title: Myocardial bridging in absence of coronary artery disease: proposal of a new classification based on clinical-angiographic data and long-term follow-up.
abstract: BACKGROUND
  There is no widely accepted classification to guide therapy in patients with symptomatic myocardial bridging (MB).
  
  
  METHODS
  A retrospective analysis of 157 patients with chest pain, angiographic MB of the left anterior descending artery without obstructive coronary artery disease (CAD) was performed. Patients were evaluated for clinical symptoms, objective signs of ischemia by stress test, intracoronary Doppler flow measurement and coronary flow reserve. 100 patients without CAD or MB served as controls.
  
  
  RESULTS
  There was no difference in clinical symptoms and objective signs of ischemia between controls and patients with MB. The length of MB was 22.6 +/- 7.8 mm, maximal systolic luminal diameter reduction 71 +/- 16%, and maximal mid-diastolic luminal reduction 34.7 +/- 13% as demonstrated by quantitative coronary angiography (QCA). Intracoronary Doppler showed significantly increased average peak flow velocity (APV), average systolic peak velocity (ASPV), average diastolic peak flow velocity (ADPV), and maximal peak velocity (MPV) in MB versus proximal and distal segments at rest and after maximal vasodilatation (p < 0.001 for all parameters). Coronary flow reserve was significantly higher proximally (2.9 +/- 0.9) compared with segments distal to the MB (2.0 +/- 0.6, p < 0.01). We propose a new MB classification for symptomatic patients with MB:Type A:incidental finding on angiography, no objective signs of ischemia; Type B: objective signs of ischemia, and Type C: with or without objective signs of ischemia and altered intracoronary hemodynamics (by QCA/CFR/intracoronary Doppler). 5-Year follow-up data based on this classification showed that types B and C responded well to beta-blockers or calcium channel antagonists. Patients with type C refractory to medical therapy were treated with stenting of the MB.
  
  
  CONCLUSIONS
  Patients with MB without CAD did not have a higher prevalence of chest pain or abnormal non-invasive stress tests compared to patients without CAD or MB. Intracoronary hemodynamic measurement is a novel approach that may be valuable in defining the functional significance of MB. We propose a classification of symptomatic patients with MB without CAD using non-invasive and invasive parameters to guide therapeutic choices.
authors.affiliation: Division of Cardiology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA. schwarze@cshs.org
authors.forename: Ernst R
authors.initials: ER
authors.lastname: Schwarz
authors.forename: Rajiv
authors.initials: R
authors.lastname: Gupta
authors.forename: Philipp K
authors.initials: PK
authors.lastname: Haager
authors.forename: Juergen
authors.initials: J
authors.lastname: vom Dahl
authors.forename: Heinrich G
authors.initials: HG
authors.lastname: Klues
authors.forename: Juergen
authors.initials: J
authors.lastname: Minartz
authors.forename: Barry F
authors.initials: BF
authors.lastname: Uretsky
mesh_terms: D000328:Adult; D000787:Angina Pectoris / Q000145:classification / Q000000981:diagnostic imaging; D017023:Coronary Angiography; D003324:Coronary Artery Disease; D015150:Echocardiography, Doppler; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D054084:Myocardial Bridging / Q000145:classification* / Q000000981:diagnostic imaging*; D017202:Myocardial Ischemia / Q000145:classification / Q000000981:diagnostic imaging; D012189:Retrospective Studies; D018084:Ultrasonography, Interventional