Особенности клиники и диагностики ишемической болезни сердца у женщин. Часть 2

Abstract

Во второй части обзора показано применении различных методов визуализации міокарда с использованием стресс-тестов у лиц женского пола и проанализировано течение ИБС у женщин. Рассмотрены предложения различных исследователей относительно усовершенствования эффективности неинвазивного тестирования женщин с подозрением на ИБС и новые согласительные документы по этому поводу; В другій частині огляду показано застосування різних методів візуалізації міокарду з використанням стрес-тестів у осіб жіночої статі і проаналізовано перебіг ішемічної хвороби серця (ІХС) у жінок. Розглянуті пропозиції різних дослідників щодо удосконалення ефективності неінвазивного тестування жінок із підозрою на ІХС і нові погоджувальні документи з цього приводу; In the second part of the review the using of the different methods of the myocardial visualization by means of stress-tests in female patients is presented and the course of ischemic heart disease (IHD) in women is analyzed. Radionuclide perfusion imaging on exertion or pharmacological stress, being a reliable indicator of transient myocardial ischemia, has a number of limitations in women (weakening of a radiation signal by mammary gland’s tissue, smaller sizes of the chambers of a heart). Simultaneous using of stress test and myocardial visualization increases the predictive value of methods. In addition to it, for some time past precision of radionuclide perfusion imaging has improved due to more advanced equipment and using of Technetium Sestamibi. But it is necessary to mark that radionuclide perfusion imaging is less informative in case of univascular lesion, which occurs more often e x actly in women. Clinical value of stress-echocardiography (EchoCG) is the same both for women and men and is important for evaluation of myocardial contractile ability. It is possible to use different stress-agents, but preference must be given to pharmacological tests. It is connected with less exertion tolerance in women. Carried out researches (sensitivity and specificity of stress tests with estimation by electrocardiogram (ECG), Thallium perfusion imaging, and ultrasound myocardial visualization were compared) have shown the ma x imal effectiveness of ultrasound visualization of myocardium in women. Low reproducibility of ischemic changes on ECG during carrying out of stress tests and practically absence of possibility to reveal hypokinetic zones by stress-EchoCG are typical for the patients with microvascular angina (the latter with diffuse coronary atherosclerosis without obstructive lesions is more prevalent among women than among men). In these cases carrying out of positron emission tomography and magnetic resonance imaging (MRI) are more effective for visualization. Coronary angiography (CAG) is “a gold standard” in diagnostics of IHD at estimation of coronary bloodstream by now. At the same time, the recent data testify about the increase of cardiovascular incidents in women with IHD without stenosis of coronary arteries, although the opposite opinion was present earlier. It is marked that these female patients aren’t included into the low-risk group, but they need aggressive prophyla x is of cardiovascular diseases. Low calcium inde x at the multispiral computed tomography (CT) e x cludes presence of obstructive IHD effectively. New (2014) conciliatory document of the American Heart Association (AHA) indicates that the choice of diagnostic method must be based on the level of the risk of patient’s cardiovascular diseases. Low-risk women are not candidates for diagnostic testing, at the same time in case of insignificant increase or intermediate risk it is necessary to prescribe treadmill testing. Women with symptoms of IHD and functional disturbances, abnormal rest ECG, abnormalities or doubtful results of treadmill testing must be sent to EchoCG or other methods of estimation of myocardial perfusion, among which MRI is a method of choice. It is marked that MRI and CT-angiography are effective methods of diagnostics of coronary arteries’ obstructive lesions and IHD in women with appropriate symptomatology. Despite the fact that female IHD occurs later than male one, its course is more severe, with greater quantity of complications. The comparison of a clinical course of IHD of female patients of childbearing and climacteric age has showed more favorable prognosis for a disease in women with presence of menstrual cycle than women of menopausal period.