Clinical Investigation
Adenosine Stress Magnetic Resonance Imaging in Women With Low Risk Chest Pain: The Emory University Experience

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Abstract

Objectives

The purpose of this study was to evaluate the accuracy of adenosine stress magnetic resonance imaging (ASMRI) for the evaluation of women with low-risk chest pain (CP).

Background

Coronary artery disease (CAD) can present differently among women than among men. There is increased interest in the use of ASMRI for lower risk patients in the emergency department to rule out CAD, and it would be valuable to assess its performance specifically in women.

Methods

This study included 82 women with low-risk CP who presented to the emergency department during a 2-year period at our institution and were evaluated by ASMRI. Clinical events were followed by review of medical records.

Results

The specificity of ASMRI for ischemia detection in this small cohort of patients was 100%. Sensitivity was 94.9%, negative predictive value 100%, and positive predictive value 42.9%.

Conclusions

ASMRI may be used as the initial imaging modality for ruling out CAD in women with low-risk CP because of its very high sensitivity, specificity, and negative predictive value for the detection of ischemia. Further randomized controlled trials comparing ASMRI with established noninvasive nuclear and echocardiographic stress modalities are needed.

Section snippets

Study Patients

Between July 2007 and May 2008, ASMRI was performed on 82 women presenting to the emergency department at our institution with low-risk acute CP. The decision to refer patients for the ASMRI protocol rather than ordering an alternative diagnostic modality was left to the discretion of the emergency department physician. Our single-center study had institutional review board approval from the Emory University Institutional Review Board. Patients were observed for clinical instability over at

RESULTS

During our study, 82 women with a mean age of 57 years underwent ASMRI. Baseline characteristics are listed in Table 1. The indication for all the studies was CP. Women in the ASMRI group were followed up for a mean period of 250 days. No deaths from cardiovascular or other causes were noted during the follow-up period.

In the ASMRI population, 7 women were positive for ischemia. Six were advised to undergo further evaluation, whereas the seventh was managed conservatively because of the small

DISCUSSION

It is estimated that mortality from CAD is increasing more rapidly among women than among men in both the developed and the developing world.8 Women have a higher risk of perioperative morbidity and mortality after coronary artery bypass graft9 and have a higher rate of vascular complications from percutaneous coronary intervention compared with men.10 Because of the propensity for atypical ischemic symptoms among women in the emergency department5 and the risk of missed diagnosis11 as well as

LIMITATIONS

This is a small single-center retrospective study. We did not examine the menopause status of women, which could be relevant as CAD is less prevalent in premenopausal women.29 Because of the low-risk profile of our population, invasive coronary angiography, the gold standard for evaluation of CAD, could not be justified routinely. Finally, follow-up was by review of records at our hospital. We cannot rule out the possibility that patients could have had events at outside hospitals which we

CONCLUSION

Our study suggests that ASMRI is a safe and accurate prognostic tool in women with low-risk CP.

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