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Diagnostic value of perfusion-CMR in patients with angina pectoris but normal coronary angiograms assessed by intracoronary acetylcholine-testing
  1. Ali Yilmaz*,
  2. Anastasios Athanasiadis,
  3. Heiko Mahrholdt,
  4. Matthias Voehringer,
  5. Peter Ong,
  6. Stefan Hill,
  7. Eva-Maria Kispert,
  8. Melanie Seebo,
  9. Udo Sechtem
  1. 1 Robert-Bosch-Krankenhaus, Germany
  1. Correspondence to: Ali Yilmaz, Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, 70376, Germany; ali.yilmaz{at}


Objectives: Perfusion-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. The aim of this study was to evaluate whether pathological myocardial-perfusion cardiovascular magnetic resonance (CMR) imaging (perfusion-CMR) 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 I) an adenosine-stress perfusion-CMR study, II) coronary angiography and III) 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 (LGE)-CMR. Diagnostic left ventriculography and multi-plane coronary angiography were performed prior to 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 as compared to 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 a targeted therapy.

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