title: Diagnostic value of perfusion cardiovascular magnetic resonance in patients with angina pectoris but normal coronary angiograms assessed by intracoronary acetylcholine testing.
abstract: BACKGROUND
  Perfusion cardiovascular magnetic resonance (CMR) has a high sensitivity for the detection of significant coronary artery disease (CAD). However, the specificity of this method is lower than its sensitivity. The reason for this observation is hitherto unclear and has been either explained by 'false-positive' results or by microvascular dysfunction in patients without CAD.
  
  
  OBJECTIVE
  To evaluate whether pathological myocardial perfusion-CMR imaging in symptomatic patients without significant CAD is associated with coronary epicardial or microvascular dysfunction.
  
  
  METHODS
  In this retrospective study, 42 patients who presented with unstable angina pectoris underwent (a) an adenosine-stress perfusion-CMR study; (b) coronary angiography; (c) intracoronary acetylcholine (ACh) testing following coronary angiography with exclusion of significant CAD. The CMR protocol comprised cine imaging followed by adenosine first-pass perfusion imaging and late gadolinium enhancement-CMR. Diagnostic left ventriculography and multiplane coronary angiography were performed before intracoronary ACh testing.
  
  
  RESULTS
  An adenosine-induced, reversible subendocardial perfusion defect was detected in 22/42 patients (52%) without significant CAD. Coronary epicardial vasospasm was detected in 10/42 patients (24%) while microvascular dysfunction was found in 20/42 patients (48%). Patients with a reversible stress-induced perfusion defect had significantly more often a pathological coronary epicardial or microvascular vasoreaction (20/22; 91%) during intracoronary ACh testing than those without a perfusion defect (10/20; 50%; p<0.01). Univariate correlation analyses revealed a substantial association between a pathological ACh-testing result and a perfusion defect in the antecedent CMR study (r= +0.45; p<0.01).
  
  
  CONCLUSIONS
  Reversible perfusion defects depicted by perfusion-CMR in patients without significant CAD are mostly due to coronary epicardial or microvascular dysfunction, and correct interpretation of such perfusion-CMR results may enable targeted treatment.
authors.affiliation: Division of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstrasse 110, Stuttgart 70376, Germany. ali.yilmaz@rbk.de
authors.forename: Ali
authors.initials: A
authors.lastname: Yilmaz
authors.forename: Anastasios
authors.initials: A
authors.lastname: Athanasiadis
authors.forename: Heiko
authors.initials: H
authors.lastname: Mahrholdt
authors.forename: Matthias
authors.initials: M
authors.lastname: Voehringer
authors.forename: Peter
authors.initials: P
authors.lastname: Ong
authors.forename: Stefan
authors.initials: S
authors.lastname: Hill
authors.forename: Eva-Maria
authors.initials: EM
authors.lastname: Kispert
authors.forename: Melanie
authors.initials: M
authors.lastname: Seebo
authors.forename: Udo
authors.initials: U
authors.lastname: Sechtem
mesh_terms: D000109:Acetylcholine / Q000008:administration & dosage; D000241:Adenosine; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000175:diagnosis*; D003287:Contrast Media; D017023:Coronary Angiography; D005260:Female; D019786:Gadolinium DTPA; D006801:Humans; D018810:Magnetic Resonance Angiography; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging; D012189:Retrospective Studies; D014665:Vasodilator Agents / Q000008:administration & dosage
chemical_list: D003287:Contrast Media; D014665:Vasodilator Agents; D019786:Gadolinium DTPA; D000241:Adenosine; D000109:Acetylcholine