AHA的新聞發表 - 婦女心臟造影及PCI的共識


  Feb. 1, 2005 - 根據美國心臟協會(AHA)星期二在紐約發表的新聞指出,運動間心電圖(ECG)被視為心臟病最不具侵犯性的試驗法,但是這項檢驗法雖然對男性很好用,卻不見得適用於女性;這是該協會希望表達的兩項共識之一。
  
  紐約Northshore大學附設醫院的心臟科核子醫學主任Jennifer H. Mieres醫師表示,運動間ECG只對能在腳踏運動器上持續7分鐘的女性有效;Mieres醫師指出,女性心臟病患者通常較男性虛弱,也較為年長,而這些女性患者通常併發一些其他的病症,如糖尿病及關節炎等;這些病變都會讓她們無法在腳踏器上持續運動7分鐘以上。
  
  所以,對於無法忍受運動間心電圖的女性患者,AHA藍絲帶委員會建議使用壓力型心臟超音波(stress echocardiography),或單光子放射電腦斷層掃描(SPECT);Mieres醫師目前主導該項新共識的撰寫,並擔任撰寫委員會的主任委員。
  
  在心臟造影方面,有以下聲明及建議事項:
  •女性有胸部疼痛的現象,或有其他類似冠狀動脈心臟病的症狀時,如果可以運動的話,必須先進行腳踏器的運動測試。
  •對於ECG異常,或無法做運動的女性,應該使用SPECT或壓力型心臟超音波。
  •糖尿病的女性患者皆應該進行心臟造影檢查。
  •患有多囊性卵巢病變及新陳代謝等症狀的患者,也應該進行心臟造影的檢查(SPECT或 stress echo)。
  
  第二項的共識聲明是有關於經皮冠狀動脈介入性治療(PCI)的使用;撰寫委員會的主導者Alexandra J. Lansky醫師表示,在美國,女性患者每年只有使用到33%的PCI治療,死於心臟病的女性患者也多於男性。
  
  之所以會有這個現象,是因為先前的研究指出,PCI會對女性造成較高的死亡率及併發症;然而,AHA的評估發現,這項療法對於女性卻是安全有效的,藉由藥物傳導支架的使用,療效也在改善當中;Lansky醫師表示,藥物傳導支架目前在支架系統的使用中,佔了60%~70%的比率。
  
  Lansky醫師對Medscape表示,藥物傳導支架看起來對糖尿病及小血管病變的患者具有顯著的效果,這是在女性患者身上所看到的現象;最新的資料顯示,一旦支架成功的被置入,女性的血管再形成率會與男性相同。
  
  有關於PCI的建議如下:
  •要儘速診斷並提早治療;女性一般都會延緩進行支架置入或血管再造;相對的,男性一旦發現到疑似心血管疾病時,通常都會提早接受到類似治療;建議應以相同的標準來對待男女患者。
  •對於糖尿病及小血管病變的患者,進行更進一步研究來將治療最佳化,因為這兩種疾病在女性族群裡較為流行。
  •對於ST提升的心肌梗塞女性患者,治療的途徑及方式應該更精確,因為女性患者會有較高的死亡率及出血風險。
  
  第三篇論文發表於2月1日的循環(Circulation)期刊中,都為有關於醫師們對於男性及女性心臟病患者的不同處理態度;300位一般科醫師、100位婦產科醫師及100位心臟科醫師,總數有500位受訪,基於臨床上的標準治療程序,醫師們被詢問到他們對風險及治療計畫如何的作評估。
  
  紐約長老派教會醫院的心臟病預防科主任Lori Mosca醫師向Medscape表示,醫師們一直將女性的風險看得比男性低,而忽略了臨床上顯示出來的表徵。
  
  在另外一篇論述裡,Mosca醫師提出報告指出,相較於同樣高風險的男性患者,對女性而言,一些常用的標準預防措施通常被醫師們忽略,如阿斯匹靈、降膽固醇藥物及心臟復健等;然而,只有17%的心臟科醫師知道因心臟病致死的女性比男性還多;一般科別醫師中,只有8%了解心臟病的威脅,婦產科醫師只有13%。
  
  任職於科羅拉多大學丹佛保健醫學中心,且為AHA董事長當選人Robert H. Eckel醫師表示,女性的心臟病一直被低估的情況,特別讓人感到困擾,因為心臟病每年奪取了將近50萬女性的生命,換言之,每一分鐘就有一位女性因心臟病而死亡。

AHA Releases New Consensus Sta

By Peggy Peck
Medscape Medical News

Feb. 1, 2005 — The exercise electrocardiogram (ECG), the "workhorse of noninvasive cardiac testing," is not as universally useful in women as it is in men, according to one of two new consensus statements released Tuesday at a press conference in New York by the American Heart Association (AHA).

