Examining the Gender Bias in Evaluating Coronary Disease in Women

Gender discrepancies have developed in the evaluation of coronary heart disease (CHD), arising from such early myths as "CHD is a man's disease." The challenge is to make sure that the noninvasive testing for CHD in women is sensitive and specific enough to lead to the correct treatment. Coronary angiography, the gold standard for CHD diagnosis, must be interpreted along with functional information. The standard noninvasive test--stress electrocardiograph (ECG)--is associated with up to 40% false-positive S-T segment depressions in women, versus fewer than 10% in men. The predictive value of exercise stress testing in women is particularly poor. In one study, stress ECG had a specificity of 61%, a sensitivity of 68%, a positive predictive value of 0.61, and a negative predictive value of 0.68. Stress echocardiography can have high sensitivity (86%) and specificity (86%), but often examiners stop the test before detecting less severe areas of damage. Also, acquiring adequate images is difficult in women with breast implants or large breasts. Nuclear perfusion imaging with thallium-201 has shown a sensitivity of 84% to 90% and a specificity of 75% to 87% in women, but the diagnostic accuracy can be reduced in patients who are obese or have large breasts. A higher-energy radiotracer, technetium-99m (Tc-99m) sestamibi, has been introduced. In one study, the sensitivity of the 2 agents was similar (85% to 90%), while the specificity of Tc-99m was higher (84% to 94%) than that of thallium-201 (71%).