risiko, therapeutische Aspekte, Prognose und Ausgang. Kardiovaskuläre Erkrankungen umfassen zahlreiche Krankheitsbilder. Diese Übersicht fokussiert auf kardiovaskuläre und kardiale Pathologien.

Methode Diese Übersicht fasst den aktuellen Stand der Literatur zu kardiovaskulären Erkrankungen bei Frauen aus einem radiologischen Gesichtspunkt zusammen. Ziel ist es, geschlechtsspezifische Unterschiede darzustellen und das Potenzial der CT- und MR-Bildgebung zu präsentieren. Besondere Aufmerksamkeit wird auf zugrunde liegende physiologische und pathophysiologische Prozesse gelegt, die Klinik und die Qualität der Versorgung, damit die Thematik umfassend verstanden werden kann. Kardiovaskuläre und kardiale Pathologien mit einem geschlechtsspezifischen Muster werden präsentiert und mit typischen CT- und MR-Befunden illustriert.

Ergebnisse und Schlussfolgerung Geschlechtsspezifische Unterschiede sind nicht nur durch Geschlechtshormone verursacht, sondern wurzeln im Epigenom und beziehen zahlreiche physiologische Systeme ein. Kardiovaskuläre Erkrankungen zeigen ein Spektrum geschlechtsspezifischer Charakteristika, das von der Inzidenz über die Klink, Krankheitsverlauf zur Prognose reicht. Das ist von Bedeutung für Vortestwahrscheinlichkeiten, Aussagekraft von Tests und für die Strategie und Interpretation der Bildgebung. Schlüsselthemen sind die obstruktive und nicht obstruktive koronare Herzerkrankung (KHK), die mikrovaskuläre Angina, der Herzinfarkt mit nicht obstruktiver KHK und die koronararterielle Dissektion. Geschlechtsspezifische Muster finden sich auch bei den Erkrankungen des Myokards und dem Herzversagen, wie bei den Schwangerschafts-assoziierten Herzerkrankungen, dem Takotsub- Syndrom und der Anthracyclin-induzierten Kardiotoxizität.

Kernaussagen: 

• Kardiovaskuläre Erkrankungen haben geschlechtsspezifische Charakteristika.

• Strategie und Interpretation der Bildgebung sollten für Frauen adaptiert werden.

• Die Bildgebung unterstützt einen geschlechtsspezifischen Ansatz im Management von kardiovaskulären Erkrankungen.

Citation Format

• Sommer OJ, Hergan K, . Kardiovaskuläre Erkrankungen: Was die Radiologin und der Radiologe wissen müssen. Fortschr Röntgenstr 2023; 195: 309 – 318

