Effect of Gender on Spect Myocardial Perfusion Imaging Results in Egypt

doi:10.21203/rs.3.rs-3909278/v1

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Effect of Gender on Spect Myocardial Perfusion Imaging Results in Egypt

https://doi.org/10.21203/rs.3.rs-3909278/v1

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Background

Ischemic heart disease (IHD) is one of the leading causes of morbidity and mortality around the world. Men are more affected than women and the more the population age, the more is the prevalence. There was a concern about improper referral of women to MPI testing. We aim to study if there a gender effect on the results of MPI studies and if this could have an impact on future referral or investigation selection for diagnosis of IHD as a general or specially in women.

Methods

The current study was a retrospective observational study that enrolled 443 consecutive patients who were candidates for myocardial perfusion imaging. The study was conducted throughout the period from January 2021 to October 2023.

Results

Female gender represented 266 (60%) while male represented in 177 (40%). Males demonstrated significantly higher age (55 ± 10 vs. 49 ± 9, P < .0001), weight (85 ± 11 vs. 83 ± 13, P = 0.006), height (166 ± 4 vs. 165 ± 4, P = 0.02), and smoking (35% vs. 0%, P < 0.001) than females. Male gender was associated with ten times increased risk of positive MPI (OR = 10, 95% CI = 5.348–18.868, P < 0.001). Diabetes was associated with an increased risk of positive MPI (OR = 1.82, 95% CI = 1.052–3.148, P = 0.032).

Conclusions

Positive MPI test are more common in males. Female patients with positive MPI were younger in age than male patients. Diabetes mellitus and age are traditional strong predictors for the presence of positive MPI test.

Gender

female

myocardial

perfusion

ischemia

Ischemic heart disease (IHD) is one of the leading causes of morbidity and mortality around the world [1]. The age standardized IHD prevalence in Egypt was 5.89% in 2019 with a nearly 5% increase from previous values reported in 2005 [2]. Men are more affected than women and the more the population age, the more is the prevalence [3].

The diagnosis of IHD needs careful history taking and risk profile assessment [4]. The choice of the diagnostic investigation depends on the pretest probability [5]. Myocardial perfusion imaging (MPI) is one of the non-invasive tools to diagnose IHD [6]. MPI test could identify patients who may benefit from revascularization [7]. There was a concern about improper referral of women to MPI testing [8]. We aim to study if there a gender effect on the results of MPI studies and if this could have an impact on future referral or investigation selection for diagnosis of IHD as a general or specially in women.

Ethical consent

This study was ethically approved by Al-Azhar University's Research Ethics. Written informed consents from all the participants were obtained. The study protocol conformed to the Helsinki Declaration, the ethical norm of the World Medical Association for human testing.

Inclusion criteria

symptomatic male or female patients with typical chest pain or unexplained dyspnea and fatigue referred to myocardial perfusion imaging unit to investigate the presence or absence of coronary artery disease. All are adult (age > 18years old) and able to exercise on treadmill.

Exclusion Criteria

1) Arrhythmia like atrial fibrillation and any other arrhythmias that interfere with gated SPECT results 2) LBBB in ECG 3) History of chronic obstructive airway disease,4) pulmonary hypertension. 5) Pregnancy or breast-feeding. 6) Morbid obesity and weight more than 120 Kg that is beyond the table tolerability

All cases were subjected to the following: Detailed history taking including risk factors of IHD (HTN, diabetes, smoking, dyslipidemia and FH of premature CAD), Baseline measurements of weight, height were recorded, and body mass index (BMI) was calculated according to this Quetelet index: Weight (Kg)/ height (m²). Symptoms as chest pain and dyspnea. Thorough clinical examination was done including HR, BP, chest and cardiac examination in addition to resting twelve leads surface ECG.

Myocardial perfusion SPECT studies: Stress protocol: treadmill exercising stress test according to Bruce procedure was performed to a total of 443 individuals [9].

Myocardial Perfusion Imaging (MPI)

In accordance with a two-day procedure, a gated-SPECT MPI was performed for each patient. Patients with diaphragmatic and/or breast attenuation for females were corrected by prone position. Using a dual-head (Philips Cardio-MD system) camera with low-energy, high-resolution collimators, supine pictures were collected. The normal methods were followed in the processing of each radionuclides imaging and the related data.

