Persistent Chest Pain in Absence of Angiographic Significant Coronary Artery Disease is Associated with Permanent Myocardial Perfusion Defects in Magnetic Resonance Imaging in Post-menopausal Women

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Abstract

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.

Disclosure
Maria Grazia Modena is a consultant for Fujifilm. She constantly contributes to the development of Synapse™ Cardiovascular - Fujifilm's cardiovascular image and information management system - within the EU market. This study is part of the ÔÇ£Progetto Strategico Salute della DonnaÔÇØ, sponsored by Istituto Superiore di Sanit├á, Rome, Italy. The other authors have no conflicts of interest to declare.
Correspondence
Maria Grazia Modena, Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Via del Pozzo, 71. 41100 Modena, Italy. E: mariagrazia.modena@unimore.it
Received date
02 February 2011
Accepted date
14 February 2011
Citation
European Cardiology - Volume 7 Issue 1;2011:7(1):21-24
Correspondence
Maria Grazia Modena, Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Via del Pozzo, 71. 41100 Modena, Italy. E: mariagrazia.modena@unimore.it

Pages

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.

Methods
Study Population

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.

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