Reduced Survival in Patients with “Coronary Microvascular Disease”

Abstract

The syndrome of chest pain, abnormal stress test, and nonflow limiting coronary artery disease (CAD) is common and is attributed to coronary microvascular disease (µVD). It is associated with increased hospital admissions and health care costs. But its impact on long-term survival is not known. Of the 9941 consecutive patients who had an exercise stress test for evaluation of chest pain between May 1991 and July 2007, 935 had both a positive stress test and a coronary angiogram within 1 year of their stress test forming the study cohort. Significant angiographic CAD defined as ≥70% stenosis of an epicardial coronary artery or ≥50% stenosis of the left main coronary artery was present in 324 patients. Rest (n = 611) were considered to have coronary µVD. Compared with patients with significant epicardial CAD, patients with coronary µVD were younger (63 ± 11 vs. 65 ± 10 years, p = 0.002), and had lower left ventricular wall thickness (p < 0.02), systolic blood pressure (BP; p = 0.002), pulse pressure (0.0008), systolic BP with exercise (p = 0.0001), and pulse pressure with exercise (p < 0.0001). Those with coronary µVD had a better survival compared with those with significant epicardial CAD, but worse than that expected for age- and gender-matched population (p < 0.0001). Coronary µVD as a cause of chest pain and positive stress test is common. All-cause mortality in patients with coronary µVD is worse than in an age- and gender-matched population control, but better than those with significant epicardial CAD.

Keywords

chest pain - coronary artery disease - microvascular disease - survival - prognosis

• References

• 1 Crea F, Lanza GA. Angina pectoris and normal coronary arteries: cardiac syndrome X. Heart 2004; 90 (4) 457-463
• 2 Lanza GA, Buffon A, Sestito A , et al. Relation between stress-induced myocardial perfusion defects on cardiovascular magnetic resonance and coronary microvascular dysfunction in patients with cardiac syndrome X. J Am Coll Cardiol 2008; 51 (4) 466-472
• 3 Cannon III RO, Camici PG, Epstein SE. Pathophysiological dilemma of syndrome X. Circulation 1992; 85 (3) 883-892
• 4 el-Tamimi H, Davies GJ, Sritara P, Hackett D, Crea F, Maseri A. Inappropriate constriction of small coronary vessels as a possible cause of a positive exercise test early after successful coronary angioplasty. Circulation 1991; 84 (6) 2307-2312
• 5 Kaski JC. Pathophysiology and management of patients with chest pain and normal coronary arteriograms (cardiac syndrome X). Circulation 2004; 109 (5) 568-572
• 6 von Mering GO, Arant CB, Wessel TR , et al; National Heart, Lung, and Blood Institute. Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004; 109 (6) 722-725
• 7 Suwaidi JA, Hamasaki S, Higano ST, Nishimura RA, Holmes Jr DR, Lerman A. Long-term follow-up of patients with mild coronary artery disease and endothelial dysfunction. Circulation 2000; 101 (9) 948-954
• 8 Pepine CJ, Anderson RD, Sharaf BL , et al. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 2010; 55 (25) 2825-2832
• 9 From AM, Kane G, Bruce C, Pellikka PA, Scott C, McCully RB. Characteristics and outcomes of patients with abnormal stress echocardiograms and angiographically mild coronary artery disease (<50% stenoses) or normal coronary arteries. J Am Soc Echocardiogr 2010; 23 (2) 207-214
• 10 Kaski JC, Rosano GM, Collins P, Nihoyannopoulos P, Maseri A, Poole-Wilson PA. Cardiac syndrome X: clinical characteristics and left ventricular function. Long-term follow-up study. J Am Coll Cardiol 1995; 25 (4) 807-814
• 11 Bugiardini R. Women, 'non-specific' chest pain, and normal or near-normal coronary angiograms are not synonymous with favourable outcome. Eur Heart J 2006; 27 (12) 1387-1389
• 12 Johnson BD, Shaw LJ, Pepine CJ , et al. Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women's Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 2006; 27 (12) 1408-1415
• 13 Schächinger V, Britten MB, Zeiher AM. Prognostic impact of coronary vasodilator dysfunction on adverse long-term outcome of coronary heart disease. Circulation 2000; 101 (16) 1899-1906
• 14 Buchthal SD, den Hollander JA, Merz CN , et al. Abnormal myocardial phosphorus-31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angiograms. N Engl J Med 2000; 342 (12) 829-835
• 15 Lang RM, Bierig M, Devereux RB , et al; Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18 (12) 1440-1463