In all instances, 99mTc SestaMIBI was utilized (the routine tracer used in our laboratory). Based on the usual paradigm, myocardial perfusions were determined as the relative percent tracers’ absorption in each of the 17 segments. Experts in nuclear cardiology interpreted each MPI scan using both quantitative and qualitative analysis of the results. Every segment was scored based on the tracer uptake as; (0) normal uptake, (1) mildly reduced, (2) moderately reduced, (3) severely reduced and (4) absent tracer uptake. A summed rest score (SRS) and summed stress score (SSS) were obtained by adding the scores of the 17 segments of the rest and stress images, respectively. The summed difference score (SDS) was determined by subtracting the SRS from the SSS.

Studies were classified as normal when (SSS < 4) or abnormal when (SSS > 4). The gated images were processed by quantified gated SPECT software to obtain LVEF. Additional high-risk perfusion scanning indicators, such as elevated lungs heart ratio (LHR), transient ischemic dilatation (TID), and aberrant regional and global wall movement anomalies, were described independently [10].

Statistical analysis

Data management and statistical analysis were done using SPSS version 28 (IBM, Armonk, New York, United States). Quantitative data were assessed for normality using the Kolmogorov–Smirnov test and direct data visualization methods. According to normality, quantitative data were summarized as means and standard deviations or medians and ranges. Categorical data were summarized as numbers and percentages. Quantitative data were compared according to gender using the independent t-test or Mann-Whitney (U) test for normally and non-normally distributed quantitative variables, respectively. Categorical data were compared using the Chi-square or Fisher’s exact test, if appropriate. Multivariate logistic regression analysis was done to predict positive MPI. Odds ratios with 95% confidence intervals were calculated. All statistical tests were two-sided. P values less than 0.05 were considered significant.

The current study included 443 participants with a mean age of 51 ± 9 years. The average weight was 84 ± 12 kg, and the average height was 165 ± 4 cm, resulting in a mean BMI of 30.6 ± 3.8. Approximately 42.9% of participants had diabetes mellitus, 14.4% had a positive family history, and 51% had hypertension. Regarding smoking habits, 14% of participants reported being current smokers, and 1.6% were ex-smokers. Additionally, 21.4% of participants had dyslipidemia. Menopause female patients were detected in 41.9%.

Female gender includes 266 (60%) while male represented in 177 (40%). Males demonstrated significantly higher age (55 ± 10 vs. 49 ± 9, P < .0001), weight (85 ± 11 vs. 83 ± 13, P = 0.006), height (166 ± 4 vs. 165 ± 4, P = 0.02), and smoking (35% vs. 0%, P < 0.001) than females. In contrast, positive family history was significantly higher in females (17.3%) than in males (10.2%) (P = 0.037).

There were no significant differences reported regarding BMI (P = 0.195), diabetes mellitus (P = 0.831), hypertension (P = 0.269), and dyslipidemia (P = 0.992).

Males demonstrated significantly higher abnormal resting ECG (49.2% vs. 21.1%, P < 0.001), resting SBP (127 ± 16 vs. 123 ± 15, P = 0.018), resting DBP (82 ± 11 vs. 79 ± 9, P = 0.006), exercise duration (median = 8.3 vs. 7.6, P = 0.021), METS (median = 6.7 vs. 6.4, P = 0.011), positive ischemic changes on ECG (36.2% vs. 20.3, P < 0.001), EDV (median = 101 vs. 77, P < 0.001), ESV (median = 38 vs. 21, P < 0.001), TID (median = 1 vs. 0.9, P < 0.001), and positive MPI (55.4% vs. 9.4%, P < 0.001) compared to females. Additionally, exercise stage significantly differed according to gender (P < 0.001), with stages IV and V being higher in males (38.4% and 5.6%) than in females (29.7% and 1.1%). Furthermore, the exercise associated symptoms differed according to gender (P < 0.001), with chest pain being higher in males (31.6%) than in females (13.5%). In comparison, fatigue was higher in females (32.3%) compared to males (16.4%).

In contrast, females demonstrated significantly higher heart rate (88 ± 13 vs. 83 ± 12, P < 0.001), MAHR (166 ± 16 vs. 153 ± 21, P < 0.001), MAHR% (95 ± 8 vs. 91 ± 9, P < 0.001), EF (67 ± 6 vs. 57 ± 15, P < 0.001), LHR (median = 0.32 vs. 0.45, P < 0.001), and diaphragmatic attenuation (36.1% vs. 22%, P = 0.002) than males.

