Table 21Summary of key findings

Key QuestionStrength of EvidenceConclusions
KQ 1: Diagnostic accuracy of NITs in womenECG: High
ECHO: High
CMR: Low
Coronary CTA: Low
94 studies described the diagnostic accuracy of NITs in comparison to another NIT or coronary angiography in women. Of these 94 studies, 78 studies included sufficient data to estimate the sensitivity and specificity of the NIT compared with coronary angiography.
Summary from all studies with no known CAD:
41 studies (13 good quality, 22 fair, 6 poor) of exercise ECG showed a summary sensitivity of 62% and specificity of 68%
22 studies (8 good quality, 13 fair, 1 poor) of exercise/stress ECHO showed a summary sensitivity of 79% and specificity of 83%
30 studies (10 good quality, 15 fair, 5 poor) of exercise/stress radionuclide perfusion imaging (SPECT, PET) showed a summary sensitivity of 81% and specificity of 78%
6 studies (5 good quality, 1 fair) of CMR imaging showed a summary sensitivity of 72% and specificity of 84%
8 studies (4 good quality, 4 fair) of coronary CTA showed a summary sensitivity of 93% and specificity 77%
Overall, within a given modality, the summary sensitivities and specificities were similar for both types of populations (mixed populations of known and unknown CAD and no known CAD) and for all studies when compared with good-quality studies. When accounting for only the good-quality studies, it appeared that the diagnostic accuracy of detecting CAD in women with unknown CAD was better (in descending order) for coronary CTA, SPECT, ECHO, CMR, and ECG. For the newer technologies (i.e., coronary CTA and CMR), more studies in women would be needed to support these findings since the 95% CIs were quite wide.
In testing for a statistically significant difference between the diagnostic accuracy of testing modalities in women, our analyses determined that for women with no previously known CAD, there were differences between the performance of the available modalities (p < 0.001). The sensitivity of ECHO and SPECT was significantly higher than that of ECG. Specificity of ECG was less than that of CMR (borderline) and of ECHO. In the subset of studies that were good-quality and where there was no known CAD in the included population, our analyses again demonstrated differences between performance of tests (p = 0.006) with the specificity of ECG being less than that of CMR and ECHO.
Sensitivity analyses exploring mixed populations of women with known and no known CAD showed no statistically significant difference in the sensitivities and specificities from our primary analysis. An analysis exploring the prevalence of CAD across the different NIT modality studies also showed no statistically significant difference. In addition, there were very few studies (1 SPECT, 1 ECHO, and 3 ECG) that did not complete a coronary angiography in all patients who underwent the NIT; therefore the results are minimized for verification bias. Finally we found no evidence of publication bias across the different modalities in our 4 populations of interest (studies of women with no known CAD, good-quality studies of women with no known CAD, studies of women from mixed populations, and good-quality studies of women from mixed populations).
KQ 2: Predictors of diagnostic accuracy in womenInsufficient11 studies (4 good quality, 5 fair, 2 poor) described diagnostic accuracy, and 9 of these examined predictors of diagnostic accuracy of different NITs in women.
The predictors assessed included (1) postmenopausal women ages 55 to 64 (1 study), (2) race/ethnicity (2 studies), (3) heart size (4 studies), (4) pretest probability (3 studies), and (5) use of beta blocker medications (1 study).
We identified no studies examining the influence of age alone, functional status, or body size on diagnostic accuracy in women.
In terms of the NIT modality, we found four studies of stress ECHO, six studies of stress ECG, two studies of CMR, and four studies of SPECT that reported these predictors.
Insufficient evidence was available to draw definitive conclusions about predictors given the small number of studies for each predictor and for each modality, as well as the combination of predictor by modality.
KQ 3: Improving risk stratification, decisionmaking, and outcomes in womenInsufficient13 studies (3 good quality, 9 fair, 1 poor) reported prognostic, outcome, or decisionmaking data comparing one NIT with another NIT or with coronary angiography in women with symptoms suspicious for CAD.
We found 8 studies assessing risk stratification and prognostic information, 2 studies assessing decisionmaking for treatment options, and 4 studies that provided comparative clinical outcomes.
There were insufficient data to demonstrate that the use of specific NITs (compared with coronary angiography) routinely provided incremental risk stratification, prognostic information, or other meaningful information to improve decisionmaking and improve patient outcomes.
Most findings reported in the literature would require significant confirmation and replication in larger studies with women.
KQ 4: Safety concernsInsufficient13 studies (9 good quality, 4 fair) reported data pertinent to safety concerns or risks associated with the use of NITs to diagnose CAD in women with symptoms suspicious for CAD.
Safety data were reported on the following modalities: (1) stress ECG (4 studies), (2) ECHO (6 studies), (3) SPECT (3 studies), (4) CMR (2 studies), and (5) coronary CTA (4 studies).
Data specific to women on access site complications, contrast agent-induced nephropathy, nephrogenic systemic fibrosis, or anaphylaxis associated with NITs were not reported in any of the studies included in this report.
Other than higher mean effective radiation doses for coronary CTA studies for women compared with men (from 3 out of 4 studies reporting radiation exposure levels), the extant literature does not provide sufficient evidence to conclude whether safety concerns, risks, or radiation exposure associated with different NITs to diagnose CAD in patients with suspected CAD differ significantly between women and men.

From: Summary and Discussion

Cover of Noninvasive Technologies for the Diagnosis of Coronary Artery Disease in Women
Noninvasive Technologies for the Diagnosis of Coronary Artery Disease in Women [Internet].
Comparative Effectiveness Reviews, No. 58.
Dolor RJ, Patel MR, Melloni C, et al.

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