Myocardial Scar Is Prevalent and Associated With Subclinical Myocardial Dysfunction in Women With Suspected Ischemia But No Obstructive Coronary Artery Disease

Wei, Janet; Bakir, May; Darounian, Navid; Li, Quan‐Lin; Landes, Sofy; Mehta, Puja K.; Shufelt, Chrisandra; Handberg, Eileen M.; Kelsey, Sheryl F.; Sopko, George; Pepine, Carl J.; Petersen, John W.; Berman, Daniel S.; Thomson, Louise; Merz, C. Noel Bairey

doi:10.1161/circulationaha.117.031999

Cited by 26 publications

(12 citation statements)

References 5 publications

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“…24 We have also documented an almost 8% myocardial scar in CMD population, detected by cardiac MRI late gadolinium enhancement (LGE), and approximately 1% annual new LGE in women with CMD, the majority of whom do not have a clinical history of myocardial infarction. 25 Our finding of a high prevalence of ambulatory ischemia and specifically SI extends these findings and support further investigation into understanding mechanistic pathways in order to develop treatment targets. Recurrent episodes of ischemia have been demonstrated via biopsy to be associated with anatomic changes including myocardial cellular degeneration, increased fibrosis, and hypertrophy.…”

Section: Discussionsupporting

confidence: 76%

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

Roy

Aldiwani

Darouian

et al. 2020

International Journal of Cardiology

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Background: Up to two-thirds of patients with obstructive coronary artery disease (CAD) have silent ischemia (SI), which predicts an adverse prognosis and can be a treatment target in obstructive CAD. Over 50% of women with ischemia and no obstructive CAD have coronary microvascular dysfunction (CMD), which is associated with adverse cardiovascular outcomes. We aimed to investigate the prevalence of SI in CMD in order to consider it as a potential treatment target.Methods: 36 women with CMD by coronary reactivity testing and 16 age matched reference subjects underwent 24-hr 12-lead ambulatory ECG monitoring (Mortara Instruments) after antiischemia medication withdrawal. Ambulatory ECG recordings were reviewed by two-physician consensus masked to subject status for SI measured by evidence of ≥ 1 minute horizontal or downsloping ST segment depression ≥ 1.0 mm, measured 80 ms from the J point.Results: Demographics, resting heart rate, and systolic blood pressure were similar between CMD and reference subjects. Thirty-nine percent of CMD women had a total of 26 SI episodes vs. 0 episodes in the reference group (p=0.002). Among these women 13/14 (93%) had SI, and few episodes (3/26, 12%) were symptomatic. Mean HR at the onset of SI was 96±13 bpm and increased to 117±16 bpm during the ischemic episodes. 87% reported symptoms that were not associated with ST depressions.

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Section: Discussionsupporting

confidence: 76%

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

Roy

Aldiwani

Darouian

et al. 2020

International Journal of Cardiology

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“…The diagnostic challenge in these cases seems to be augmenting the potential therapeutic shortfalls for patients with MINOCA. Approximately one-third of all women with suspected ischemia and no obstructive CAD have late gadolinium enhancement, suggestive of myocardial scar ( 9 ). The absence of an evidence-based treatment may be another key factor contributing to the undertreatment of patients with MINOCA when compared with patients with obstructive CAD before and after angiography ( 10 ).…”

Section: Discussionmentioning

confidence: 99%

Myocardial Infarction and Persistent Angina With No Obstructive Coronary Artery Disease

et al. 2020

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Women with myocardial infarction with no obstructive coronary artery disease (MINOCA) are increasingly recognized. Women with MINOCA are at high risk for major adverse cardiovascular events. In this case, we focus on the importance of early identification and management of MINOCA to improve patients’ angina and related quality of life. ( Level of Difficulty: Beginner. )

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“…Occult myocardial infarction in patients with ANOCA may be clinically relevant. In a substudy of the WISE cohort, Wei et al 54 performed CMR imaging in 340 female patients with ANOCA. A total of 26 patients (8%) had hyperenhancement on LGE imaging, with 18 patients having evidence of occult myocardial infarction (mean scar size 5.1 g), and 8 patients had a non-ischaemic pattern (mean scar size 8.9 g).…”

Section: Discussionmentioning

confidence: 99%

Rationale and design of the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study

et al. 2018

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IntroductionAngina with no obstructive coronary artery disease (ANOCA) is a common syndrome with unmet clinical needs. Microvascular and vasospastic angina are relevant but may not be diagnosed without measuring coronary vascular function. The relationship between cardiovascular magnetic resonance (CMR)-derived myocardial blood flow (MBF) and reference invasive coronary function tests is uncertain. We hypothesise that multiparametric CMR assessment will be clinically useful in the ANOCA diagnostic pathway.Methods/analysisThe Stratified Medical Therapy Using Invasive Coronary Function Testing In Angina (CorMicA) trial is a prospective, blinded, randomised, sham-controlled study comparing two management approaches in patients with ANOCA. We aim to recruit consecutive patients with stable angina undergoing elective invasive coronary angiography. Eligible patients with ANOCA (n=150) will be randomised to invasive coronary artery function-guided diagnosis and treatment (intervention group) or not (control group). Based on these test results, patients will be stratified into disease endotypes: microvascular angina, vasospastic angina, mixed microvascular/vasospastic angina, obstructive epicardial coronary artery disease and non-cardiac chest pain. After randomisation in CorMicA, subjects will be invited to participate in the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) substudy. Patients will undergo multiparametric CMR and have assessments of MBF (using a novel pixel-wise fully quantitative method), left ventricular function and mass, and tissue characterisation (T1 mapping and late gadolinium enhancement imaging). Abnormalities of myocardial perfusion and associations between MBF and invasive coronary artery function tests will be assessed. The CorCMR substudy represents the largest cohort of ANOCA patients with paired multiparametric CMR and comprehensive invasive coronary vascular function tests.Ethics/disseminationThe CorMicA trial and CorCMR substudy have UK REC approval (ref.16/WS/0192).Trial registration number NCT03193294.

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Myocardial Scar Is Prevalent and Associated With Subclinical Myocardial Dysfunction in Women With Suspected Ischemia But No Obstructive Coronary Artery Disease

Cited by 26 publications

References 5 publications

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

Myocardial Infarction and Persistent Angina With No Obstructive Coronary Artery Disease

Rationale and design of the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study

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