Prediction of positive MPI

Multivariate logistic regression analysis was done to predict positive MPI. The model was built clinically, including age, gender, BMI, smoking, diabetes mellitus, hypertension, family history, dyslipidemia, abnormal resting ECG, and heart rate. The significant predictors were male gender, diabetes mellitus, and abnormal resting ECG. Male gender was associated with ten times increased risk of positive MPI (OR = 10, 95% CI = 5.348–18.868, P < 0.001). Diabetes was associated with an increased risk of positive MPI (OR = 1.82, 95% CI = 1.052–3.148, P = 0.032). Abnormal resting ECG was associated with about five times increased risk of positive MPI (OR = 4.626, 95% CI = 2.647–8.086, P < 0.001) (Table 1).

Table (1) Multivariate logistic regression analysis to predict positive MPI.

	OR (95% CI)	P-value
Age (years)	1.017 (0.987–1.047)	0.274
Male gender	10 (5.348–18.868)	< 0.001*
Body mass index	0.974 (0.908–1.044)	0.454
Current smoking	0.766 (0.371–1.584)	0.472
Diabetes	1.82 (1.052–3.148)	0.032*
Hypertension	0.947 (0.557–1.609)	0.84
Positive family history	0.541 (0.229–1.276)	0.161
Dyslipidemia	1.824 (0.943–3.529)	0.074
Abnormal resting ECG	4.626 (2.647–8.086)	< 0.001*
Heart rate	0.991 (0.971–1.013)	0.431

*Significant P-value; OR: Odds ratio; 95% CI: 95% Confidence interval.

In the current study we classify our patients to positive and negative MPI

Positive MPI patient

As shown in Table 2, the mean age of MPI-positive patients was 55 ± 9. Males predominated (79.7%) more than females (20.3%). The mean weight and height were 84 ± 11 kg and 166 ± 4 cm, respectively. The mean body mass index was 30.6 ± 3.6. Half of the patients had diabetes mellitus (50.4%). Half of the females (50.4%) were menopause. Only 9.8% had a positive family history. Hypertension was reported in 56.1%. About one-third were current smokers (29.3%), and only 5.7% were ex-smokers. Dyslipidemia was reported in 27.6%.

Males demonstrated significantly higher age (56 ± 8 vs. 52 ± 10, P = 0.039), height (166 ± 4 vs. 164 ± 4, P = 0.037), and smoking (36.7% current smokers vs. 0%, P < 0.001) than females. No significant differences were reported regarding the remaining parameters, as shown in Table 2.

Table (2) General characteristics of MPI-positive patients and according to gender

		Total (n = 123)	Males (n = 98)	Females (n = 25)	P-value
Age (years)	Mean ± SD	55 ± 9	56 ± 8	52 ± 10	0.039*
Weight (kg)	Mean ± SD	84 ± 11	85 ± 11	81 ± 13	0.135
Height (cm)	Mean ± SD	166 ± 4	166 ± 4	164 ± 4	0.037*
Body mass index (kg/m²)	Mean ± SD	30.6 ± 3.6	30.8 ± 3.4	30.1 ± 4.3	0.398
Diabetes mellitus	n (%)	62 (50.4)	46 (46.9)	16 (64)	0.128
Menopause	n (%)	13 (52)	-	13 (52)	-
Positive Family history	n (%)	12 (9.8)	8 (8.2)	4 (16)	0.239
Hypertension	n (%)	69 (56.1)	55 (56.1)	14 (56)	0.991
Current smoker	n (%)	36 (29.3)	36 (36.7)	0 (0)	< 0.001*
Ex-smoker	n (%)	7 (5.7)	7 (7.1)	0 (0)
Dyslipidemia	n (%)	34 (27.6)	25 (25.5)	9 (36)	0.295
*Significant P-value

Clinical characteristics at rest and exercise

Two-thirds (61.8%) of MPI-positive patients demonstrated abnormal resting ECG. The mean heart rate was 84 ± 12. The mean resting systolic and diastolic blood pressure were 129 ± 15 and 82 ± 10 mmHg, respectively. The median exercise duration was 7.2 minutes, ranging from 2.5 to 13.7 minutes. The most frequent exercise stage was stage III (39.8%), followed by stage IV (27.6%), stage II (23.6%), stage I (7.4%), and stage V (1.6%). The median METS was 5.9, ranging from 1.4–13. The mean maximum achieved heart rate was 149 ± 18 b/m, while the mean maximum achieved heart rate percentage was 89 ± 7%. Half of the patients (51.6%) demonstrated positive ECG changes for ischemia, while one-third (36.6%) had negative changes. Only 10.6% and 1.6% showed submaximal stress test and equivocal changes, respectively. Regarding affected vessels, 52.4% had inferior affection, 47.6% had anterior affection, 36.5% had inferolateral affection, and 12.7% had anterolateral affection. Limiting chest pain was observed in 10.6% of the patients. The most frequent associated symptoms were chest pain (51.2%), followed by dyspnea (42.3%), fatigue (4.9%), and only (1.6%) had no associated symptoms. The mean systolic and diastolic blood pressures at maximum exercise were 168 ± 26 and 96 ± 12 mmHg, respectively.

