Erika Jones

Cardiac syndrome X and microvascular coronary dysfunction.

Women with cardiac chest pain indicated by signs and symptoms of myocardial ischemia in the absence of obstructive CAD are often labelled as cardiac syndrome X (CSX). A subset of patients with CSX may have symptoms of ischemia due to microvascular dysfunction. Angina due to microvascular coronary dysfunction (MCD) is an etiologic mechanism in women with vascular dysfunction. New data provide improve understanding of coronary vascular dysfunction and resultant myocardial ischemia that characterize MCD among patients with cardiac syndrome X. MCD has an adverse prognosis and health care cost expenditure comparable to obstructive CAD. The high prevalence of this condition, particularly in women, adverse prognosis and substantial health care costs, coupled with a lack of evidence regarding treatment strategies, places MCD as a research priority area.

Review articleCardiac Syndrome X and Microvascular Coronary Dysfunction

Women with cardiac chest pain indicated by signs and symptoms of myocardial ischemia in the absence of obstructive CAD are often labelled as cardiac syndrome X (CSX). A subset of patients with CSX may have symptoms of ischemia due to microvascular dysfunction. Angina due to microvascular coronary dysfunction (MCD) is an etiologic mechanism in women with vascular dysfunction. New data provide improve understanding of coronary vascular dysfunction and resultant myocardial ischemia that characterize MCD among patients with cardiac syndrome X. MCD has an adverse prognosis and health care cost expenditure comparable to obstructive CAD. The high prevalence of this condition, particularly in women, adverse prognosis and substantial health care costs, coupled with a lack of evidence regarding treatment strategies, places MCD as a research priority area.

Heart failure hospitalization in women with signs and symptoms of ischemia: A report from the women's ischemia syndrome evaluation study

BACKGROUND Women with signs and symptoms of ischemia, no obstructive coronary artery disease, and preserved left ventricular ejection fraction enrolled in the National Heart Lung and Blood Institute (NHLBI) sponsored Womens Ischemia Syndrome Evaluation (WISE) study have an unexpectedly high rate of subsequent heart failure (HF) hospitalization. We sought to verify and characterize the HF hospitalizations. METHODS A retrospective chart review was performed on 223 women with signs and symptoms of ischemia, undergoing coronary angiography for suspected coronary artery disease followed for 6±2.6years. Data were collected from a single site in the WISE study. RESULTS At the time of study enrollment, the women were 57±11years of age, all had preserved left ventricular ejection fraction, and 81 (36%) had obstructive CAD (defined as >50% stenosis in at least one epicardial artery). Among the 223 patients, 25 (11%) reported HF hospitalizations, of which 14/25 (56%) had recurrent HF hospitalizations (>2 hospitalizations). Medical records were available in 13/25 (52%) women. Left ventricular ejection fraction was measured in all verified cases and was found to be preserved in 12/13 (92%). HF hospitalization was not related to obstructive CAD. CONCLUSION Among women with signs and symptoms of ischemia undergoing coronary angiography for suspected obstructive CAD, HF hospitalization at 6-year follow-up was predominantly characterized by a preserved ejection fraction and not associated with obstructive CAD.

Cardiac magnetic resonance imaging for myocardial perfusion and diastolic function-reference control values for women.

