Relation of results of exercise stress tests in young women to phases of the menstrual cycle

doi:10.1016/0002-9149(88)91334-3

The American Journal of Cardiology

Volume 61, Issue 1, 1 January 1988, Pages 197-199

https://doi.org/10.1016/0002-9149(88)91334-3 Get rights and content

Abstract

ST-segment depression that occurs in the course of exercise stress testing is considered a “positive” response for myocardial ischemia. Exercise testing results in significant ST segment shifts in 14% to 67% of women without angiographic evidence of coronary artery disease.¹ It has been suggested that the high frequency of false-positive ischemic ST segment shifts among women is related to relatively high estrogen levels.^2–4 A systematic study of that hypothesis has not been previously reported, and is the subject of this report.

References (4)

SP Glasser et al.
The Clinical Approach to Exercise Testing
MD Jaffe
Effect of estrogens on postexercise electrocardiogram
Br Heart J
(1977)

There are more references available in the full text version of this article.

Cited by (43)

Myocardial ischaemia detection in women
2016, Annales de Cardiologie et d'Angeiologie
Rechercher une ischémie myocardique consiste à utiliser un ou plusieurs tests permettant le diagnostic de coronaropathie avec le double objectif de rapidité et d’à-propos diagnostique. Chez les femmes en comparaison aux hommes, la puissance diagnostique des différents tests est généralement plus faible. Ainsi, pour s’affranchir de cette pénalisation liée au sexe, il faut définir une stratégie diagnostique basée sur la stratification du niveau de risque a priori, et identifier avec précision les patientes relevant d’une exploration invasive. Cette mise au point reprend les performances des différents tests diagnostiques non invasifs au travers d’une approche volontairement féminine et définit en fonction du niveau de risque de coronaropathie et du caractère symptomatique ou non les outils de l’arsenal thérapeutique.
Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms.
Stress myocardial perfusion imaging by CMR provides strong prognostic value to cardiac events regardless of patient's sex
2011, JACC: Cardiovascular Imaging
Citation Excerpt :
Compared with men, women more often present with atypical symptoms, have a higher burden of microvascular dysfunction, are less likely to perform an adequate exercise test due to comorbidities, and are more difficult to image due to smaller heart size and breast attenuation. It has also been reported that varying estrogen levels may cause digitalis-like false positivity on stress ECG testing (18). These factors, either alone or in combination, may make exercise ECG, stress nuclear scintigraphy, or echocardiography less accurate in assessing women with chest pain.
The major aim of this study is to test the hypothesis that stress cardiac magnetic resonance (CMR) imaging can provide robust prognostic value in women presenting with suspected ischemia, to the same extent as in men.
Compelling evidence indicates that women with coronary artery disease (CAD) experience worse outcomes than men owing to a lack of early diagnosis and management. Numerous clinical studies have shown that stress CMR detects evidence of myocardial ischemia and infarction at high accuracy. Compared to nuclear scintigraphy, CMR is free of ionizing radiation, has high spatial resolution for imaging small hearts, and overcomes breast attenuation artifacts, which are substantial advantages when imaging women for CAD.
We performed stress CMR in 405 patients (168 women, mean age 58 ± 14 years) referred for ischemia assessment. CMR techniques included cine cardiac function, perfusion imaging during vasodilating stress, and late gadolinium enhancement imaging. All patients were followed for major adverse cardiac events (MACE).
At a median follow-up of 30 months, MACE occurred in 36 patients (9%) including 21 cardiac deaths and 15 acute myocardial infarctions. In women, CMR evidence of ischemia (ISCHEMIA) demonstrated strong association with MACE (unadjusted hazard ratio: 49.9, p < 0.0001). While women with ISCHEMIA(+) had an annual MACE rate of 15%, women with ISCHEMIA(−) had very low annual MACE rate (0.3%), which was not statistically different from the low annual MACE rate in men with ISCHEMIA(−) (1.1%). CMR myocardial ischemia score was the strongest multivariable predictor of MACE in this cohort, for both women and men, indicating robust cardiac prognostication regardless of sex.
In addition to avoiding exposure to ionizing radiation, stress CMR myocardial perfusion imaging is an effective and robust risk-stratifying tool for patients of either sex presenting with possible ischemia.
How to improve noninvasive coronary artery disease diagnostics in premenopausal women?. The influence of menstrual cycle on ST depression, left ventricle contractility, and chest pain observed during exercise echocardiography in women with angina and normal coronary angiogram
2008, American Heart Journal
Citation Excerpt :
The causative role of estrogens is supported by the lower prevalence of false-positive responses after 45 years of age, when there is a decrease in plasma concentration of these hormones with an increase in prevalence of coronary disease. Clark et al16 suggested that progesterone fluxes are implicated in the ECG abnormalities observed in women. It is also possible that both estradiol and progesterone as well as their ratio is important in the development of false-positive ECG stress tests.
The aim was to assess the influence of menstrual cycle on results of exercise echocardiography and electrocardiography.
Premenopausal women (n = 28) with regular monthly menses, presented typical angina, positive electrocardiogram (ECG) exercise stress test, and normal coronary angiogram were recruited. Exercise supine bicycle echocardiography with simultaneous recording of 12-lead ECG was performed once a week for 4 consecutive weeks. Occurrence of angina, time to angina, time to significant ST deviation, and segmental myocardial contractility were analyzed. Blood samples were drawn to estimate follicle-stimulating hormone, luteinizing hormone, β-estradiol, progesterone concentration and confirm the position in menstrual cycle.
