Table 3.

Diagnostic Testing in Women

	Utilization	Limitations	Sensitivity & Specificity*
Coronary artery calcium scoring	• Predictors of subclinical CHD particularly in women • Risk stratify women with an intermediate FRS		Sensitivity 95% Specificity 66%
Exercise treadmill testing	• Initial diagnostic test for symptomatic women, capable of exercising	• Uninterpretable ECG • Exercise limitation	Sensitivity 61% Specificity 70%
Dobutamine stress echocardiography	• Identification of obstructive CAD and estimation of prognosis in premenopausal woman • Detection of obstructive CAD and risk among symptomatic women with intermediate to high IHD risk	• Image artifacts due to respiration and patient habitus/motion	Sensitivity 80% Specificity 84%
Exercise stress echocardiography	• Identification of obstructive CAD and estimation of prognosis for symptomatic women at intermediate-high IHD risk and with any of the following: (a) resting ST-segment abnormalities, (b) functional disability, or (c) indeterminate or intermediate-risk stress ECG • Diastolic function and pulmonary artery pressures may be reasonable in the echocardiographic evaluation of women presenting with dyspnea	• Exercise limitation • Image artifacts due to respiration and patient habitus/motion	Sensitivity 79% Specificity 83%
Single-photon emission tomography (SPECT) myocardial perfusion imaging (MPI) exercise	• Symptomatic women at intermediate-high IHD risk and with (a) resting ST-segment abnormalities, (b) functional disability, or (c) indeterminate or intermediate-risk stress ECG, stress MPI with SPECT or PET is recommended for identification of obstructive CAD and estimation of prognosis • Symptomatic women with an intermediate-high IHD risk who also have abnormal rest ST-segment changes or functional disability	• Radiation exposure • Dense breast and obesity reduce specificity • Lower cardiac mass in women causing lower sensitivity for ischemia and inaccurate TID	Sensitivity 82% Specificity 81%
Pharmacological stress myocardial perfusion imaging (MPI)			Sensitivity 93% Specificity 78%
Stress positron emission tomography (PET)	• Symptomatic women at intermediate-high IHD risk and with (a) resting ST-segment abnormalities, (b) functional disability, or (c) indeterminate or intermediate-risk stress ECG, stress MPI with SPECT or PET is recommended for identification of obstructive CAD and estimation of prognosis • Extent and severity of myocardial perfusion and wall-motion abnormalities, as well as LVEF assessment at rest and after stress. • Calculate absolute blood flow across the coronary vessels, which leads to the calculation of PET MFR, aid in the detection of microvascular CAD • Ability to quantify myocardial blood flow and coronary flow reserve to diagnose ischemia, even in the absence of obstructive CAD		Sensitivity 90% Specificity 89%
Stress cardiac magnetic resonance (CMR)	• Premenopausal woman with functional disability • Symptomatic women at intermediate-high IHD risk and with (a) resting ST-segment abnormalities, (b) functional disability, or (c) indeterminate or intermediate risk, it may be reasonable to use stress CMR, especially vasodilator stress • Perfusion CMR, as the index procedure within the diagnostic evaluation • Assessment of subendocardial perfusion		Sensitivity 89% Specificity 80%
Coronary CTA	• Detailed anatomical information and has a high diagnostic and prognostic accuracy for the detection of CHD • Risk stratification of women after an indeterminate stress test, also for women with persistent symptoms despite a negative stress test	• Poor predictors of the hemodynamic significance of CAD	Sensitivity 96% Specificity 92%