Angina, heart failure with preserved ejection fraction (HFpEF) and coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease (CAD) are more common in women and are associated with adverse cardiovascular prognosis. Cardiac magnetic resonance imaging (CMRI) is established for assessment of left ventricular (LV) morphology and systolic function and is increasingly used to assess myocardial perfusion and diastolic function. Indeed, stress CMRI allows measurement of myocardial perfusion reserve index (MPRI) using semi-quantitative techniques, and quantification of LV volumetric filling patterns provides valuable insight into LV diastolic function. The utility of these two techniques remains limited, because reference control values for MPRI and LV diastolic function in asymptomatic middle-aged, women have not previously been established. To address this limitation, we recruited twenty women, without clinical cardiovascular disease or cardiovascular risk factors, with normal maximal Bruce protocol exercise treadmill testing. Subjects underwent CMRI (1.5 tesla) using a standardized protocol of adenosine stress and rest perfusion and LV cinematic imaging. Commercially available with automated CMRI segmentation was used for calculation of MPRI, LV filling profiles, and ejection fraction. Mean age was 54±9 years and mean body mass index was 25±4 kg/m(3). The exercise treadmill testing results demonstrated a normotensive group with normal functional capacity and hemodynamic response. We report reference control values for semi-quantitative MPRI as well as measures of LV systolic and diastolic function including ejection fraction, stroke volume, peak filling rate (PFR), PFR adjusted for end-diastolic volume (EDV) and stroke volume, time to PFR, and EDV index. The data herein provide reference values for MPRI and diastolic function in a cohort of healthy, middle-aged of women. These reference values may be used for comparison with a variety of patient populations, including women with CMD and HFpEF.

LATE GADOLINIUM ENHANCEMENT AND ADVERSE CARDIAC EVENTS AT 1 YEAR FOLLOW-UP IN WOMEN WITH SIGNS AND SYMPTOMS OF ISCHEMIA AND NO OBSTRUCTIVE CORONARY DISEASE: A REPORT FROM THE WOMEN’S ISCHEMIA SYNDROME EVALUATION

methods: We identified a subgroup of 173 women who underwent 1.5T CMRI at baseline and one year in the Women’s Ischemia Syndrome Evaluation. LGE was determined by blinded visual scores and quantified with CAAS MRV software (Pie Medical Imaging, Netherlands). Ischemic LGE pattern was defined as subendocardial or transmural in a coronary distribution, while nonischemic LGE pattern was midmyocardial or epicardial. Interval myocardial infarction (MI), stroke, and hospitalization for angina or heart failure were recorded.

PREVALENCE OF MYOCARDIAL SCAR IN WOMEN WITH SIGNS AND SYMPTOMS OF ISCHEMIA BUT NO OBSTRUCTIVE CORONARY ARTERY DISEASE: A REPORT FROM THE WOMEN’S ISCHEMIA SYNDROME EVALUATION

Moderated Poster ContributionsStable Ischemic Heart Disease Moderated Poster Theater, Poster Hall B1Sunday, March 15, 2015, 10:00 a.m.-10:10 a.m.Session Title: Ischemia in Women without Obstructive Coronary Artery DiseaseAbstract Category: 26. Stable Ischemic Heart Disease: ClinicalPresentation Number: 1205M-05Authors: May Bakir, Janet Wei, Louise Thomson, John Petersen, Quanlin Li, Erika Jones, Puja Mehta, Chrisandra Shufelt, Daniel Berman, Eileen Handberg, Sheryl Kelsey, George Sopko, Carl Pepine, C. Noel Bairey Merz, Cedars-Sinai Medical Center, Los Angeles, CA, USABackground: Women with signs and symptoms of ischemia and no obstructive coronary artery disease (CAD) have an elevated major adverse cardiac event rate. We evaluated the presence, extent and distribution of scar using cardiac magnetic resonance imaging (CMRI) late gadolinium enhancement (LGE) in the Women’s Ischemia Syndrome Evaluation.methods: Women (n=344) with signs and symptoms of ischemia and no obstructive CAD underwent 1.5T CMRI LGE. Scans were read blindly for presence and segmental distribution of LGE. Scar size was quantified using Pie Medical Imaging software. LGE type was defined as ischemic when subendocardial or transmural and localized to a coronary artery distribution, and non-ischemic when mid-myocardial or epicardial. Fisher’s exact and two sample t-tests were used for statistical analysis.results: LGE was present in 20 (5.8%) women, including 15 (75%) with ischemic LGE. Women with non-ischemic LGE (n=5) had larger scar size compared to women with ischemic LGE (Table). There were no significant differences in cardiac risk factors among women with no LGE, ischemic LGE, or non-ischemic LGE, and there was no significant correlation between LGE presence and cardiac risk factors.Conclusion: Women with signs and symptoms of ischemia and no obstructive CAD have a 5.8% prevalence of myocardial scar detected by CMRI, with a predominant ischemic LGE pattern. These findings demonstrate that these women can develop irreversible myocardial injury, which may be clinically under-diagnosed.No LGE(n=324)Ischemic LGE(n=15)Non-ischemic LGE(n=5)Age 54 ± 11 years 55 ± 8 years 37 ± 15 yearsBody Mass Index 30 ± 8 32 ± 11 35 ± 7Hypertension 40% 31% 75%Diabetes 11% 14% 50%Dyslipidemia 20% 10% 33%Family History of Coronary Artery Disease 48% 21% 50%Scar pattern n/a4 LAD6 LCX4 RCA1 LAD and RCA3 patchy epicardial1 midmyocardial ASH1 RV insertion pointsScar size n/a 4.83 ± 3.12g* 9.57 ± 6.10g*ASH= asymmetric septal hypertrophy, LAD= left anterior descending artery, LCX= left circumflex artery, LGE= late gadolinium enhancement, RCA= right coronary artery, RV= right ventricular*p=0.0034

