Ischemia With No Obstructive Coronary Artery Disease

Figure 1. Case 1: Electrocardiograms at Attending Cardiologist’s Practice Upon the onset of chest pain, the electrocardiogram showed inverted T waves in lead III and alterations in aVF, highlighted in red (A), which rapidly reversed at cessation of symptoms (B).

Figure 2. Case 1: Basal Coronary Angiography and Coronary Functional Testing (A) Absence of obstructive coronary artery disease at coronary angiography. (B) Absence of functionally significant left anterior descending artery stenoses: RFR = 0.92 (n.v. >0.9), FFR = 0.91 (n.v. >0.8). Coronary functional testing, highlighted in red, was positive for microvascular dysfunction: CFR = 2.0 (n.v. >2.0), IMR = 34 (n.v. <25). CFR = coronary flow reserve; FFR = fractional flow reserve; IMR = index of microvascular resistance; n.v. = normal value; RFR = resting full-cycle ratio.

Figure 3. Case 2: Basal Coronary Angiography and Coronary Functional Testing (A) Absence of obstructive coronary artery disease at coronary angiography. (B) Absence of functionally severe left anterior descending artery stenoses: FFR = 0.81 (n.v. >0.8). Coronary functional testing, highlighted in red, was negative for microvascular dysfunction: CFR = 3.8 (n.v. >2.0), IMR = 18 (n.v. <25). CFR = coronary flow reserve; FFR = fractional flow reserve; IMR = index of microvascular resistance; n.v. = normal value.

Figure 4. Case 2: Vasoreactivity Test With Intracoronary Administration of Four Increasing Doses of Acetylcholine (2-20-100-200 μg) (A) Basal coronary angiography. (B) The intracoronary administration of 200 μg of acetylcholine induced significant epicardial spasm of the mid-distal segment of the left anterior descending artery, with concomitant occurrence of anginous symptoms and electrocardiographic alterations. (C) Epicardial spasm promptly regressed after intracoronary administration of nitroglycerin.

Figure 5. Case 2: ECG Alterations During Vasoreactivity Test (A) Basal electrocardiogram (ECG). (B) After intracoronary administration of acetylcholine, ECG showed transitory T-wave inversion in the anterolateral leads.

Figure 6. Case 3: Invasive Diagnostic Workup (A) Angiographic documentation of intermediate, diffused calcific stenosis of the left anterior descending (LAD) artery. (B) Functional assessment of the LAD lesion with pathological values of fractional flow reserve (FFR) (FFR = 0.71, n.v. >0.8). (C) Intravascular ultrasound showing pathological values of minimum lumen area on the proximal segment of the LAD artery (minimum lumen area = 3.82 mm 2). n.v. = normal value.

Figure 7. Case 3: Coronary Angiography Before and After LAD PCI (A) Basal coronary angiography. (B) Coronary angiography after left anterior descending artery (LAD) percutaneous coronary intervention (PCI) with implantation of 2 overlapping drug-eluting stents.