Females demonstrated significantly higher maximum achieved heart rate (156 ± 12) than males (147 ± 19) (P = 0.036). No significant differences were reported regarding the remaining parameters as shown in Table 3.

Table (3) Clinical characteristics at rest and exercise of MPI-positive patients according to gender

		Total (n = 123)	Males (n = 98)	Females (n = 25)	P-value
Abnormal resting ECG	n (%)	76 (61.8)	62 (63.3)	14 (56)	0.505
Heart rate (b/m)	Mean ± SD	84 ± 12	83 ± 12	87 ± 11	0.102
Resting SBP (mmHg)	Mean ± SD	129 ± 15	129 ± 14	127 ± 18	0.411
Resting DBP (mmHg)	Mean ± SD	82 ± 10	83 ± 10	80 ± 10	0.260
Exercise duration (min)	Median (range)	7.2 (0.5–13.7)	7.4 (1.4–13.7)	6.5 (0.5–10.2)	0.076
Exercise stage
Stage I	n (%)	9 (7.3)	7 (7.1)	2 (8)	0.087
Stage II	n (%)	29 (23.6)	22 (22.4)	7 (28)
Stage III	n (%)	49 (39.8)	35 (35.7)	14 (56)
Stage IV	n (%)	34 (27.6)	32 (32.7)	2 (8)
Stage V	n (%)	2 (1.6)	2 (2)	0 (0)
METS	Median (range)	5.9 (1.4–13)	6.25 (2.1–13)	5.2 (1.4–11)	0.098
MAHR( B/m)	Mean ± SD	149 ± 18	147 ± 19	156 ± 12	0.036*
MAHR (%)	Mean ± SD	89 ± 7	89 ± 8	91 ± 5	0.113
ECG changes
Positive for ischemia	n (%)	63 (51.2)	48 (49)	15 (60)	0.324
Negative for ischemia	n (%)	45 (36.6)	37 (37.8)	8 (32)
Equivocal	n (%)	2 (1.6)	1 (1)	1 (4)
Submaximal stress test	n (%)	13 (10.6)	12 (12.2)	1 (4)
Anterior affection^†	n (%)	30 (47.6)	23 (47.9)	7 (46.7)	0.933
Inferior affection^†	n (%)	33 (52.4)	26 (54.2)	7 (46.7)	0.612
Inferolateral affection^†	n (%)	23 (36.5)	18 (37.5)	5 (33.3)	0.770
Anterolateral affection^†	n (%)	8 (12.7)	6 (12.5)	2 (13.3)	0.933
*Significant P-value; †Percentages were calculated based on those with positive ischemic changes on ECG; METS: Metabolic Equivalent of Task; MAHR: Maximum achieved heart rate; SBP: Systolic blood pressure; DBP: Diastolic blood pressure

MPI findings

Approximately half (52%) of the MPI-positive patients demonstrated one defect, while the remaining (48%) had two defects. Male patients demonstrated ischemia in 88 cases; 14 cases had ischemia (total reversible defect) only and 74 cases had ischemia and scar (partially reversible) while 10 cases had scar only (fixed defect) with no ischemia. None of female patients had scar (fixed defect). Ischemia (total reversible defect) was present in 10 cases only while the remaining had both ischemia and fixed defects (partially reversible).

The median and range of ischemia was 15.5% ranging from (2–46) in male compared to 16% ranging from (3–33) in female. This difference didn’t reach to a significant difference.

The scar in totally irreversible or partially reversible ischemia was present in 84 cases in male and 15 cases in female. The median for all was 9% (range 2–67), median in male was 10% ( range 2–67) and median in female was 7% and range from (2–33). The median SSS was 17.5%, with values ranging from (7–57) in male and 13% with value range from (7–42) in female. The median sum difference was 8% in male with a range from 1 to 32 in male. The median SDS in female was 10%, with values ranging from 0 to 32. Regarding ischemia severity, mild, moderate and severe diseases represented 35%, 19.5%, and 45.5%, respectively. The mean dose rest and stress were 28 ± 1 and 27 ± 1, respectively. The median EDV and ESV were 120 and 49, respectively. The mean EF was 52 ± 15.

