Prevalence and disease features of myocardial ischemia with non-obstructive coronary arteries: Insights from a dynamic CT myocardial perfusion imaging study
Introduction
Obstructive coronary artery disease (CAD) is the major cause for angina pectoris and ischemic heart disease (IHD) [1]. Detection of hemodynamically significant coronary stenosis is of clinical importance to guide proper treatment strategy, such as optimal medical therapy or revascularization [2]. However, myocardial ischemia in the absence of obstructive coronary stenosis can also be encountered in clinical practice and known as ischemia with non-obstructive coronary arteries (INOCA) [3].
Similar to IHD caused by coronary stenosis, INOCA is not a benign entity and has been reported to be associated with unfavorable prognosis if misdiagnosed or not properly treated [[3], [4], [5]]. Precise evaluation of coronary anatomy as well as myocardial perfusion is fundamental for accurate diagnosis of INOCA [6]. CT myocardial perfusion imaging (CT-MPI) combined with coronary computed tomography angiography (CCTA) has been recognized as an ideal one-stop shop imaging modality and may be helpful for detection of INOCA [7]. Moreover, with the latest technical development, dynamic CT-MPI is able to quantitatively assess myocardial blood flow (MBF) at low radiation exposure [[8], [9], [10], [11], [12]]. We hypothesized that dynamic CT-MPI was not only useful for diagnosing INOCA but also could reflect the disease features, such as ischemic severity and presence of high-risk plaque (HRP), as well. Therefore, the current study aimed to investigate the prevalence and disease features of INOCA in patients with suspected chronic coronary syndrome as revealed by dynamic CT-MPI.
Section snippets
Patient population
The hospital ethics committee approved this retrospective study and informed consent was waived in all patients. Patients with suspected chronic coronary syndrome and intermediate to high pre-test probability of obstructive CAD (according to updated Diamond and Forrester Chest Pain Prediction Rule) were referred for dynamic CT-MPI + CCTA and retrospectively included. All image data of these patients were reviewed and included from two tertiary hospitals. The exclusion criteria were: 1) patients
Clinical characteristics
A total of 503 patients with dynamic CT-MPI + CCTA were retrospectively reviewed. One hundred and eighty-nine patients were excluded due to various reasons of exclusion (details shown in Online Supplement Fig. E2). Of these 189 patients, 12 patients were excluded due to uninterpretable image quality of CCTA, which was caused by breathing artifact (5 cases) or arrythmia related artifact (7 cases). Finally, a total of 314 patients were included in the analysis. Detailed demographic data are
Discussion
The major finding of the current study is that the overall prevalence of INOCA was low (6.4%) in patients with suspected chronic coronary syndrome and intermediate to high pre-test probability of obstructive CAD. In addition, HRPs were less frequently presented in patients with INOCA, compared with patients having obstructive coronary stenosis.
INOCA is primarily driven by the presence of microvascular dysfunction or coronary artery spasm, which are not uncommonly encountered in clinical
Disclosures
None.
Funding sources
This study is supported by Medical Guidance Scientific Research Support Project of Shanghai Science and Technology Commission (Grant No.: 19411965100), Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant Support (Grant No.: 20161428).
Conflicts of interest
There are no conflicts of interest.
References (24)
- et al.
Insights from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) study: part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease
J. Am. Coll. Cardiol.
(2006) - et al.
Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome
J. Am. Coll. Cardiol.
(2009) - et al.
Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality
J. Am. Coll. Cardiol.
(2007) - et al.
Cardiac-specific conversion factors to estimate radiation effective dose from dose-length product in computed tomography
JACC Cardiovasc. Imaging
(2018 Jan) Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015
Lancet
(2016)- et al.
ESC guidelines for the diagnosis and management of chronic coronary syndromes: the Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC)
Eur. Heart J.
(2019) - et al.
Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events
Eur. Heart J.
(2012) - et al.
Determinants of long-term clinical outcomes in patients with angina but without obstructive coronary artery disease: a systematic review and meta-analysis
Eur. Heart J.
(2018) - et al.
An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with european society of cardiology working group on coronary pathophysiology & microcirculation endorsed by coronary vasomotor disorders international study group
Eur. Heart J.
(2020) - et al.
Ischemia and No Obstructive Stenosis (INOCA) at CT angiography, CT myocardial perfusion, invasive coronary angiography, and SPECT: the CORE320 study
Radiology.
(2020)
Clinical outcomes of dynamic computed tomography myocardial perfusion imaging combined with coronary computed tomography angiography versus coronary computed tomography angiography-guided strategy
Circ. Cardiovasc. Imaging.
Detection of hemodynamically significant coronary stenosis: CT myocardial perfusion versus machine learning CT fractional flow reserve
Radiology
Cited by (10)
Prognostic value of coronary CT angiography and CT myocardial perfusion imaging among patients with and without Diabetes
2023, European Journal of RadiologyRole of coronary computed tomography angiography (CTA) post the ISCHEMIA trial: Precision prevention based on coronary CTA-derived coronary atherosclerosis
2022, Journal of CardiologyCitation Excerpt :In a study of 314 patients with intermediate-to-high pretest probability of CAD who underwent coronary CTA and dynamic computed tomography (CT) myocardial perfusion imaging (CT-MPI) [29], INOCA patients showed a higher prevalence of positive remodeling on coronary CTA and dynamic CT-MPI compared to patients with normal/near-normal findings, whereas other high-risk plaque (HRP) features, i.e. spotty calcification, napkin-ring sign, and low-attenuation, did not differ between the two groups. Additionally, patients with obstructive CAD were more likely to have these HRP features than those with normal or near-normal findings and INOCA [29]. Similarly, the Combined Non-invasive Coronary Angiography and Myocardial Perfusion Imaging Using 320 Detector Computed Tomography (Core320) study with approximately 10% INOCA patients, as confirmed by coronary CTA/CT perfusion (8%) or ICA/SPECT (12%) [30] showed that patients with INOCA had more pronounced positive remodeling than those with non-obstructive CAD and no ischemia, as identified by CT perfusion.
Microvascular Myocardial Ischemia in Patients With Diabetes Without Obstructive Coronary Stenosis and Its Association With Angina
2023, Korean Journal of RadiologyTake advantage of myocardial perfusion imaging to promote image diagnosis and clinical research of ischemia with non‑obstructive coronary arteries
2023, Chinese Journal of Radiology (China)
- 1
Dr. Yi Xu and Dr. Lihua Yu contributed equally to this study.