Can myocardial perfusion imaging predict outcome in patients with angina and ischemia but no obstructive coronary artery
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Department of Nuclear Cardiology, Assuta Medical Center, Tel Aviv, Israel Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel Department of Cardiology, Barzilai Medical Center, Ashkelon, Israel
Received Aug 11, 2020; accepted Aug 11, 2020 doi:10.1007/s12350-020-02338-3
See related article, https://doi.org/10.10 07/s12350-020-02252-8.
Stable angina is a characteristic symptom of ischemic heart disease, related to demand/supply imbalance of myocardial blood flow (MBF). Obstructive coronary artery disease (CAD), commonly defined as C 50% diameter stenosis of at least one major coronary artery as seen at coronary angiography, is frequently the underlying anatomical feature associated with angina. However, up to 40% of coronary angiograms performed in patients with angina or documented ischemia are reported as non-obstructive CAD or normal.1 Patients presenting with chest pain and ischemia but no obstructive coronary artery disease (INOCA) are increasingly seen due to improved imaging methods for detection of ischemia, and increased availability of either invasive or CT-based coronary angiography. The American College of Cardiology-National Cardiovascular Data Registry and the Women’s Ischemic Syndrome Evaluation (WISE) databases suggest that 3-4 million women and men with chest pain or ischemia have no obstructive CAD.2 It has been recognized that this patient population have higher morbidity, impaired quality of life, and poorer outcome with repeat hospitalizations due to angina and heart failure, and repeated
Reprint requests: Tali Sharir, MD, Department of Nuclear Cardiology, Assuta Medical Center, 96 Igal Alon, C Building, 67891 Tel Aviv, Israel; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
non-invasive testing and angiography procedures.2-5 Yet, due to under-diagnosis, these patients often fall between the cracks. INOCA consists of heterogenic patient population, and represents a diagnostic and therapeutic challenge, since the etiologies and mechanisms associated with this entity are multifactorial.6 Coronary microvascular disease (CMD) is a possible underlying mechanism responsible for INOCA, typically defined as impaired vasodilatation of arterioles (500 micron in diameter), not visualized at coronary angiography, leading to an inadequate increase in blood flow from rest to stress, and has been shown to co-exist with myocardial diseases and obstructive CAD. However, it often exists in the absence of structural or inflammatory cardiac disease. Historically, the only practical methods available for the assessment of CMD have been invasive, such as intracoronary Doppler flow wire or thermodilution, evaluating coronary reactivity to adenosine.7 However, invasive assessment of coronary function is rarely carried out as a routine procedure. The advent of noninvasive techniques such as positron-emission tomography (PET) and cardiac magnetic-resonance (CMR) increase the feasibility of diagnosing reduced myocardial flow reser
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