Perspective:

The following are 10 points to remember about this consensus statement from the American Heart Association:

1. This statement synthesizes current evidence on the diagnostic and prognostic accuracy for exercise treadmill testing (ETT) with electrocardiography (ECG), stress echocardiography, stress myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT) or positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and cardiac CT angiography (CCTA) in women with ischemic heart disease (IHD) symptomatology.

2. Recommendations for testing differ by pretesting risk groups. In general, premenopausal women with symptoms should be considered at low risk, excluding those with diabetes mellitus. Symptomatic women in their fifth decade of life should be considered at low to intermediate IHD risk if they are capable of performing routine activities of daily living (ADLs). If functionally limited, then they would be considered as intermediate risk. Symptomatic women in their 60s are also generally considered as being at intermediate IHD risk, whereas women ≥70 years old with ischemic symptoms are considered at high IHD risk. High-risk equivalent states, including peripheral arterial disease and long-standing or poorly controlled diabetes mellitus for women ages >40 years, categorize a woman at high IHD risk.

3. With some exceptions, women at low IHD risk are not candidates for a diagnostic evaluation.

4. An initial exercise ECG–first strategy is recommended for women at low and intermediate IHD risk who can exercise. If an ETT is indeterminate (e.g., negative ECG in the setting of submaximal exercise [below age-predicted level or failure to achieve >85% predicted maximal heart rate]) or abnormal, the next step should be additional diagnostic testing with stress imaging. Individualized decision making and targeted anti-ischemic therapies after the ETT should consider the woman’s ongoing symptom burden and the degree of abnormalities noted during the ETT.

5. For symptomatic women with functional disability, an indeterminate ETT, or an abnormal rest ECG, echocardiography or MPI is recommended, or CMR may be considered a reasonable test option. CCTA may also be considered reasonable for women at intermediate IHD risk.

6. Premenopausal women at intermediate IHD risk who are functionally disabled generally should undergo echocardiography or CMR, but may undergo MPI or CCTA if an effective radiation dose of <3 mSv is possible.

7. Radiation dose-reduction techniques should be used in all women undergoing clinically necessary (or appropriate) stress MPI whenever possible. In younger women, the choice of a test should be based on concerns about radiation exposure and increased projected cancer risk and not higher reported accuracy. For the premenopausal woman with functional disability, alternative tests, such as stress echocardiography or CMR, are encouraged; MPI may be considered when radiation exposure levels are ≤3 mSv.

8. Risk stratification is based on the extent and severity of inducible abnormalities noted on the stress examination. Moreover, evidence supports CMR and CCTA as being accurate in the detection of obstructive coronary artery disease (CAD) and for IHD risk assessment of symptomatic women, whereas these modalities were considered research techniques in 2005 (when these recommendations were last updated).

9. CCTA can uniquely provide information on the obstructive and nonobstructive burden of CAD, which may be reasonable to guide post-test management approaches for women.

10. Acquisition of additional comparative effectiveness evidence remains essential to further improve and guide testing and the treatment of women presenting with ischemic symptoms, and is an important aim for future research.