B-TYPE NATRIURETIC PEPTIDE DOES NOT CORRELATE WITH INVASIVE OR NONINVASIVE MEASURES OF CORONARY MICROVASCULAR DYSFUNCTION IN WOMEN WITH PRESERVED EJECTION FRACTION: A REPORT FROM THE WOMEN'S ISCHEMIA SYNDROME EVALUATION- CORONARY VASCULAR DYSFUNCTION (WISE-CVD) STUDY

Women with symptoms/signs of ischemia and no obstructive coronary artery disease often have coronary microvascular dysfunction (CMD), diagnosed by invasive coronary reactivity testing (CRT). CMD has recently been proposed to be a precursor to heart failure with preserved ejection fraction. The

Endothelial Dysfunction and Coronary Microvascular Dysfunction in Women With Angina and Nonobstructive Coronaries

Abstract Precordial pain is the primary cardiac-related complaint in 7%–24% of general population. Women represent a special segment in which evaluation of precordial pain is particularly challenging. In the absence of significant coronary stenosis, they have been classified as cardiac syndrome X. Availability of more sophisticated techniques to investigate coronary circulation, such radioisotopes and endothelial analysis by coronary flow measurements are changing this scenario. Angina due to coronary microvascular dysfunction (CMD) is now recognized in women with chest pain and normal coronaries at the classical angiogram and cardiac syndrome x terminology is no longer used. Thus CMV is defined based on: (1) presence of myocardial ischemia; and (2) presence of my coronary vascular dysfunction in macro- and microvascular beds. An abnormal response to intracoronary acetylcholine predicts future cardiovascular events such as angina, myocardial infarction heart failure, need for revascularization, and death. Cardiac events have been noted only in patients with severe endothelial dysfunction and not only mild dysfunction. In addition, the worst prognosis is observed when a significant atheroma burden coincides with severe endothelial dysfunction. A reduction in coronary flow reserve, an imbalance between NO bioavailability and endothelin-1, and slow coronary blood flow are also possible underlying mechanisms. Insulin resistance, increased sodium/potassium exchange in red blood cells, hyperglycemia, inflammation, and smooth muscle abnormalities (both vascular and nonvascular) may be additional mechanisms. These findings establish a new paradigm in the pathophysiology of angina with normal coronary arteries specifically for women.

False-positive stress testing: Does endothelial vascular dysfunction contribute to ST-segment depression in women? A pilot study

The utility of exercise‐induced ST‐segment depression for diagnosing ischemic heart disease (IHD) in women is unclear.