The mean Lung heart ratio was 0.38 ± 0.07. The median transient ischemic dilatation was 1.19, ranging from 0.7–0.9. Males demonstrated significantly higher scar (median = 8 vs. 2, P = 0.003), EDV (median = 126 vs. 96, P < 0.001), and ESV (median = 59 vs. 33, P < 0.001) but lower ejection fraction (49 ± 16 vs. 62 ± 8, P < 0.001) than females. No significant differences were reported regarding the remaining parameters as shown in Table 4.

Table (4) Positive MPI findings in all patients and according to gender

		Total (n = 123)	Males (n = 98)	Females (n = 25)	P-value
Numbers of defect
One	n (%)	64 (52)	48 (49)	16 (64)	0.18
Two	n (%)	59 (48)	50 (51)	9 (36)
Total ischemia %	Median (range)	16 (2–46)	15.5 (2–46)	16 (3–33)	0.33
Total scar %	Median (range)	9 (2–67)	10 (2–67)	7 (2–33)	0.003
SSS %	Median (range)	16 (7–57)	17.5 (7–57)	13 (7–42)	0.25
SRS %	Median (range)	5 (1–56)	6 .5 (0–56)	2 (0–31)	0.02
SDS%	Median (range)	8 (1–32)	8 (0–32)	10 (0–32)	0.065
Ischemia severity
Mild (SSS < 6)	n (%)	43 (35.0)	34 (34.7)	9 (36.0)	0.762
Moderate (SSS 6–10)	n (%)	24 (19.5)	18 (18.4)	6 (24.0)
Severe (SSS > 10)	n (%)	56 (45.5)	46 (46.9)	10 (40.0)
Dose rest	Mean ± SD	28 ± 1	28 ± 1	28 ± 2	0.629
Dose stress	Mean ± SD	27 ± 1	27 ± 1	27 ± 2	0.576
EDV (mL)	Median (range)	120 (44–413)	126 (44–413)	96 (46–160)	< 0.001*
ESV (mL)	Median (range)	49 (7–342)	59 (11–342)	33 (7–86)	< 0.001*
EF (%)	Mean ± SD	52 ± 15	49 ± 16	62 ± 8	< 0.001*
LHR	Mean ± SD	0.38 ± 0.07	0.38 ± 0.06	0.37 ± 0.1	0.770
TID	Median (range)	1.19 (0.7–9.0)	1.19 (0.7–9)	1.1 (0.8–1.3)	0.405

*Significant P-value; EDV: End diastolic volume; ESV: End systolic volume; EF: Ejection fraction; LHR: Lung heart ratio; TID: Transient ischemic dilatation SSS: sum stress score SRS: sum rest score SDS: sum difference score

Medications

The most frequent medication used by MPI-positive patients was aspirin (70.7%), followed by beta-blockers (43.9%), anti-lipids (36.6%), ACEI (36.6%), Plavix (35.8), nitroglycerin (32.5%), ARBs (5.7%), and CCB (4.1%).

Males demonstrated significantly higher use of nitroglycerin (36.7% vs. 16%, P = 0.048) and aspirin (75.5% vs. 52%, P = 0.021). No significant differences were observed regarding the remaining drugs according to gender as shown in Table 5.

Table (5) Medications used in MPI-positive patients according to gender.

		Total (n = 123)	Males (n = 98)	Females (n = 25)	P-value
Beta blockers	n (%)	54 (43.9)	47 (48)	7 (28)	0.073
Nitroglycerin	n (%)	40 (32.5)	36 (36.7)	4 (16)	0.048*
Aspirin	n (%)	87 (70.7)	74 (75.5)	13 (52)	0.021*
Plavix	n (%)	44 (35.8)	35 (35.7)	9 (36)	0.979
Anti-lipids	n (%)	45 (36.6)	35 (35.7)	10 (40)	0.691
ACEI	n (%)	45 (36.6)	40 (40.8)	5 (20)	0.054
ARBs	n (%)	7 (5.7)	5 (5.1)	2 (8)	0.577
CCB	n (%)	5 (4.1)	4 (4.1)	1 (4)	1.0
*Significant P-value; ACEI: Angiotensin-Converting Enzyme Inhibitors; ARBs: Angiotensin II Receptor Blockers; CCB: Calcium channel blockers

Females represented around 60% of our patients included in this study. This percentage and numbers are much higher than represented in many other MPI studies with male predominance. This related to the culture in Egypt and Middle East that female patients and their families prefer female physicians for their medical care and managements as our hospital belong to a faculty of medicine for girls.

