We studied a population of post-menopausal women with persistent chest pain (PChP) in order to investigate the relationship between myocardial perfusion at rest and during a stress test using magnetic resonance imaging (MRI). Our goals were to document whether transient myocardial perfusion is induced by dipyridamole infusion and if perfusion defects are also present at rest. The study population consisted of 45 consecutive women (mean age 57.6±8.7 years), who reported chest pain symptoms. PChP was defined as self-reported continuing chest pain after one year. We compared the results of the perfusion MRI studies in subgroups with and without obstructive coronary artery disease (CAD). The latest tools and technologies of Synapse™ Cardiovascular – Fujifilm's cardiovascular (CV) image and information management system – helped us to achieve clear and comprehensive outcomes. In the group of women with PChP and non-obstructive CAD, 16 of 34 (48%) showed a well-evident left ventricular perfusion defect at baseline (four in one segment; eight in two segments and four in three or more segments). The localisation of the perfusion defects – seen using Synapse Cardiovascular – were anteroapical (n=6); septal (n=10); and inferoor inferolateral (n=4). These defects were ‘permanent’ or ‘fixed’, i.e. were present at rest and were neither induced nor modified by the administration of dipyridamole. In any of the women with CAD we found these anomalies. ‘Fixed’ perfusion defects at MRI – probably due to permanent damage of the coronary microcirculation – suggest a disease state typical for post-menopausal women with PChP.
Support: The publication of this article was funded by Fujifilm Medical Systems.
Women with angina but no obstructive coronary artery disease (CAD) at coronary angiography have long been considered a low-risk population.1–3 Instead, data from the Women‘s ischaemia syndrome evaluation (WISE) study4 demonstrated that persistent chest pain (PChP) – also in the absence of CAD – is not a benign condition. These patients experienced major cardiovascular (CV) events, such as myocardial infarction and stroke at approximately double the rate found in women with neither PChP/CAD. However, the misinformation among physicians about these issues may keep women from receiving appropriate cardiac care.2,5 Coronary microcirculation abnormalities, defined as microvascular endothelium dysfunction, play a pathophysiological role in patients with angina and no significant coronary stenosis.6,7 In clinical practice, the presence of myocardial perfusion abnormalities can be highlighted as inducible, using magnetic resonance imaging (MRI).8,9 The above-cited study was conducted on populations with typical ST segment depression during an exercise stress test, in the absence of significant CAD (so-called ‘cardiac syndrome X’).10 In the present study, we included a population of post-menopausal women with PChP, referred for coronary angiography to further evaluate the basis for suspected ischaemia, in order to investigate the relationship between myocardial perfusion at rest and during a stress test, using MRI. Our goals were to document if transient myocardial perfusion are induced by dipyridamole infusion and if perfusion defects are also present at rest. The presence of delayed enhancement (DE) as an indicator of myocardial necrosis was also analysed during MRI study.
The study population consisted of 45 consecutive women (mean age 57.6±8.7 years) with PChP, according to the WISE study.11 These women reported at least one year of chest pain. One year was chosen because a persistent chest pain for this period is necessary for the diagnosis of PChP. All patients underwent clinical examination, electrocardiogram and echocardiogram at the first clinic. Within 15 days of the first clinical approach, all patients underwent coronary angiography and a perfusion CV MRI.
- Lichtlen PR, Bargheer K, Wenzlaff P, Long-term prognosis of patients with angina like chest pain and normal coronary angiographic findings, J Am Coll Cardiol, 1995;25:1013–8.
- Cannon RO III, Epstein SE, Microvascular angina as a cause of chest pain with angiographically normal coronary arteries. Am J Cardiol, 1988;61:1338–43.
- Ockene IS, Shay MJ, Alpert JS, et al., Unexplained chest pain in patients with normal coronary angiograms: a follow-up study of functional status, N Engl J Med, 1980;303:1249–52.
- Johnson BD, Shaw LJ, Pepine CJ, et al., Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBIsponsored Women‘s Ischaemia Syndrome Evaluation (WISE) study, Eur Heart J, 2006;27:1408–15.
- Bugiardini R, Bairey Merz CN, Angina with “normal” coronary artery disease: a changing philosophy, JAMA, 2005;293:477–84.
- Cannon RO III, Camici PG, Epstein SE, Pathophysiological dilemma of syndrome X, Circulation, 1992;85:883–92.
- Camici PG, Crea F, Coronary microvascular dysfunction, N Engl J Med, 2007;356:830–40.
- Panting JR, Gatehouse PD, Yang GZ, et al., Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging, N Engl J Med, 2002;346:1948–53.
- Lanza GA, Buffon A, Sestito A, et al., Relation between stress-induced myocardial perfusion defects on cardiovascular magnetic resonance and coronary microvascular dysfunction in patients with cardiac syndrome X, J Am Coll Cardiol, 2008;51:466–72.
- Crea F, Lanza GA, Angina pectoris and normal coronary arteries: cardiac syndrome X, Heart, 2004;90:457–63.
- Bairey Merz N, Bonow RO, Sopko G, et al., Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2–4, 2002: executive summary, Circulation, 2004;109:805–7.
- Schwitter J, Wacker CM, van Rossum AC, et al., MR IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial, Eur Heart J, 2008;29:480–9.
- Simonetti OP, Kim RJ, Fieno DS, An improved MR imaging technique for the visualization of myocardial infarction, Radiology, 2001;218:215–23.
- Mahrholdt H, Wagner A, Judd RM, Assessment of myocardial viability by cardiovascular magnetic resonance imaging, Eur Heart J, 2002;23:602–19.
- Dewey M, Laule M, Taupitz M, et al., Myocardial viability: assessment with three-dimensional MR imaging in pigs and patients, Radiology, 2006;239:703–9.
- Sicari R, Palinkas A, Pasanisi EG, et al., Long-term survival of patients with chest pain syndrome and angiographically normal or near-normal coronary arteries: the additional prognostic value of dipyridamole echocardiography test (DET), Eur Heart J, 2005;26:2136–41.
- Cannon RO, Epstein SE, “Microvascular angina” as a cause of chest pain with angiographically normal coronary arteries, Am J Cardiol, 1988;61:1338–43.
- Egashira K, Inou T, Hirooka Y, et al., Evidence of impaired endothelium-dependent coronary vasodilatation in patients with angina pectoris and normal coronary angiograms, N Engl J Med, 1993;328:1659–64.
- Bugiardini R, Manfrini O, Pizzi C, et al., Endothelial function predicts future development of coronary artery disease. A study on women with chest pain and normal angiograms, Circulation, 2004;109:2518–23.
- Beache GM, Herzka DA, Boxerman JL, et al., Attenuated myocardial vasodilator response in patients with hypertensive hypertrophy revealed by oxygenationdependent magnetic resonance imaging, Circulation, 2001;104:1214–7.
- Doyle M, Fuisz A, Kortright E, et al., The impact of myocardial flow reserve on the detection of coronary artery disease by perfusion imaging methods: an NHLBI WISE study, Cardiovasc Magn Reson, 2003;5:475–85.
- Scognamiglio R, Negut C, Ramondo A, et al., Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus, J Am Coll Cardiol, 2006;47:65–71.
- De Lorenzo A, Lima RS, Siqueira-Filho AG, Pantoja MR, Prevalence and prognostic value of perfusion defects detected by stress technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease, Am J Cardiol, 2002;90:827–32.