Safety of Coronary Reactivity Testing in Women With No Obstructive Coronary Artery Disease

Abstract

Objective We evaluated the safety of coronary reactivity testing (CRT) in symptomatic women with evidence of myocardial ischemia and no obstructive coronary artery disease (CAD). Background Microvascular coronary dysfunction (MCD) in women with no obstructive CAD portends an adverse prognosis of 2.5% annual major adverse cardiovascular event (MACE) rate. The diagnosis of MCD is established by invasive CRT, yet the risk of CRT is unknown. Methods We evaluated 293 symptomatic women with ischemia and no obstructive CAD, who underwent CRT at three experienced centers. Microvascular function was assessed using a Doppler wire and injections of adenosine, acetylcholine, and nitroglycerin in the left coronary artery. CRT-related serious adverse events (SAE), adverse events (AE), and follow-up MACE (death, nonfatal myocardial infarction (MI), nonfatal stroke, or hospitalization for heart failure) were recorded. Results CRT-SAEs occurred in 2 women (0.7%) during the procedure: one had coronary artery dissection, and one developed MI associated with coronary spasm. CRT-AEs occurred in 2 women (0.7%) and included one transient air microembolism and one deep venous thrombosis. There was no CRT-related mortality. In the mean follow-up period of 5.4 years, the MACE rate was 8.2%, including 5 deaths (1.7%), 8 non-fatal MIs (2.7%), 8 nonfatal strokes (2.7%), and 11 hospitalizations for heart failure (3.8%). Conclusions In women undergoing CRT for suspected MCD, contemporary testing carries a relatively low risk compared to the MACE rate in these women. These results support the use of CRT by experienced operators for establishing definitive diagnosis and assessing prognosis in this at-risk population.

Cardiovascular Disease in Women

“…154, 155 An annual major adverse cardiovascular event rate of 2.5% is present in women with CMD and risk factors for CMD have not been fully elucidated. 156 CMD is characterized by a decrease in the size of epicardial vessels and microvasculature, diffuse atherosclerotic disease, increased arterial stiffness and fibrosis, altered remodeling, and the presence of endothelial or smooth muscle dysfunction. 157 The microcirculation cannot be investigated by angiogram, thus, several techniques for functional assessment, of coronary flow reserve (non-invasive and invasive) have evolved, however the gold standard is an invasive coronary reactivity test.…”

“…The WISE study highlighted the importance of CMD in women 141 and supported the use of invasive coronary vasomotor testing as a safe method for definitive diagnosis and assessment of prognosis in high-risk women. 156 Early detection of endothelial dysfunction, measured by brachial artery flow-mediated vasodilation, has also been associated with a substantial increase in IHD in women. 158 Additional simpler noninvasive techniques have emerged, with specially designed fingertip probes to measure the peripheral reactive hyperemia index, a measure thought to reflect endothelial function.…”

Prior myocardial infarction is associated with coronary endothelial dysfunction in women with signs and symptoms of ischemia and no obstructive coronary artery disease

“…The change in coronary diameter in response to high dose ACH was significantly different between the two groups (p = 0.013) (Table 2). There was no coronary artery spasm noted to highest dose of ACH in this protocol (36.4 µg) , with coronary artery spasm defined as >70% vasoconstriction (7). …”

“…Study was IRB approved and all participants gave written informed consent. Participants underwent clinically indicated CRT via a highly standardized protocol as previously published (7), with Doppler tipped guidewire (Flowire®,Volcano) placed in the left anterior descending coronary artery. Bolus injections of intracoronary adenosine (18 µg, 18 µg and 36 µg) were used to determine coronary flow reserve (CFR).…”

Cold Pressor Stress Cardiac Magnetic Resonance Myocardial Flow Reserve Is Not Useful for Detection of Coronary Endothelial Dysfunction in Women with Signs and Symptoms of Ischemia and No Obstructive CAD

“…[16] While CRT has been shown to be safe [16] it is time consuming and requires an experienced interventionist with advanced training to perform, and therefor is not routinely available. Studies have demonstrated that cardiac magnetic resonance imaging (CMRI) with myocardial perfusion imaging has been shown to be predictive of death, MI, hospitalization for worsening angina in women with CMD.…”