Current coronary angiographic techniques cannot image vessels smaller than 0. Figure 2. Magnetic resonance image with acetylcholine challenge in a patient with microvascular disease. The inner black area arrow is the area of ischemia. Because the coronary microvasculature controls total coronary resistance and therefore regulates myocardial blood flow, measuring myocardial blood flow at maximum vasodilation, termed coronary flow reserve , can indirectly evaluate the degree of microvascular dysfunction.
In terms of noninvasive imaging, perfusion magnetic resonance imaging Figure 2 or positron emission tomography is often performed. Coronary flow reserve can also be measured by invasive means in the catheterization laboratory after maximum hyperemia is induced by adenosine or other such vasodilatory agents. Proposed therapy for microvascular angina. Once a diagnosis has been made, lifestyle modification, antianginal agents, angiotensin-converting enzyme inhibitors, and statins have been suggested for therapy.
However, no therapy to date has proven overwhelmingly effective in these patients, and a disproportionate number of women suffer from chronic symptoms despite these treatments. Currently, researchers are looking for new agents to treat microvascular disease. Figure 3. A, diastole; B, systole. It is often associated with sudden emotional or physical stress. Patients present with signs and symptoms of myocardial infarction without demonstrable epicardial coronary artery disease. The hallmark of stress cardiomyopathy is left ventricular dysfunction, often severe, with classic apical ballooning that resembles a Japanese fishing pot takotsubo used to trap octopuses, hence the name Figure 3.
According to a review by Akashi et al 42 based on previously reported Mayo Clinic criteria, the diagnosis of stress cardiomyopathy includes each of the following:. Studies have implicated estrogen deficiency, as it appears to attenuate the levels of cardioprotective substances in the body that in part regulate catecholamine surges and may also increase the level of oxidative stress.
Several mechanisms for this condition have been proposed. The condition may be caused by multivessel epicardial coronary spasm or spontaneously resolved plaque rupture, resulting in stunned myocardium. However, the regional distribution of wall-motion abnormality is often out of proportion to the level of cardiac enzyme elevation, and in the case of plaque rupture, is frequently not consistent with a single coronary vessel.
Outcomes and Management of Women with Microvascular Angina and Microvascular Coronary Dysfunction
However, it is difficult to establish a causal relationship, since apical ballooning could result in microvascular dysfunction. Treatment of stress cardiomyopathy has not been standardized, in part because the left ventricular dysfunction often resolves spontaneously within several weeks. However, this continues to be a matter of debate.
There is also no clear indication for other standard therapies for acute coronary syndrome such as aspirin and heparin, and their use appears to vary in clinical practice. Although most patients improve with time and recurrence is exceedingly rare, it should be emphasized that they may present acutely with severe hemodynamic instability and cardiogenic shock. Therefore, advanced means of support, such as an intra-aortic balloon pump, may be indicated until the patient recovers from the acute phase of the disease.
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Skip to main content. Addressing Disparities in Health Care. Cardiovascular disease in women: Prevention, symptoms, diagnosis, pathogenesis. Cleveland Clinic Journal of Medicine. The main limitations of PET are limited availability and increased cost. Quantitative CMR perfusion measurements correlate well with fractional flow reserve measurements of hemodynamically significant coronary stenoses Limitations pertain mainly to high cost, limited availability and expertise, and limited functional analysis in the presence of arrhythmias.
Diagnostic accuracy appears to be similarly high among women Strict patient selection is crucial for satisfactory image quality and diagnostic accuracy.
A 'diamond' approach to personalized treatment of angina
A major advantage of coronary CTA in appropriately selected patients is the very high negative predictive value that can reassure physicians to safely defer performance of ICA. Disadvantages of the method include relatively limited yet growing availability, high radiation, and reduced image quality in the presence of arrhythmias or elevated heart rate. As outlined above, available non-invasive modalities for diagnosis of SCAD differ distinctly in terms of diagnostic accuracies, predictive values, and costs.
In patients with clinically suspected SCAD, three key question need to be answered to determine patient suitability for non-invasive testing, type of stress exercise vs. Non-invasive testing is not recommended in patients who are deemed eligible for direct referral for ICA or unsuitable for specific cardiac testing Figure 1. When functional stress imaging is chosen, selection of the exact modality for a given patient is based on specific characteristics that may adversely affect the performance or interpretability of a test.
Basic principles regarding suitability of certain patient groups for certain testing modes are summarised below. It is important to remember, however, that for many patients there may not be a single appropriate test, but rather more than 1 or even all tests may be reasonably well suited.
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In the latter case, physician judgment and available local expertise should determine the correct test for an individual patient The value of non-invasive anatomic evaluation of CAD as an alternative to functional testing is also emphasised if certain strict prerequisites are met. In individuals with clinically suspected SCAD, possible strategies for initial diagnosis may range from no specific testing to non-invasive cardiac testing to direct referral for ICA. Non-invasive testing to establish diagnosis of SCAD is appropriate for patient with an intermediate pre-test probability of disease.
Appropriate selection of the exact non-invasive modality that is most suitable for a given patient is based on clinical characteristics in combination with local resources and specific features of different testing modalities.
Table 1. Clinical pre-test probabilities of SCAD in patients with stable chest pain symptoms. Adapted from 1. Women with Typical Angina. Men with Atypical Angina. Montalescot G, et al. Eur Heart J.
Am J Cardiol. J Nucl Cardiol. A multicenter experience. J Am Coll Cardiol.
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Nucl Med Commun. Lancet ; Eur Heart J ; 34 10 J Am Coll Cardiol ; Salerno M, Beller GA. Circ Cardiovasc Imaging. Wolk MJ, et al. Address for correspondence: Konstantinos C. Other ressources : View here the guideline track on stable coronary artery disease. All rights reserved. Did you know that your browser is out of date?
Appropriate use of non-invasive testing for diagnosis of stable coronary artery
To get the best experience using our website we recommend that you upgrade to a newer version. Learn more. Sign in to My ESC. ESC sub specialties communities. Associations Working Groups Councils. Read your latest personalised notifications Sign in No account yet? Don't miss out Read your latest personalised notifications Ok, got it. Loading quicklinks Appropriate use of non-invasive testing for diagnosis of stable coronary artery disease An article from the e-journal of the ESC Council for Cardiology Practice Vol.
Konstantinos C. Koskinas , FESC. Topic s : Coronary Artery Disease Chronic. Strong clinical evidence of SCAD with comorbidities and quality of life making revascularisation an unlikely option call for limited testing and initiation of medical therapy as part of a conservative approach - even if the diagnosis has not been confirmed by specific testing.