May 9, 2009Open Access
Ver artículo completoLack of Correlation Between Noninvasive Stress Tests and Invasive Coronary Vasomotor Dysfunction in Patients With Nonobstructive Coronary Artery Disease
PICO estructurado
Does noninvasive stress testing predict invasive coronary vasomotor dysfunction in patients with nonobstructive coronary artery disease?
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Población
376 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 cardiac catheterization with provocation.
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Intervención
Noninvasive stress tests (exercise ECG, stress echocardiography, or stress nuclear imaging)
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Comparador
Invasive coronary vasomotor assessment (intracoronary acetylcholine and/or adenosine)
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Resultado
Diagnostic accuracy (sensitivity and specificity) of noninvasive stress tests to predict coronary vasomotor dysfunction (defined as percentage increase in coronary blood flow of <=50% to intracoronary acetylcholine and/or a coronary flow reserve ratio of <=2.5 to intracoronary adenosine)surrogate
A negative noninvasive stress test does not reliably rule out coronary vasomotor dysfunction in symptomatic patients with nonobstructive coronary artery disease, highlighting the need for invasive assessment.
Resumen
BACKGROUND: 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. METHODS AND RESULTS: 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. CONCLUSIONS: 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.