Exercise intracoronary physiology using handgrip isometric exercise can unmask ischemia caused by myocardial bridging in patients with persistent post-PCI angina.
May aid diagnosis of myocardial bridge ischemia in persistent post-PCI angina; single case leaves open need for validation studies.
A 60-year-old gentleman presented with persistent angina 7 months after percutaneous coronary intervention to the proximal left anterior descending artery (LAD). Serial electrocardiographs and cardiac biomarkers were negative. Repeat coronary angiography revealed a patent stent with a myocardial bridge (MB) in the mid LAD (Panel A). A moderate ostial stenosis, with negative intracoronary physiology [normal instantaneous wave free ratio (iFR) and fractional flow reserve (FFR)] in the third diagonal. A Verrata pressure wire was advanced to the distal segment of the LAD (Panel B). An iFR of 0.86 was obtained (Panel D) and following administration of intravenous adenosine an FFR of 0.83 (Panel E). Handgrip isometric exercise was performed to assess the MB during increased inotropism (PanelsBi and Bii). Repeat FFR during exercise was positive 0.77 (Panel C). An iFR pullback revealed a pressure jump at the level of the MB (Panel F). A decision was made to optimize medical treatment, which improved symptoms. At follow up, the patient remains angina free.
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Ryan et al. (2016) studied this question.