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. 2019 May 1:282:7-15.
doi: 10.1016/j.ijcard.2018.10.073. Epub 2018 Oct 23.

Accuracy of non-invasive stress testing in women and men with angina in the absence of obstructive coronary artery disease

Vedant S Pargaonkar  1 , Yuhei Kobayashi  1 , Takumi Kimura  1 , Ingela Schnittger  1 , Eric K H Chow  2 , Victor F Froelicher  1 , Ian S Rogers  1 , David P Lee  1 , William F Fearon  1 , Alan C Yeung  1 , Marcia L Stefanick  3 , Jennifer A Tremmel  4
Affiliations

Accuracy of non-invasive stress testing in women and men with angina in the absence of obstructive coronary artery disease

Vedant S Pargaonkar et al. Int J Cardiol. .

Abstract

Objective: While >20% of patients presenting to the cardiac catheterization laboratory with angina have no obstructive coronary artery disease (CAD), a majority (77%) have an occult coronary abnormality (endothelial dysfunction, microvascular dysfunction (MVD), and/or a myocardial bridge (MB)). There are little data regarding the ability of noninvasive stress testing to identify these occult abnormalities in patients with angina in the absence of obstructive CAD.

Methods: We retrospectively evaluated 155 patients (76.7% women) with angina and no obstructive CAD who underwent stress echocardiography and/or electrocardiography before angiography. We evaluated Duke treadmill score, heart rate recovery (HRR), metabolic equivalents, and blood pressure response. During angiography, patients underwent invasive testing for endothelial dysfunction (decrease in epicardial coronary artery diameter >20% after intracoronary acetylcholine), MVD (index of microcirculatory resistance ≥25), and intravascular ultrasound for the presence of an MB.

Results: Stress echocardiography and electrocardiography were positive in 58 (43.6%) and 57 (36.7%) patients, respectively. Endothelial dysfunction was present in 96 (64%), MVD in 32 (20.6%), and an MB in 83 (53.9%). On multivariable logistic regression, stress echo was not associated with any abnormality, while stress ECG was associated with endothelial dysfunction. An abnormal HRR was associated with endothelial dysfunction and MVD, but not an MB.

Conclusion: Conventional stress testing is insufficient for identifying occult coronary abnormalities that are frequently present in patients with angina in the absence of obstructive CAD. A normal stress test does not rule out a non-obstructive coronary etiology of angina, nor does it negate the need for comprehensive invasive testing.

Keywords: Angina; Coronary artery disease; Echocardiography; Electrocardiography.

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Figures

Figure 1.
Figure 1.. Demonstrative example of occult coronary abnormalities in patients with angina in the absence of obstructive CAD
(A) Coronary angiogram with diffuse vasoconstriction after 100 μg intracoronary acetylcholine demonstrating diffuse epicardial endothelial dysfunction. (B) Coronary physiology measurements demonstrating microvascular dysfunction with an IMR of 32.7. (C) Still frame of intravascular ultrasound (IVUS) inside a myocardial bridge. Arrows point to characteristic echolucent half-moon sign (halo), with a thickness of 0.45 mm.
Figure 2(A).
Figure 2(A).. Sensitivity, specificity, PPV, NPV of stress echo in identifying the presence of any abnormality, endothelial dysfunction, microvascular dysfunction, and myocardial bridge
CI = confidence interval, NPV = negative predictive value, PPV = positive predictive value
Figure 2(B).
Figure 2(B).. Sensitivity, specificity, PPV, NPV of stress ECG in identifying the presence of any abnormality, endothelial dysfunction, microvascular dysfunction, and myocardial bridge
CI = confidence interval, NPV = negative predictive value, PPV = positive predictive value
Figure 2(C).
Figure 2(C).. Sensitivity, specificity, PPV, NPV of comprehensive stress test in identifying the presence of any abnormality, endothelial dysfunction, microvascular dysfunction, and myocardial bridge
CI = confidence interval, NPV = negative predictive value, PPV = positive predictive value
See this image and copyright information in PMC

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