Published Online
on May 8, 2009

A more recent version of this article appeared on June 1, 2009

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Original Article

Lack of Correlation between Non-Invasive Stress Tests and Invasive Coronary Vasomotor Dysfunction in Patients with Non-Obstructive Coronary Artery Disease

Andrew Cassar; Panithaya Chareonthaitawee; Charanjit S. Rihal; Abhiram Prasad; Ryan J. Lennon; Lilach O. Lerman and Amir Lerman¹

Mayo College of Medicine, Rochester, MN

¹ E-mail: lerman.amir{at}mayo.edu

Background—Despite a non-obstructive coronary angiogram, many patients may still have an abnormal coronary vasomotor response to provocation and to myocardial demand during stress. The ability of non-invasive stress tests to predict coronary vasomotor dysfunction in patients with non-obstructive coronary artery disease is unknown.

Methods and Results—All patients with non-obstructive coronary artery disease who had invasive coronary vasomotor assessment and a non-invasive 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 50% to intracoronary acetylcholine (endothelium-dependent dysfunction) and/or a coronary flow reserve ratio of 2.5 to intracoronary adenosine (endothelium-independent dysfunction). We determined the sensitivity and specificity of various non-invasive stress tests to predict coronary vasomotor dysfunction in these patients.

On invasive testing, 233 (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 non-invasive stress testing, 157 (42%) had a positive imaging study and 56 (15%) a positive ECG stress test. The non-invasive stress tests had limited diagnostic accuracy for predicting coronary vasomotor dysfunction (41% sensitivity [95%CI 34-47] and 57% specificity [95%CI 49-66]), endothelium-dependent dysfunction (41% sensitivity [95%CI 34-49] and 58% specificity [95%CI 50-65]) or endothelium-independent dysfunction (46% sensitivity [95%CI 37-56] and 61% specificity [95%CI 54-67]. The exercise ECG test was more specific but less sensitive than the imaging tests.

Conclusion—The current study suggests that a negative non-invasive stress test does not rule out coronary vasomotor dysfunction in symptomatic patients with non-obstructive coronary artery disease. This underscores the need for invasive assessment or novel more sensitive non-invasive imaging for these patients.

Key Words: coronary disease • microcirculation • Coronary vasomotor dysfunction • endothelial dysfunction • endothelium-dependent dysfunction • endothelium-independent dysfunction • stress test