Department of Internal Medicine, Mayo College of Medicine, Rochester, MN 55905, USA.
Circ Cardiovasc Interv. 2009 Jun;2(3):237-44. doi: 10.1161/CIRCINTERVENTIONS.108.841056. Epub 2009 May 8.
Despite a nonobstructive coronary angiogram, many patients may still have an abnormal coronary vasomotor response to provocation and to myocardial demand during stress. The ability of noninvasive stress tests to predict coronary vasomotor dysfunction in patients with nonobstructive coronary artery disease is unknown.
All patients with nonobstructive coronary artery disease who had invasive coronary vasomotor assessment and a noninvasive stress test (exercise ECG, stress echocardiography, or stress nuclear imaging) within 6 months of the cardiac catheterization with provocation at our institution were identified (n=376). Coronary vasomotor dysfunction was defined as a percentage increase in coronary blood flow of <or=50% to intracoronary acetylcholine (endothelium-dependent dysfunction) and/or a coronary flow reserve ratio of <or=2.5 to intracoronary adenosine (endothelium-independent dysfunction). We determined the sensitivity and specificity of various noninvasive stress tests to predict coronary vasomotor dysfunction in these patients. On invasive testing, 233 patients (63%) had coronary vasomotor dysfunction, of which 187 patients (51%) had endothelium-dependent dysfunction, 109 patients (29%) had endothelium-independent dysfunction, and 63 patients (17%) had both. On noninvasive stress testing, 157 (42%) had a positive imaging study and 56 (15%) a positive ECG stress test. The noninvasive stress tests had limited diagnostic accuracy for predicting coronary vasomotor dysfunction (41% sensitivity [95% CI, 34 to 47] and 57% specificity [95% CI, 49 to 66]), endothelium-dependent dysfunction (41% sensitivity [95% CI, 34 to 49] and 58% specificity [95% CI, 50 to 65]), or endothelium-independent dysfunction (46% sensitivity [95% CI, 37 to 56] and 61% specificity [95% CI, 54 to 67]). The exercise ECG test was more specific but less sensitive than the imaging tests.
This study suggests that a negative noninvasive stress test does not rule out coronary vasomotor dysfunction in symptomatic patients with nonobstructive coronary artery disease. This underscores the need for invasive assessment or novel more sensitive noninvasive imaging for these patients.
尽管冠状动脉造影无阻塞，但许多患者在应激时仍可能存在异常的冠状动脉血管舒缩反应和心肌需求。非侵入性应激试验预测非阻塞性冠状动脉疾病患者冠状动脉血管舒缩功能障碍的能力尚不清楚。
本研究确定了在我院进行有创冠状动脉血管舒缩功能评估和非侵入性应激试验（运动心电图、应激超声心动图或应激核成像）后 6 个月内有创冠状动脉血管舒缩功能评估的所有非阻塞性冠状动脉疾病患者（n=376）。冠状动脉血管舒缩功能障碍定义为冠状动脉血流增加<或=50%至乙酰胆碱（内皮依赖性功能障碍）和/或冠状动脉血流储备比<或=2.5 至腺苷（内皮非依赖性功能障碍）。我们确定了各种非侵入性应激试验预测这些患者冠状动脉血管舒缩功能障碍的敏感性和特异性。在有创检查中，233 例患者（63%）存在冠状动脉血管舒缩功能障碍，其中 187 例（51%）存在内皮依赖性功能障碍，109 例（29%）存在内皮非依赖性功能障碍，63 例（17%）同时存在两种情况。在非侵入性应激试验中，157 例（42%）影像学检查阳性，56 例（15%）心电图应激试验阳性。非侵入性应激试验预测冠状动脉血管舒缩功能障碍的诊断准确性有限（41%的敏感性[95%CI，34 至 47]和 57%的特异性[95%CI，49 至 66]），内皮依赖性功能障碍（41%的敏感性[95%CI，34 至 49]和 58%的特异性[95%CI，50 至 65]）或内皮非依赖性功能障碍（46%的敏感性[95%CI，37 至 56]和 61%的特异性[95%CI，54 至 67]）。运动心电图检查比影像学检查更特异，但敏感性较低。
本研究表明，症状性非阻塞性冠状动脉疾病患者阴性非侵入性应激试验不能排除冠状动脉血管舒缩功能障碍。这突出表明这些患者需要进行有创评估或新型更敏感的非侵入性成像。
