Cardiac Evaluation in Women with Dyspnea

Introduction to Cardiac Risk in Women

Women presenting with dyspnea are at substantial risk for missed cardiac diagnoses and should undergo systematic cardiac evaluation, as unexplained dyspnea alone carries more than twice the mortality risk of typical angina and increases sudden cardiac death risk 4-fold, according to the American College of Cardiology 1, 2
The American College of Cardiology recommends that healthcare providers maintain heightened suspicion for unstable angina/NSTEMI when evaluating women, particularly those with unexplained dyspnea, diabetes, older age, or history of heart failure or stroke 1, 2

Women of any age presenting with dyspnea should undergo cardiac evaluation, as recommended by the American College of Cardiology 1, 2
Patients with diabetes mellitus are at high risk and should be evaluated for cardiac disease, according to the American College of Cardiology 1, 2
Older patients presenting with dyspnea should be evaluated for cardiac disease, as recommended by the American College of Cardiology 1, 2
Those with unexplained dyspnea, even without angina, are at high risk and should undergo cardiac evaluation, according to the American College of Cardiology 1, 2
Patients with a history of heart failure or stroke should be evaluated for cardiac disease, as recommended by the American College of Cardiology 1, 2

Chest radiography and ECG are standard initial tests, but have limited sensitivity when used alone, according to the American College of Radiology 3, 4, 5
Transthoracic echocardiography (resting) is rated as "usually appropriate" and should be performed in all patients with dyspnea of suspected cardiac origin, as recommended by the American College of Radiology 3, 4, 5
BNP or NT-proBNP measurement should be obtained in all patients with acute dyspnea, and elevated levels warrant echocardiography, according to the American College of Cardiology 6, 7

Stress echocardiography is recommended for symptomatic women at intermediate-high risk with resting ST-segment abnormalities, functional disability, or indeterminate/intermediate-risk stress ECG, as recommended by the American Heart Association 8
Coronary CT angiography (CCTA) has emerged as a noninvasive alternative for determining presence, severity, and composition of coronary artery plaque, according to the American College of Radiology 3, 4, 5
Cardiac MRI with function and morphology assessment is rated as "usually appropriate" and should be considered in patients with suspected cardiac disease, as recommended by the American College of Radiology 4, 5

Never assume dyspnea without chest pain is non-cardiac, as this assumption leads to underdiagnosis and increased mortality in women, according to the American College of Cardiology 1, 2
Do not rely solely on telephone evaluation, and patients with symptoms suggesting ACS must be evaluated in person by a physician, as recommended by the American College of Cardiology 2
Avoid dismissing symptoms as anxiety, musculoskeletal pain, or other benign conditions without systematic cardiac evaluation, according to the American College of Cardiology 1, 2