Microvascular angina in an unexpected scenario

    Authors

    Keywords

    coronary artery disease, stress testing, microvascular dysfunction

    DOI

    https://doi.org/10.15836/ccar2024.387

    Full Text

    **Introduction**: Ischemic heart disease can be caused by coronary artery stenosis, dysfunction, or both. Most of the coronary vessels are located inside the myocardium and hence unavailable to direct angiographical visualization. Patients with stable microvascular disease are typically female, obese, hypertensive and have positive stress testing results with unremarkable stenoses on coronarography. (1-3) **Case report**: 45-year-old male, with positive family history, was admitted because of typical intermittent chest pain. The laboratory investigations confirmed dyslipidemia. Echocardiography documented normal sized chambers, with preserved left ventricular systolic function (both ejection fraction and global strain) and right ventricular longitudinal function. There were no signs of hypertrophy or valve disease. Treadmill exercise stress test showed significantly positive results: 4 millimeters ST-segment depression in anteroseptolateral ECG leads (**Figures 1** and **2**Figure 2), as well as hypertensive reaction. Due to all findings and risk factors, coronarography was performed which excluded epicardial coronary stenoses. An optimal medical therapy was prescribed, and the patient was discharged. First ambulatory control showed symptoms had significantly receded. Nuclear stress testing showed a small region of basal inferior wall ischemia. Cardiac magnetic resonance imaging did not show myocardia oedema nor postcontrast imbibition. Further work-up to confirm coronary microvascular dysfunction would include invasive functional coronary testing using or noninvasive tests (stress echocardiography, PET, perfusion CCTA, and CMR). FIGURE 1. Exercise electrocardiogram testing. FIGURE 2. Repeated exercise electrocardiogram testing. **Conclusion**: Atypical finding of non-obstructive coronary artery disease in a man with multiple risk factors emphasizes the importance of differential diagnosis, optimal medical therapy and in clinical practice still unmet need for functional coronary testing.

    Literature

    1. Knuuti J, Ballo H, Juarez-Orozco LE, Saraste A, Kolh P, Rutjes AWS, et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J. 2018;39:3322–30. https://doi.org/10.1093/eurheartj/ehy267
    2. Mowatt G, Brazzelli M, Gemmell H, Hillis GS, Metcalfe M, Vale L, et al. Systematic review of the prognostic effectiveness of SPECT myocardial perfusion scintigraphy in patients with suspected or known coronary artery disease and following myocardial infarction. Nucl Med Commun. 2005;26:217–29. https://doi.org/10.1097/00006231-200503000-00006
    3. Belsey J, Savelieva I, Mugelli A, Camm AJ. Relative efficacy of antianginal drugs used as add-on therapy in patients with stable angina: a systematic review and meta-analysis. Eur J Prev Cardiol. 2015;22:837–48. https://doi.org/10.1177/2047487314533217
    Cardiologia Croatica
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    Microvascular angina in an unexpected scenario

    Extended Abstract
    Issue11-12
    Published
    Pages387-388
    PDF via DOIhttps://doi.org/10.15836/ccar2024.387
    coronary artery disease
    stress testing
    microvascular dysfunction

    Authors

    Tereza Knaflec*ORCIDZabok General Hospital and Hospital of Croatian Veterans, Zabok, Croatia
    Siniša RoginićORCIDZabok General Hospital and Hospital of Croatian Veterans, Zabok, Croatia
    Iva ZecORCIDZabok General Hospital and Hospital of Croatian Veterans, Zabok, Croatia
    Martina RoginićORCIDZabok General Hospital and Hospital of Croatian Veterans, Zabok, Croatia
    Nikolina Mijač MikačićORCIDZabok General Hospital and Hospital of Croatian Veterans, Zabok, Croatia

    *Correspondence email: tknaflec@gmail.com

    Full Text

    Introduction: Ischemic heart disease can be caused by coronary artery stenosis, dysfunction, or both. Most of the coronary vessels are located inside the myocardium and hence unavailable to direct angiographical visualization. Patients with stable microvascular disease are typically female, obese, hypertensive and have positive stress testing results with unremarkable stenoses on coronarography. (1–3)

    Case report: 45-year-old male, with positive family history, was admitted because of typical intermittent chest pain. The laboratory investigations confirmed dyslipidemia. Echocardiography documented normal sized chambers, with preserved left ventricular systolic function (both ejection fraction and global strain) and right ventricular longitudinal function. There were no signs of hypertrophy or valve disease. Treadmill exercise stress test showed significantly positive results: 4 millimeters ST-segment depression in anteroseptolateral ECG leads (Figures 1 and 2Figure 2), as well as hypertensive reaction. Due to all findings and risk factors, coronarography was performed which excluded epicardial coronary stenoses. An optimal medical therapy was prescribed, and the patient was discharged. First ambulatory control showed symptoms had significantly receded. Nuclear stress testing showed a small region of basal inferior wall ischemia. Cardiac magnetic resonance imaging did not show myocardia oedema nor postcontrast imbibition. Further work-up to confirm coronary microvascular dysfunction would include invasive functional coronary testing using or noninvasive tests (stress echocardiography, PET, perfusion CCTA, and CMR).

    FIGURE 1. Exercise electrocardiogram testing.

    FIGURE 2. Repeated exercise electrocardiogram testing.

    Conclusion: Atypical finding of non-obstructive coronary artery disease in a man with multiple risk factors emphasizes the importance of differential diagnosis, optimal medical therapy and in clinical practice still unmet need for functional coronary testing.

    Literature

    1. 1.
      Knuuti J, Ballo H, Juarez-Orozco LE, Saraste A, Kolh P, Rutjes AWS, et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J. 2018;39:3322–30.DOI
    2. 2.
      Mowatt G, Brazzelli M, Gemmell H, Hillis GS, Metcalfe M, Vale L, et al. Systematic review of the prognostic effectiveness of SPECT myocardial perfusion scintigraphy in patients with suspected or known coronary artery disease and following myocardial infarction. Nucl Med Commun. 2005;26:217–29.DOI
    3. 3.
      Belsey J, Savelieva I, Mugelli A, Camm AJ. Relative efficacy of antianginal drugs used as add-on therapy in patients with stable angina: a systematic review and meta-analysis. Eur J Prev Cardiol. 2015;22:837–48.DOI