Kavitha Yaddanapudi Stony brook University New York

Kavitha Yaddanapudi Stony brook University New York

8 million ER visits a year for chest pain 2-10% have Acute coronary syndrome (ACS) Coronary CTA(CCTA) -safe alternative to standard of care (SOC) and reduced length of stay (ROMCAT II, CT-STAT) No missed ACS in large studies Normal CCTA no 2yr MACE In our institution we perform between 5 and 10 CCTA s from ER in 16 hr/day coverage

Death from CAD is higher in women than in men (1). 1 in 3 women die form CAD compared to 1 in 5 from cancer (CDC) Mortality and morbidity are higher in women than men after acute myocardial infarction. Vaccarino et al premenopausal women early myocardial infarction mortality rate was more than twice that for agematched men (6.1% vs. 2.9%; p 0.001). Angina prevalence is higher in women than men with a ratio of 1.2:1 (2). On conventional catheter coronary angiography however women have shown to have lower incidence of obstructive coronary artery disease (3).

CONFIRM study has shown increased risk of mortality with obstructive and non obstructive CAD especially in younger patients and women with multivessel disease (high hazards ratio) Non obstructive CAD in symptomatic women-risk of 16% for adverse events compared to 9% in no CAD (WISE study) CAD in women unfortunately is under diagnosed and undertreated (Circ 2005) Awareness of heart disease risk is underrecognised in womenonly 54% know the significant risk Fewer than 1 in 5 doctors know that women more than men die of CAD each year (3)

The focus on obstructive disease for therapeutic outcomes is a possible cause for adverse outcomes in women (JACC Oct 2009) Need for assessment of the burden of CAD in womenspecifically non obstructive disease Role of CCTA-identify non obstructive disease in symptomatic women with high IHD events who may benefit from medical treatment (AHA consensus statement 2014)

High sensitivity and specificity Is a mirror to the burden of epicardial coronary artery disease and calcium burden Normal CCTA has been shown to have good prognosis on prior large studies (JACC 2011) With newer machines and protocols decreased radiation dose typically <5 msv Faster investigation and turn around times In the ER setting decreases LOS, saves money and time Great risk stratification tool

Acute chest pain No known coronary artery disease With one or more risk factors Without ischemic electrocardiographic (ECG) changes No elevated initial troponin Requiring further risk stratification.

We retrospectively evaluated premenopausal symptomatic women who underwent CCTA with the purpose of evaluating the burden of CAD in this population Retrospective evaluation the CCTA and the medical records in 498 premenopausal female patients who presented to our ER with acute chest pain and underwent CCTA between 2010-12. Risk factors evaluated were age, family history, diabetes, hypertension, obesity (BMI), hyperlipidemia and smoking (current, former or never).

CCTA results were categorized as normal, nonobstructive (<50% stenosis), borderline (around 50%) and obstructive coronary artery disease CAD (includes moderate and severe obstruction >50%). CCTA was interpreted by 2 expert readers at different time points We used Chi square test to examine marginal association between a categorical risk factor and CAD further evaluation with multivariable regression analysis

Age range is 22-55 yrs. 498 patients - a total of 106 (21%) had CAD - 85 (17.07 %) had non obstructive CAD -11(2.2%) had obstructive CAD -10 (2%) had borderline obstructive CAD. Increasing age was associated with higher incidence of CAD ( p 0.0070 )with no CAD on CCTA in females <35yrs.

Patients who never smoked and who had quit smoking >1year had a similar risk of CAD (18.75 and 18.99 %) compared to current smokers who had twice the risk of CAD( 36.3%). Hypertension (p 0.004), hyperlipidemia (p 0.05), family history (p0.01), diabetes (0.0001) and obesity (p 0.0001), were significantly associated with presence of CAD on CCTA. The significant independent risk factors for presence of CAD were age (p = 0.0043), diabetes (p=0.0236) and obesity (p=0.0014) based on multivariable regression analysis.

The prevalence of CAD in premenopausal females presenting to the ER with chest pain is 21.2 % as diagnosed by CCTA. This is 4 times higher compared to a general population prevalence of 0.6-5.6% ( AHA in 2013). ROMCAT II 42% abnormal CCTA in women with 5% obstructive disease, however mean age was higher 55+-7 yrs. The risk factors strongly associated with presence of CAD and a positive CCTA were increasing age, diabetes and obesity.

No functional component No end organ or perfusion changes on routine CCTA Downstream testing is higher Higher radiation dose than SOC Studies non diagnostic

Radiation dose from prospectively gated CCTA ranges between 3-5 msv Concern for breast dose especially in young females Breast is one of the most radiosensitive organs Weighting factor for breast has been increased in 2008 as a reflection of detrimental effects of breast radiation from.05 to.12 (ICRP 2008). Dose can be reduced by shielding and displacement devices (Foley, et al. AJR 2011) Dose from CCTA is equal to a year of background radiation

Doses in msv EHJ 2011

There is a high burden of CAD as detected by CCTA in young females presenting with chest pain to the ER, who might traditionally go undiagnosed for years Other non invasive testing will not reveal the disease burden in these patients The burden of CAD in these women as identified on CCTA can guide further medical management We hypothesize this disease burden as identified on CCTA accounts for a portion of the under diagnosed CAD in addition to microvascular disease that is contributing to the worse overall outcome.

Women under 35 years of age have very low incidence of CAD and given detrimental effects of breast radiation should be carefully screened before preforming CCTA Women >35 years of age can undergo CCTA when symptomatic to further risk stratify the patients resulting in better medical management both acute and long term Stringent scan related precautions in all young females is mandatory to decrease the radiation dose burden.

Stony Brook Medicine Core Lab for partial funding of this project