Brief Communications Left Ventricular Dysfunction Secondary to Ischemia in Women With Angina and Normal Coronary Angiogram. Five Years Follow-Up

Introduction: To assess if myocardial ischemia evidenced through both perfusion abnormalities and post-stress left ventricular ejection fraction reduction by gated single photon emission tomography (SPECT) myocardial scintigraphy in women with angina and normal coronary angiograms, as well as the presence of endothelial dysfunction, can predict cardiac events during a medium term follow-up. Methods: Thirty-two postmenopausal women (mean age: 58 ± 8 years) with angina and normal coronary epicardial arteries were included. Each underwent technetium-99m methoxyisobutylisonitrile gated-SPECT myocardial scintigraphy (2-day protocol: exercise stress – rest), and brachial artery endothelial function measured by ultrasonography. All patients were followed during 5 years. Cardiac death and acute coronary syndromes (ACS) were considered as end points. Results: The most prevalent risk factors were high blood pressure (66% of patients), smoking habit (47%), and obesity (38%). Fortyfour percent of patients experienced angina both during stress and at rest. In thirteen cases (41%), the gated-SPECT was abnormal (small to moderate reversible perfusion defects and post-stress LVEF reduction ≥5%); while in 19 (59%) was normal. Fourteen patients (44%) showed a brachial artery vasodilator responsiveness after 5 minutes of ischemia lower than 5%, which in 8 cases coincided with the presence of an abnormal gated-SPECT. There were one cardiac death and five ACS. Seventy-nine percent of patients with normal scintigraphy, and 84% of those with abnormal scintigraphy were free of cardiac events at five years; while 78% of patients with normal brachial vasodilatory response, and 85% of those with an abnormal response were free of cardiac events. Conclusions: The presence of myocardial ischemia evidenced by gated-SPECT, as well as endothelial dysfunction, are not suggestive of a worse prognosis at medium term in postmenopausal women with angina and normal coronary angiograms. Introduction In patients who have typical exertional angina and a positive electrocardiographic (ECG) exercise stress test without significant coronary stenosis (syndrome X), [1] coronary microcirculation abnormalities have been shown to play a pathophysiological role [2-4]. At least half the patients diagnosed with cardiac syndrome X have some microvascular coronary dysfunction [5]. Data from the National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation (WISE) study have shown a 2.5% annual risk of adverse cardiac events, including death, myocardial infarction, stroke, and congestive heart failure in subjects with microvascular coronary dysfunction [5,6]. Gulati et al [7] have found a five-year annualized event rate for cardiovascular events of 7.9% among women with normal epicardial coronary arteries. A few studies performed with isotopic techniques have shown a decrease in the left ventricular ejection fraction (LVEF) during exercise in approximately 30% of patients with syndrome X [8,9]. We have found that stress-induced ischemia is associated with post-stress LVEF reduction as a probable manifestation of myocardial stunning (persistent contractile dysfunction despite reperfusion after ischemia) in postmenopausal women with typical angina and normal coronary angiography [10,11]. Nonetheless, to our knowledge, there are no data so far regarding the prognostic value of gated-single photon emission tomography (SPECT) myocardial perfusion imaging (MPI) in postmenopausal women with angina and nonobstructive coronary artery disease. Objectives To investigate if myocardial ischemia evidenced through both perfusion abnormalities and post-stress LVEF reduction by gated-SPECT MPI in women with angina and normal coronary angiograms, as well as the presence of endothelial dysfunction, can predict cardiac events at a medium term follow-up (FU). Material and Methods We included 32 postmenopausal female patients (mean age: 58 ± 8 years) with typical angina and without previous myocardial infarction (MI), selected on the basis of having had a coronary angiogram (performed between May 2004 and December 2005), which disclosed no evidence of coronary artery disease, defined as no angiographic luminal irregularities. Patients were excluded if they had a history of estrogen replacement therapy. 7mo. Congreso Virtual de Cardiología 7th. Virtual Congress of Cardiology