"Exercise ECG is only useful for women who can remain on the treadmill for more than seven minutes," explained Jennifer H. Mieres, MD, director of nuclear cardiology at Northshore University Hospital in Manhasset, New York, and an assistant professor at New York University School of Medicine. She noted that women with heart disease are typically older and frailer than men. "These women often have comorbities such as diabetes and arthritis that prevent them from staying on the treadmill for more than seven minutes," she told Medscape.

Thus, the AHA blue ribbon committee is recommending cardiac imaging studies with either stress echocardiography or SPECT to evaluate women who are unable to tolerate exercise ECG. Dr. Mieres chaired the writing committee that drafted the new consensus statement and is also vice-chair of the AHA's Cardiac Imaging Committee.

Specifically, the cardiac imaging statement recommends:

  • Women with chest pain or other symptoms suggestive of coronary heart disease should have exercise treadmill testing if capable of exercise.
  • Use SPECT or stress echocardiography for women with abnormal resting ECG or women unable to exercise.
  • Women with diabetes are candidates for cardiac imaging.
  • Women with polycystic ovary disease or metabolic syndrome may also be candidates for cardiac imaging (SPECT or stress echo).

The second new consensus statement deals with the use of percutaneous coronary interventions (PCI) in women. Alexandra J. Lansky, MD, chair of the writing group for the PCI statement, said, "Only 33% of the PCI procedures performed in the United States each year are performed in women, even though more women than men die from heart disease each year."

One reason for the imbalance in referrals for PCI is that earlier studies suggested that women had high death and complication rates with these procedures. But the AHA review finds that these procedures are not only safe and effective in women, but that outcomes are continuing to improve—especially since the introduction of drug-eluting stents, which Dr. Lansky said are now used in about 60% to 70% of stenting procedures.

"These drug-eluting stents appear to improve outcomes in patients with diabetes and small vessel disease," which are two conditions often found in women, Dr. Lansky told Medscape. The latest data suggest that once a stent is successfully placed, the "revascularization rate in women is similar to that in men," she said.

The recommendations in the PCI statement include:

  • Prompt diagnosis and early referral for treatment. Women face great delays for stenting or angioplasty. By contrast, men are usually promptly referred for these procedures for suspected cardiovascular disease. The goal should be the same for women.
  • Further research to optimize therapy for patients with diabetes and small vessel coronary disease — two conditions that are prevalent in the female population.
  • More refined treatment pathways and strategies for ST elevation myocardial infarction in women, who have higher death rates and bleeding risk than in men.

A third paper published in the Feb. 1 issue of Circulation and featured at the press conference detailed physician attitudes toward heart disease risk in women versus men. Five hundred physicians — 300 primary care physicians along with 100 obstetrician-gynecologists and 100 cardiologists — were asked to assess risk and treatment plans based on standard of care for patients described in detailed clinical scenarios.

Lead author Lori Mosca, MD, PhD, director of preventive cardiology at New York–Presbyterian Hospital and an associate professor of medicine at Columbia University, told Medscape that physicians consistently rated women as lower risk than men, regardless of the clinical profile presented.

Moreover, in a second paper that accompanies the survey, Dr. Mosca reported that physicians are also less likely to recommend standard preventive measures such as aspirin, cholesterol-lowering drugs, and cardiac rehabilitation for women at high risk compared with high-risk men. Moreover, only 17% of cardiologists knew that heart disease kills more women than men, and recognition of the heart disease threat was even lower among primary care physicians (8%) and obstetricians/gynecologists (13%).

AHA president-elect Robert H. Eckel, MD, from the University of Colorado at Denver Health Sciences Center, said the continuing low profile of heart disease in women is especially disturbing because heart disease kills about half a million women per year and "one woman dies from heart disease every minute." Dr. Eckel moderated the press conference.

Circulation. Consensus statements published online Feb. 1, 2005; Circulation. (Mosca survey) 2005;111:499-510

Reviewed by Gary D. Vogin, MD

    
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