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Am Fam Physician. 1999;60(4):1226-1229

Most studies evaluating noninvasive testing for potential coronary artery disease (CAD) have been performed on men. Recent studies have found that these noninvasive tests have poorer specificity in women (i.e., more false-positive results). This may lead to a delay in establishing the diagnosis of CAD in women, which may influence their treatment and prognosis. Lewis and associates evaluated the dobutamine stress echocardiogram in women who present with chest pain and are at risk for CAD.
Women who presented with chest pain or other symptoms suggestive of myocardial ischemia were considered for the study. To be enrolled, the women also had to show clear indications for coronary angiography. After initial evaluation, a dobutamine stress echocardiogram was performed following an established protocol. Blinded persons performed wall-motion analysis of 16 myocardial segments, and a score was assigned to each patient. Coronary angiography was then performed on all the patients.
Ninety-two women were enrolled in the study, the majority of whom presented with chest pains. Sixty-seven percent of the patients reached their target heart rate during the stress test. Sixteen percent of the tests were stopped because the patients developed anginal chest pains. The dobutamine stress echocardiogram was normal in 54 of 67 patients with no significant CAD, for a specificity of 80.6 percent. Fourteen patients had wall-motion abnormalities during the tests. The highest coronary angiography severity scores were present in women with abnormal dobutamine stress echocardiograms.
In this study, only 27 percent of the women with known CAD risk factors and symptoms consistent with myocardial ischemia had significant heart disease. The dobutamine stress echocardiogram was successful in identifying women with multivessel CAD but was not as successful in women with single-vessel disease.
The authors conclude that a dobutamine stress echocardiogram is a reliable test in women with multivessel disease presenting with chest pain. However, the authors also point out that this test is usually negative in women who present with chest pain and no coronary stenosis.

editor's note: When dealing with chest pain in female patients, physicians are faced with the challenge of how best to evaluate them. Most investigations of cardiovascular disease have focused on male patients. This report gives some of the first information provided from the Women's Ischemia Syndrome Evaluation study. The information points out that the dobutamine stress echocardiogram is a good diagnostic tool in women with chest pain. However, despite enrolling patients from what was perceived as an extremely high-risk population, cardiovascular disease was only present in 27 percent of the women participants. This points up the difficulty in evaluating women who present with chest pain.—k.e.m.

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