Despite the presence of typical chest pain and unexplained dyspnea and fatigue to refer patients for MPI study; only 9.4% of female patients had a positive MPI study while the percentage was 55.4% in male patients. However, the age of female patients with positive test was younger than male patients significantly.

Moreover, our female patient’s age was younger than age reported in Cerci et al study. The mean age of their study was 64.5 ± 5.6 years (range from 55–75 years) [10].

The reasons of ischemia of female in young age may be related to the presence of multiple risk factors in our study population as all females were over- weighted to obese, 64% of them were diabetics, around half of them were menopause and more than one third of them were dyslipidemic.

Recently, other risk factors were added in women including factors related to pregnancy, hormonal factors, social factors (race, education, income and zip code) and psychological risk factors [13].

Globally, males have a higher age-standardized CVD death rate (280.8 deaths per 100,000 people in 2019) than females (204.0 deaths per 100,000 people in 2019), though this difference is not consistent across all countries. In the North Africa and Middle East region, with the highest differences in Egypt (600.0 compared to 491.6 deaths per 100,000 people for females and males respectively) [14].

Female patients with negative MPI test represent higher percentage despite their symptoms including typical chest pain. They are younger in age (mean ± SD was 48.4 ± 8.4 years) but the reason(s) for this result will be questionable and require explanation. Is the test revealed false negative result as published before? Is chest pain related to coronary spasm or psychological risk factors?

There is significant difference between male and female in scar size, EDV, ESV and EF and no significant difference regarding SSS, SRS, SD, severity of ischemia. Reviewing other literature female had less severe ischemia than men [15] but in this study the author include 4 different stress testing modalities which increases generalizability of his result.

Male patients revealed a higher percentage (55.4%) of the positive MPI test from all males participated in this study. Multivariate logistic regression demonstrated that male gender was associated with ten times increased risk of positive MPI.

Fixed Irreversible ischemia was significantly higher in males (p < 0.003) and about 10% of positive male cases had scar only with no reversible ischemia.

Males are believed to have more ischemic heart disease than females especially before menopause and as females aging the risk for development of ischemic heart disease is increasing [16].

We found in our study that a positive family history was more common in females than in males referred to MPI study; however, it was not predictive of a positive MPI result. Although Bachmann et al, 2012 reported that family history was associated with increased risk for future cardiovascular events whatever it was premature or late [17]. This was also confirmed by another study by Chacko et al, 2020 who stated that positive family history is an independent risk factor for premature coronary artery disease and that the risk increases by the increase of number of family members affected [18].

The mean exercise duration was more in males than females regardless the MPI test results, it was lower in both males and females in positive group with lesser duration in females, this was concordant with previous finding reported by Wu YT et al, 2013 [19]. This may be attributed to the low functional capacity in females than males [20].

Although the prevalence of diabetes mellitus in our study population was nearly similar between females and males, the presence of DM was associated with an 82% increased risk of positive MPI. DM is a well-established risk factor for development of ischemic heart disease and considered as coronary artery disease equivalent. DM affects both epicardial coronary arteries and microcirculation [21].

Limitations

This study has some limitations. The small number of positive female cases and lack of similar study to compare with in the Egyptian population. Females referred to cardiac SPECT-MPI with negative result may have IHD and the coronary angiography remains the gold standard for diagnosis of CAD but an invasive technique.

The final SPECT-MPI result was interpreted by expertise instead of blind interpretations.

Positive MPI test are more common in males. Female patients with positive MPI were younger in age than male patients in this study and in contrary to what documented in literatures before. Diabetes mellitus and age are traditional strong predictors for the presence of positive MPI test. However, to confirm or exclude the presence of IHD in symptomatic females with negative MPI still require furthermore affordable non–invasive method(s) to clarify the link between symptoms and ischemia in women.

CAD Coronary Artery Disease

DM Diabetes Miletus

IHD Ischemic Heart Disease

MPI Myocardial Perfusion Imaging

Ethics approval and consent to participate.

The ethics approval was done by the local University authorities (Al-Azhar University, Faculty of Medicine for Girls (Cairo), Research Ethics Committee), approval number 2023112168. A written consent was provided by all the study participants after explanation of the study steps.