Key words

cardiac - heart - CT - CT angiography - MR imaging

Publication History

Received: 15 July 2022

Accepted: 16 October 2022

Article published online:
28 December 2022

• References

• 1 Benjamin EJ, Muntner P, Alonso A. et al. Heart Disease and Stroke Statistics-2019 Update: A Report from the American Heart Association. Circulation 2019; 139: e56-e528
• 2 O’Keefe-McCarthy S. Women’s experiences of cardiac pain: a review of the literature. Can J Cardiovasc Nurs 2008; 18: 18-25
• 3 Deegan DF, Karbalaei R, Madzo J. et al. The developmental origins of sex-biased expression in cardiac development. Biol Sex Differ 2019; 10: 46-66
• 4 Murphy E, Steenbergen C. Estrogen regulation of protein expression and signaling pathways in the heart. Biol Sex Differ 2014; 5: 6-13
• 5 Kabir ME, Singh H, Lu R. et al. G Protein-Coupled Estrogen Receptor 1 Mediates Acute Estrogen-Induced Cardioprotection via MEK/ERK/GSK-3β Pathway after Ischemia/Reperfusion. PLoS One 2015; 10: e0135988
• 6 Langhans B, Ibrahim T, Hausleiter J. et al. Gender differences in contrast-enhanced magnetic resonance imaging after acute myocardial infarction. Int J Cardiovasc Imaging 2013; 29: 643-650
• 7 Dutra SG, Pereira AP, Tezini GC. et al. Cardiac autonomic modulation is determined by gender and is independent of aerobic physical capacity in healthy subjects. PLoS One 2013; 8: e77092
• 8 Beale AL, Meyer P, Marwick TH. et al. Sex Differences in Cardiovascular Pathophysiology: Why Women Are Overrepresented in Heart Failure With Preserved Ejection Fraction. Circulation 2018; 138: 198-205
• 9 Dreyer RP, Sciria C, Spatz ES. et al. Young Women With Acute Myocardial Infarction: Current Perspectives. Circ Cardiovasc Qual Outcomes 2017; 10: e003480
• 10 Isaksson RM, Holmgren L, Lundblad D. et al. Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study. Eur J Cardiovasc Nurs 2008; 7: 152-158
• 11 McDonald EG, Dayan N, Pelletier R. et al. Premature cardiovascular disease following a history of hypertensive disorder of pregnancy. Int J Cardiol 2016; 219: 9-13
• 12 Bairey Merz CN, Shaw LJ, Reis SE. et al. Insights from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006; 47: S21-S29
• 13 Ridker PM, Buring JE, Rifai N. et al. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA 2007; 297: 611-619
• 14 Makaryus AN, Sison C, Kohansieh M. et al. Implications of Gender Difference in Coronary Calcification as Assessed by CT Coronary Angiography. Clin Med Insights Cardiol 2015; 8: 51-55
• 15 Smith YR, Stohler CS, Nichols TE. et al. Pronociceptive and antinociceptive effects of estradiol through endogenous opioid neurotransmission in women. J Neurosci 2006; 26: 5777-5785
• 16 Fillingim RB, King CD, Ribeiro-Dasilva MC. et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009; 10: 447-485
• 17 DeVon HA, Pettey CM, Vuckovic KM. et al. A Review of the Literature on Cardiac Symptoms in Older and Younger Women. J Obstet Gynecol Neonatal Nurs 2016; 45: 426-437
• 18 Mieres JH, Gulati M, Bairey Merz N. et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130 (04) 350-379
• 19 Khuddus MA, Pepine CJ, Handberg EM. et al. An intravascular ultrasound analysis in women experiencing chest pain in the absence of obstructive coronary artery disease: a substudy from the National Heart, Lung and Blood Institute-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). J Interv Cardiol 2010; 23: 511-519
• 20 Rossi A, Dharampal A, Wragg A. et al. Diagnostic performance of hyperaemic myocardial blood flow index obtained by dynamic computed tomography: does it predict functionally significant coronary lesions?. Eur Heart J Cardiovasc Imaging 2014; 15: 85-94
• 21 Kaski JC, Crea F, Gersh BJ. et al. Reappraisal of Ischemic Heart Disease. Circulation 2018; 138: 1463-1480
• 22 Camici PG, Crea F. Coronary microvascular dysfunction. N Engl J Med 2007; 356: 830-840
• 23 Patel MR, Peterson ED, Dai D. et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010; 362: 886-895
• 24 Jagathesan R, Barnes E, Rosen SD. et al. Comparison of myocardial blood flow and coronary flow reserve during dobutamine and adenosine stress: Implications for pharmacologic stress testing in coronary artery disease. J Nucl Cardiol 2006; 13: 324-332
