Diastolic Dysfunction in Women With Signs and Symptoms of Ischemia in the Absence of Obstructive Coronary Artery Disease

Abstract

Background Angina, in the absence of obstructive CAD is more common in women, is associated with adverse cardiovascular morbidity and mortality, and is a major burden to the healthcare system. While advancements have been made to understand the mechanistic underpinning of this disease, the functional consequence remains unclear. Methods and Results Cardiac magnetic resonance imaging was performed to assess left ventricular (LV) function in 20 women with signs and symptoms of ischemia, but no obstructive CAD (cases), and 15 age and body mass index-matched reference controls. Functional imaging included standard cinematic imaging to assess LV morphology and global function, along with tissue tagging to assess LV tissue deformation. Systolic function was preserved in both cases and controls, with no differences in ejection fraction (mean ± SE: 63.1 ± 8% vs. 65 ± 2%), circumferential strain (−20.7±0.6 vs. −21.9±0.5%) or systolic circumferential strain rate (−105.9±6.1 vs. −109.0±3.8%/s), respectively. In contrast, we observed significant differences between cases and controls in diastolic function, as demonstrated by reductions in both diastolic circumferential strain rate (153.8 ± 8.9 vs. 191.4 ± 8.9 %/s, P < 0.05) and the peak rate of left ventricular untwisting (−99.4 ± 8.0 vs. −129.4 ± 12.8 °/s, P < 0.05), respectively. Conclusions Diastolic function is impaired in women with signs and symptoms of ischemia in the absence of CAD, as assessed by cardiac magnetic resonance tissue tagging. These results are hypothesis generating—larger studies are needed in order to define the exact mechanism(s) responsible, and to establish viable treatment strategies.

Impact of age and sex on left ventricular function determined by coronary computed tomographic angiography: results from the prospective multicentre CONFIRM study

“…48 Further, abnormalities in diastolic function have recently been observed in a CMR study in women with non-obstructive CAD and symptoms of ischaemia. 49 However, in accordance with our data, in this recent CMR study, LVEF and LV volumes were similar between patients with non-obstructive CAD and normal coronary arteries, and given the high prevalence of non-obstructive CAD in the elderly population, applying very rigorous exclusion criteria may have led to a reference population that represents a 'too healthy' part of the population. Thus, we believe that the inclusion and exclusion criteria in this study represent a reasonable balance in order to have a relevant reference population reflecting the real word for establishing normal limits.…”

Diastolic Dysfunction in Patients With Ischemic Symptoms Without Obstructive Coronary Artery Disease

“…the study by Nelson et al, 11 which would tend to refute the notion that ischemia was the direct cause of diastolic dysfunction; this may relate to the small sample size. Also, the authors did not mention the possible presence of greater relative ischemia in the subendocardial region, which, if present, may have been partially obscured by the use of total wall thickness measurements in the determination of MPRI (although the frequent presence of dark rim artifacts in this region can make analysis difficult).…”

“…In this issue of Circulation: Cardiovascular Imaging, Nelson et al 11 report the use of cardiac MRI (CMR) to evaluate diastolic function in 20 women with ischemic symptoms and preserved left ventricular ejection fraction and without obstructive CAD or history of advanced heart failure. CMR-derived measurements of systolic and diastolic function were compared between these patients and 15 healthy women matched for age and body size.…”

“…CMR-derived measurements of systolic and diastolic function were compared between these patients and 15 healthy women matched for age and body size. 11 The authors identified multiple abnormalities in diastolic function using tissue tagging analysis, a CMR technique that provides quantitative assessment of myocardial deformation throughout the cardiac cycle. 12 Specifically, patients had lower diastolic circumferential strain rate, lower peak rate of left ventricular untwisting, and longer time to peak filling rate and peak ventricular untwisting rate, as well as a trend toward longer time to peak diastolic circumferential strain rate.…”

Detection of non-obstructive coronary artery disease: Is post-stress diastolic dysfunction assessed by myocardial perfusion imaging a useful tool?

“…7 Distal embolization with non-obstructive stenosis has been raised in women. 8 Coronary reactivity dysfunction seems to be common in non-obstructive CAD and may also be considered. 9 Endothelial dysfunction results in a lack of response to factors of arterial dilatation, especially nitric oxide (NO).…”