Consent for publication

All the authors declare acceptance for publication.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was provided.

Authors' contributions

TA and FA contributed to data collection and writing the manuscript, AA contributed to data revisions and writing the manuscript, MN and NM contributed to writing the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

Khan MA, Hashim MJ, Mustafa H, Baniyas MY, Al Suwaidi SKBM, AlKatheeri R, Alblooshi FMK, Almatrooshi MEAH, Alzaabi MEH, Al Darmaki RS, Lootah SNAH (2020) Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study. Cureus 12(7):e9349. 10.7759/cureus.9349PMID: 32742886; PMCID: PMC7384703
Sadeghi M, Jamalian M, Mehrabani-Zeinabad K, Turk-Adawi K, Kopec J, AlMahmeed W, Abdul Rahim HF, Farhan HA, Anwar W, Manla Y, Fadhil I, Lui M, Roohafza H, Islam SMS, Sulaiman K, Bazargani N, Saade G, Hassen N, Alandejani A, Abdin A, Bokhari S, Roth GA, Johnson C, Stark B, Sarrafzadegan N, Mokdad AH (2023) The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990–2019. PLoS ONE 18(9):e0290286. 10.1371/journal.pone.0290286PMID: 37669274; PMCID: PMC10479892
Solola Nussbaum S, Henry S, Yong CM, Daugherty SL, Mehran R, Poppas A (2022) Sex-Specific Considerations in the Presentation, Diagnosis, and Management of Ischemic Heart Disease: JACC Focus Seminar 2/7. J Am Coll Cardiol 79(14):1398–1406 PMID: 35393022; PMCID: PMC9009217
Hedge J, Balajibabu PR, Sivaraman T (2017) The patient with ischaemic heart disease undergoing non cardiac surgery. Indian J Anaesth 61(9):705–711. 10.4103/ija.IJA_384_17PMID: 28970628; PMCID: PMC5613595
Oerbekke MS, Jenniskens K, Scholten RJPM, Hooft L (2020) Data sources and methods used to determine pretest probabilities in a cohort of Cochrane diagnostic test accuracy reviews. BMC Med Res Methodol 20(1):85. 10.1186/s12874-020-00952-wPMID: 32299367; PMCID: PMC7161259
Ora M, Gambhir S (2019 Oct-Dec) Myocardial Perfusion Imaging: A Brief Review of Nuclear and Nonnuclear Techniques and Comparative Evaluation of Recent Advances. Indian J Nucl Med 34(4):263–270. 10.4103/ijnm.IJNM_90_19PMID: 31579355; PMCID: PMC6771197
Petretta M, Acampa W, Daniele S, Zampella E, Assante R, Nappi C, Salvatore M, Cuocolo A (2016) Long-Term Survival Benefit of Coronary Revascularization in Patients Undergoing Stress Myocardial Perfusion Imaging. Circ J 80(2):485–493. 10.1253/circj.CJ-15-1093Epub 2015 Dec 18. PMID: 26686993
Doukky R, Frogge N, Appis A, Hayes K, Khoudary G, Fogg L, Williams KA Sr (2016) Impact of Appropriate Use on the Estimated Radiation Risk to Men and Women Undergoing Radionuclide Myocardial Perfusion Imaging. J Nucl Med 57(8):1251–1257. 10.2967/jnumed.115.167205Epub 2016 Apr 21. PMID: 27103019
Lin SX, Pi-Sunyer EX (2007 Winter) Prevalence of the metabolic syndrome among US middle-aged and older adults with and without diabetes–a preliminary analysis of the NHANES 1999–2002 data. Ethn Dis 17(1):35–39 PMID: 17274207
Cerci MS, Cerci JJ, Cerci RJ, Pereira Neto CC, Trindade E, Delbeke D, da Cunha CL, Vitola JV (2011) Myocardial perfusion imaging is a strong predictor of death in women. JACC Cardiovasc Imaging. ;4(8):880-8. 10.1016/j.jcmg.2011.06.009. PMID: 21835380
Khederlou H, Mohammadi A, Tajik M, Kazemshiroodi M (2023) Association between Cardiovascular Risk Factors and High-Risk Features in Myocardial Perfusion Imaging: A Multicenter Study. J Tehran Heart Cent 18(2):129–135. 10.18502/jthc.v18i2.13323PMID: 37637283; PMCID: PMC10459346
Subki AH, Agabawi AK, Hindi MM, Butt NS, Alsallum MS, Alghamdi RA, Subki SH, Alsallum F, Alharbi AA, Lodhi YI, Alandijani S, Al-Zaben F, Koenig HG, Oraif AM (2021) How Relevant is Obstetrician and Gynecologist Gender to Women in Saudi Arabia? Int J Womens Health 13:919–927. 10.2147/IJWH.S284321PMID: 34703321; PMCID: PMC8523902