• 25 Murthy VL, Naya M, Taqueti VR. et al. Effects of sex on coronary microvascular dysfunction and cardiac outcomes. Circulation 2014; 129: 2518-2527
• 26 Doyle M, Weinberg N, Pohost GM. et al. Prognostic value of global MR myocardial perfusion imaging in women with suspected myocardial ischemia and no obstructive coronary disease: results from the NHLBI-sponsored WISE (Women’s Ischemia Syndrome Evaluation) study. JACC Cardiovasc Imaging 2010; 3: 1030-1036
• 27 Niccoli G, Scalone G, Crea F. Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management. Eur Heart J 2015; 36: 475-481
• 28 Gehrie ER, Reynolds HR, Chen AY. et al. Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative. Am Heart J 2009; 158: 688-694
• 29 Tamis-Holland JE, Jneid H, Reynolds HR. et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2019; 139: e891-e908
• 30 Ballesteros-Ortega D, Martínez-González O, Gómez-Casero RB. et al. Characteristics of patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) from the ARIAM-SEMICYUC registry: development of a score for predicting MINOCA. Vasc Health Risk Manag 2019; 15: 57-67
• 31 Hanratty CG, Koyama Y, Rasmussen HH. et al. Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization. J Am Coll Cardiol 2002; 40: 911-916
• 32 Saw J, Humphries K, Aymong E. et al. Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence. J Am Coll Cardiol 2017; 70: 1148-1158
• 33 Roura G, Ariza-Solé A, Rodriguez-Caballero IF. et al. Noninvasive Follow-Up of Patients With Spontaneous Coronary Artery Dissection With CT Angiography. JACC Cardiovasc Imaging 2016; 9: 896-897
• 34 Beltrame JF, Crea F, Kaski JC. et al. International standardization of diagnostic criteria for vasospastic angina. Eur Heart J 2017; 38: 2565-2568
• 35 Jin C, Kim MH, Kang EJ. et al. Assessing Vessel Tone during Coronary Artery Spasm by Dual-Acquisition Multidetector Computed Tomography Angiography. Cardiology 2018; 139: 25-32
• 36 Bozkurt B, Khalaf S. Heart Failure in Women. Methodist Debakey Cardiovasc J 2017; 13: 216-223
• 37 Patel MR, White RD, Abbara S. et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol 2013; 61: 2207-2231
• 38 Liu CY, Liu YC, Wu C. et al. Evaluation of age-related interstitial myocardial fibrosis with cardiac magnetic resonance contrast-enhanced T1 mapping: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2013; 62: 1280-1287
• 39 Greiten LE, Holditch SJ, Arunachalam SP. et al. Should there be sex-specific criteria for the diagnosis and treatment of heart failure?. J Cardiovasc Transl Res 2014; 7: 139-155
• 40 Schlossbauer SA, Ghadri JR, Scherff F. et al. The challenge of Takotsubo syndrome: heterogeneity of clinical features. Swiss Med Wkly 2017; 147: w14490
• 41 Pelliccia F, Kaski JC, Crea F. et al. Pathophysiology of Takotsubo Syndrome. Circulation 2017; 135: 2426-2441
• 42 Lyon AR, Bossone E, Schneider B. et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2016; 18: 8-27
• 43 Koenig A, Sateriale A, Budd RC. et al. The role of sex differences in autophagy in the heart during coxsackievirus B3-induced myocarditis. J Cardiovasc Transl Res 2014; 7: 182-191
• 44 Kytö V, Sipilä J, Rautava P. The effects of gender and age on occurrence of clinically suspected myocarditis in adulthood. Heart 2013; 99: 1681-1684
• 45 Lagan J, Schmitt M, Miller CA. Clinical applications of multi-parametric CMR in myocarditis and systemic inflammatory diseases. Int J Cardiovasc Imaging 2018; 34: 35-54
• 46 Plana JC, Galderisi M, Barac A. et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2014; 15: 1063-1093
• 47 Muehlberg F, Funk S, Zange L. et al. Native myocardial T1 time can predict development of subsequent anthracycline-induced cardiomyopathy. ESC Heart Fail 2018; 5: 620-629
• 48 Tailor TD, Kicska GA, Jacobs JE. et al. Imaging of Heart Disease in Women. Radiology 2017; 282: 34-53
• 49 Pearson GD, Veille JC, Rahimtoola S. et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA 2000; 283: 1183-1188
• 50 Arora NP, Mohamad T, Mahajan N. et al. Cardiac magnetic resonance imaging in peripartum cardiomyopathy. Am J Med Sci 2014; 347: 112-117