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Non-obstructive coronary artery disease

ESC Congress 2010

Myocardial Disease

In this interesting Focus session, Prof. Maseri presented the case of a 53 year old woman with repeated episodes of epigastric pain without radiation occurring at rest, while effort tolerance was preserved. Coronary angiography showed normal coronary arteries. She was discharged on aspirin, calcium-antagonists, and beta-blockers. She remained symptom free for about a month. Then, during a very stressful period of her life, she began to present with angina during effort, sometimes on emotion. She insisted that the features of this new pain were completely different from those of the attacks leading to the previous hospital admission; indeed, this pain was located behind her upper sternum and radiated to the neck and ulnar side of the left arm.

Thus, this patient presented characteristic features of angina consistent with two distinct coronary ischemic mechanisms involving two separate regions of the ventricular wall. This conclusion was supported by the response to the provocative stressors dipyridamole and methylergometrine: microvascular dysfunction causing anterior wall ischemia in the absence of wall motional abnormalities (associated with upper sternal chest pain radiating to the left arm) revealed by dypiridamole and inferior wall ischemia caused by coronary spasm (associated with regional contractile dysfunction and the epigastric pain typically occurring spontaneously at rest) revealed by methylergometrine.

Prof. Kaski presented the case of a 66 year old woman with episodes of typical chest pain mainly during effort, which occasionally did not subsided promptly with the termination of exercise but lasted 5 to 15 minutes, with a poor response to nitroglycerine. Exercise stress test showed ST segment depression associated with her usual chest pain. Echo-dypiridamole stress test precipitated ST segment depression associated with chest pain, in the absence of regional wall motion abnormalities. Coronary angiography showed normal coronary arteries. Intracoronary injection of acetyl-choline caused diffuse coronary vasoconstriction, mainly of distal vessels, associated to ST segment depression associated with her usual chest pain.

Thus, the diagnosis was microvascular angina. Indeed, in this patient, myocardial ischemia was caused by coronary microvascular dysfunction. The patchy distribution and the limited transmural extension of the perfusion defects, determined by dysfunction of small resistance coronary artery vessels (<500 micron), may explain the absence of regional wall motion abnormalities in the presence of angina and ST segment depression caused by dypiridamole through the “steal” phenomenon. The patient was discharged on statins, ACE-inhibitors and calcium-antagonists with progressive improvement of her symptoms. A stress test carried out after few months was negative for symptoms and ECG changes.

Prof. Sechtem presented the case of a 26 year old man who presented to the hospital because of a prolonged episode of chest pain. On admission he was pain free, the ECG showed mild diffuse ST segment elevation, Troponin T was slightly elevated. Contrast-enhanced cardiac magnetic resonance was compatible with the diagnosis of myocarditis, suggested by subepicardial delayed enhancement. Coronary angiography carried out after a second episode of chest pain associated to T wave inversion, showed normal coronary arteries.

In this case also, intracoronary injection of acetyl-choline caused diffuse coronary vasoconstriction mainly of distal vessels, associated to ST segment depression associated with chest pain. A myocardial biopsy confirmed the diagnosis of myocarditis associated to the presence of parvovirus. Histology showed prearteriolar wall thickening. In this case, coronary microvascular dysfunction, probably caused by the endothelial localization of parvovirus, might be responsible for the anginal episodes complained of by the patient. He had an uneventful recovery in the absence of treatment.

The common denominator of the three clinical cases is angina with normal coronary arteries. This condition is not unusual. Indeed, about 10-20% of patients presenting with acute coronary syndrome and about 20-30% of patients presenting with stable angina and inducible myocardial ischemia, exhibit angiographically normal coronary arteries or non obstructive coronary atherosclerosis.

This Focus session clearly shows that before excluding a coronary origin of symptoms it is important to establish that symptoms are not caused by coronary spasm, microvascular angina or myocarditis. The choice of the most appropriate test depends on clinical reasoning: ergometrine test if coronary spasm is suspected; echo-dypiridamole stress test if microvascular angina is suspected; cardiac magnetic resonance if myocarditis is suspected.




Non-obstructive coronary artery disease
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.