Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California.
J Am Coll Cardiol. 2019 Feb 19;73(6):684-693. doi: 10.1016/j.jacc.2018.11.040.
Currently as many as one-half of women with suspected myocardial ischemia have no obstructive coronary artery disease (CAD), and abnormal coronary reactivity (CR) is commonly found.
The authors prospectively investigated CR and longer-term adverse cardiovascular outcomes in women with and with no obstructive CAD in the National Heart, Lung, and Blood Institute-sponsored WISE (Women's Ischemia Syndrome Evaluation) study.
Women (n = 224) with signs and symptoms of ischemia underwent CR testing. Coronary flow reserve and coronary blood flow were obtained to test microvascular function, whereas epicardial CR was tested by coronary dilation response to intracoronary (IC) acetylcholine and IC nitroglycerin. All-cause mortality, major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, stroke, and heart failure), and angina hospitalizations served as clinical outcomes over a median follow-up of 9.7 years.
The authors identified 129 events during the follow-up period. Low coronary flow reserve was a predictor of increased MACE rate (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.01 to 1.12; p = 0.021), whereas low coronary blood flow was associated with increased risk of mortality (HR: 1.12; 95% CI: 1.01 to 1.24; p = 0.038) and MACE (HR: 1.11; 95% CI: 1.03 to 1.20; p = 0.006) after adjusting for cardiovascular risk factors. In addition, a decrease in cross-sectional area in response to IC acetylcholine was associated with higher hazard of angina hospitalization (HR: 1.05; 95% CI: 1.02 to 1.07; p < 0.0001). There was no association between epicardial IC-nitroglycerin dilation and outcomes.
On longer-term follow-up, impaired microvascular function predicts adverse cardiovascular outcomes in women with signs and symptoms of ischemia. Evaluation of CR abnormality can identify those at higher risk of adverse outcomes in the absence of significant CAD. (Women's Ischemia Syndrome Evaluation [WISE]; NCT00000554).
目前，多达一半的疑似心肌缺血女性没有阻塞性冠状动脉疾病（CAD），并且通常会发现异常的冠状动脉反应性（CR）。
作者前瞻性研究了美国国立心肺血液研究所（National Heart, Lung, and Blood Institute）赞助的 WISE（女性缺血综合征评估）研究中患有和不患有阻塞性 CAD 的女性的 CR 以及更长期的不良心血管结局。
有缺血迹象和症状的女性（n=224）接受 CR 测试。获得冠状动脉血流储备和冠状动脉血流量以测试微血管功能，而通过冠状动脉内（IC）乙酰胆碱和 IC 硝酸甘油扩张反应测试心外膜 CR。全因死亡率、主要不良心血管事件（MACE）（心血管死亡、心肌梗死、卒中和心力衰竭）和心绞痛住院是中位数随访 9.7 年后的临床结局。
在随访期间，作者确定了 129 例事件。低冠状动脉血流储备是 MACE 发生率增加的预测因素（风险比[HR]：1.06；95%置信区间[CI]：1.01 至 1.12；p=0.021），而低冠状动脉血流与死亡率增加相关（HR：1.12；95%CI：1.01 至 1.24；p=0.038）和 MACE（HR：1.11；95%CI：1.03 至 1.20；p=0.006），调整了心血管危险因素后。此外，对 IC 乙酰胆碱的横截面面积减少与更高的心绞痛住院风险相关（HR：1.05；95%CI：1.02 至 1.07；p<0.0001）。心外膜 IC 硝酸甘油扩张与结局之间没有关联。
在更长的随访中，有缺血迹象和症状的女性微血管功能受损预示着不良心血管结局。CR 异常的评估可以识别在没有明显 CAD 的情况下发生不良结局风险较高的人群。（女性缺血综合征评估[WISE]；NCT00000554）。
