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Impact of Abnormal Coronary Reactivity on Long-Term Clinical Outcomes in Women
Ahmed AlBadri1, C Noel Bairey Merz2, B Delia Johnson3
1Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
Insights
Impaired microvascular function in women with suspected myocardial ischemia, even without obstructive coronary artery disease (CAD), predicts adverse cardiovascular outcomes. Evaluating coronary reactivity (CR) identifies high-risk individuals.
Area of Science:
- Cardiology
- Vascular Biology
- Women's Health
Background:
- Many women with suspected myocardial ischemia lack obstructive coronary artery disease (CAD).
- Abnormal coronary reactivity (CR) is frequently observed in these women.
Purpose of the Study:
- To investigate the relationship between CR and long-term adverse cardiovascular outcomes in women with and without obstructive CAD.
- To assess microvascular and epicardial CR in the context of cardiovascular events.
Main Methods:
- Prospective study of 224 women with ischemic symptoms undergoing CR testing.
- Measurement of coronary flow reserve and coronary blood flow for microvascular function.
- Assessment of epicardial CR via coronary dilation response to intracoronary acetylcholine and nitroglycerin.
- Clinical outcomes including mortality, major adverse cardiovascular events (MACE), and angina hospitalizations were tracked over 9.7 years.
Main Results:
- Low coronary flow reserve predicted increased MACE.
- Low coronary blood flow was associated with higher mortality and MACE risk.
- Decreased cross-sectional area in response to intracoronary acetylcholine predicted higher angina hospitalization risk.
- Epicardial nitroglycerin response showed no association with outcomes.
Conclusions:
- Impaired microvascular function is a predictor of adverse cardiovascular outcomes in women with ischemic symptoms, irrespective of obstructive CAD.
- Abnormal CR testing can identify women at higher risk for adverse events when significant CAD is absent.
Background:
Currently as many as one-half of women with suspected myocardial ischemia have no obstructive coronary artery disease (CAD), and abnormal coronary reactivity (CR) is commonly found.
Objectives:
The authors prospectively investigated CR and longer-term adverse cardiovascular outcomes in women with and with no obstructive CAD in the National Heart, Lung, and Blood Institute-sponsored WISE (Women's Ischemia Syndrome Evaluation) study.
Methods:
Women (n = 224) with signs and symptoms of ischemia underwent CR testing. Coronary flow reserve and coronary blood flow were obtained to test microvascular function, whereas epicardial CR was tested by coronary dilation response to intracoronary (IC) acetylcholine and IC nitroglycerin. All-cause mortality, major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, stroke, and heart failure), and angina hospitalizations served as clinical outcomes over a median follow-up of 9.7 years.
Results:
The authors identified 129 events during the follow-up period. Low coronary flow reserve was a predictor of increased MACE rate (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.01 to 1.12; p = 0.021), whereas low coronary blood flow was associated with increased risk of mortality (HR: 1.12; 95% CI: 1.01 to 1.24; p = 0.038) and MACE (HR: 1.11; 95% CI: 1.03 to 1.20; p = 0.006) after adjusting for cardiovascular risk factors. In addition, a decrease in cross-sectional area in response to IC acetylcholine was associated with higher hazard of angina hospitalization (HR: 1.05; 95% CI: 1.02 to 1.07; p < 0.0001). There was no association between epicardial IC-nitroglycerin dilation and outcomes.
Conclusions:
On longer-term follow-up, impaired microvascular function predicts adverse cardiovascular outcomes in women with signs and symptoms of ischemia. Evaluation of CR abnormality can identify those at higher risk of adverse outcomes in the absence of significant CAD. (Women's Ischemia Syndrome Evaluation [WISE]; NCT00000554).
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