Cho L, Davis M, Elgendy I, Epps K, Lindley KJ, Mehta PK, Michos ED, Minissian M, Pepine C, Vaccarino V, Volgman AS, ACC CVD Womens Committee Members (2020) Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review. J Am Coll Cardiol 75(20):2602–2618 PMID: 32439010; PMCID: PMC8328156
Di Cesare M, Bixby H, Gaziano T, Hadeed L, Kabudula C, Vaca McGhie D, Mwangi J, Pervan B, Perel P, Piñeiro D, Taylor S, Pinto F (2023) world heart report 2023 Confronting the World’s Number One Killer: Cardiovascular disease deaths by sex. World Heart Federation, Geneva, Switzerland, p 9
Reynolds HR, Shaw LJ, Min JK, Spertus JA, Chaitman BR, Berman DS, Picard MH, Kwong RY, Bairey-Merz CN, Cyr DD, Lopes RD, Lopez-Sendon JL, Held C, Szwed H, Senior R, Gosselin G, Nair RG, Elghamaz A, Bockeria O, Chen J, Chernyavskiy AM, Bhargava B, Newman JD, Hinic SB, Jaroch J, Hoye A, Berger J, Boden WE, O'Brien SM, Maron DJ, Hochman JS, ISCHEMIA Research Group (2020) ;. Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia: Secondary Analysis of the ISCHEMIA Randomized Clinical Trial. JAMA Cardiol. ;5(7):773–786. doi: 10.1001/jamacardio.2020.0822. Erratum in: JAMA Cardiol. 2021;6(8):980. PMID: 32227128; PMCID: PMC7105951
Majidi M, Eslami V, Ghorbani P, Foroughi M (2021) Are women more susceptible to ischemic heart disease compared to men? A literature overview. J Geriatr Cardiol 18(4):289–296. 10.11909/j.issn.1671-5411.2021.04.004PMID: 33995508; PMCID: PMC8100425
Bachmann JM, Willis BL, Ayers CR, Khera A, Berry JD (2012) Association between family history and coronary heart disease death across long-term follow-up in men: the Cooper Center Longitudinal Study. Circulation 125(25):3092–3098. 10.1161/CIRCULATIONAHA.111.065490Epub 2012 May 23. PMID: 22623718; PMCID: PMC3631594
Chacko M, Sarma PS, Harikrishnan S, Zachariah G, Jeemon P (2020) Family history of cardiovascular disease and risk of premature coronary heart disease: A matched case-control study. Wellcome Open Res 5:70. 10.12688/wellcomeopenres.15829.2PMID: 32518841; PMCID: PMC7256470
Wu YT, Chien CL, Wang SY, Yang WS, Wu YW (2013) Gender differences in myocardial perfusion defect in asymptomatic postmenopausal women and men with and without diabetes mellitus. J Womens Health (Larchmt) 22(5):439–444. 10.1089/jwh.2012.4055Epub 2013 Apr 21. PMID: 23600438; PMCID: PMC3653376
Gee MA, Viera AJ, Miller PF, Tolleson-Rinehart S (2014) Jul-Aug;34(4):255 – 62 Functional capacity in men and women following cardiac rehabilitation. J Cardiopulm Rehabil Prev. 10.1097/HCR.0000000000000066. PMID: 24977463
Severino P, D'Amato A, Netti L, Pucci M, De Marchis M, Palmirotta R, Volterrani M, Mancone M, Fedele F (2018) Diabetes Mellitus and Ischemic Heart Disease: The Role of Ion Channels. Int J Mol Sci 19(3):802. 10.3390/ijms19030802PMID: 29534462; PMCID: PMC5877663

No competing interests reported.

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Effect of Gender on Spect Myocardial Perfusion Imaging Results in Egypt

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Abstract

Background

Methods

Results

Conclusions

Background

Methods

Statistical analysis

Results

Prediction of positive MPI

In the current study we classify our patients to positive and negative MPI

Positive MPI patient

Clinical characteristics at rest and exercise

MPI findings

Medications

Discussion

Limitations

Conclusions and Recommendation

Abbreviations

Declarations

References

Additional Declarations

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