In correlation analysis, linear and logistic regression were used as appropriate. Qualitative variables were categorized into quartiles in logistic regression analysis.
Exercise ST depression was more frequently observed in both luteal phases (early luteal 78%, late luteal 86%) compared to the late follicular phase (50%, P < .05). Time to ST depression was significantly longer in late follicular phase compared to other phases. The rate of segmental exercise left ventricular hypokinesis was low and not significantly related to menstrual cycle. Using linear regression, significant positive correlation was found between estradiol-progesterone ratio and time to ST depression. Using multiple logistic regression, we confirmed that progesterone level is independent factor influencing the presence of ST depression.
In women with typical angina and normal coronary angiogram, the position in menstrual cycle influences the ST depression but not myocardial contractility during exercise echocardiography.
Coronary steal and ST elevation during dipyridamole stress testing leading to coronary artery bypass grafting
2007, Journal of Nuclear Cardiology
Citation Excerpt :
Although a dipyridamole stress test does increase HR,9 the BP9 and myocardial oxygen demand typically decrease, which makes a transmural ischemic event much less likely. However, female patients may have greater catecholamine release during a dipyridamole stress test,11 leading to increased HR and myocardial demand. Dipyridamole-induced ST-segment elevations have been reported in patients without coronary lesions at the end of test procedures and after aminophylline administration and have been attributed to the sudden ending of vasodilatory stimulation.7,12
Evaluating women with chest pain for the diagnosis of coronary artery disease
2002, Disease-a-Month
Citation Excerpt :
Women are usually older at the onset of symptoms and have other conditions such as orthopedic, vascular, and neurologic abnormalities that limit their ability to perform physical activity to bring on symptoms or to conduct diagnostic studies.17 Electrocardiogram (ECG) findings with physical stress may vary with the phase of the menstrual cycle or with estrogen therapy, both producing false-positive ST segment responses.18,19 Indeed, the treadmill ECG test is believed to be less accurate in women than in men because of a higher false-positive rate (with positive findings defined as the development of at least 1-mm horizontal or down-sloping ST segment depression extending for 0.08 seconds after the J point in response to induced myocardial stress).
The evaluation of women with chest pain for the presence of important coronary artery disease may be challenging. Coronary artery disease is the leading cause of death, but it is much more prevalent in women of older age. However, chest discomfort is a very common symptom among women of all ages. Younger women are much less likely (but not completely immune) from having significant coronary disease, but the existing forms of cardiac testing are more likely to yield false results when applied to low-risk groups. Women should be assessed for their overall level of risk for coronary disease and the severity and nature of symptoms. Noninvasive cardiac testing is best applied to women at intermediate risk. There are strengths and weaknesses for each of the available imaging modalities, but both nuclear scans and echocardiography have reasonable accuracy and reliability for detecting serious coronary disease in women. Importantly, a negative study imparts an excellent prognosis. The application of a systematic and comprehensive evaluation of women will improve detection of important coronary disease and permit reassurance to women who do not have evidence for ischemia producing coronary disease. For women whose symptoms are determined not to be caused by significant coronary disease, additional evaluation for noncardiac causes can then be undertaken. Key Words: Coronary artery disease, women, chest pain
Dis Mon 2002;48:647-658
Resting ECG is modified after oophorectomy and regresses with estrogen replacement therapy in premenopausal women
2000, Maturitas
Objective: To assess the effects of bilateral oophorectomy on the resting ECG and whether they regress with estrogen replacement therapy. Study design: Twenty-six premenopausal and 15 postmenopausal women were enrolled in the present study. All women had undergone hysterectomy and bilateral ovariectomy. All women underwent 12-lead ECG on admission to hospital. A second ECG was recorded 20–25 days after surgery. After this second ECG, premenopausal women were randomly divided into two groups. The women of Group A (n=14) received transdermal ethinyl estradiol (EE). The women of Group B (n=12) did not receive any therapy. A third ECG was performed in both groups 30–35 days after randomization. Results: Bilateral oophorectomy did not induce any significant modifications in the ECG parameters of the postmenopausal women whereas in the premenopausal women, we observed a significant increment in mean duration of the T wave, a significant decrease in its amplitude and significant reduction in ST depression in V2, V3, V4 and V5. The third ECG showed regression of the ECG modifications in Group A. In the women of Group B, the second and third ECGs were not substantially different, but there were statistically significant differences between the first and third ECGs. Conclusions: The results of the present study show that ovariectomy induces significant though not clinically evident modifications in resting ECG. These ECG changes are probably due to the sudden reduction in sex hormone plasma levels after ovariectomy. Administration of estradiol induced regression of the ECG modifications.

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Brief reportRelation of results of exercise stress tests in young women to phases of the menstrual cycle

Abstract

The Clinical Approach to Exercise Testing

Effect of estrogens on postexercise electrocardiogram

Br Heart J

Brief report
Relation of results of exercise stress tests in young women to phases of the menstrual cycle