This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Galli, M. Articles by Verna, E. Search for Related Content PubMed PubMed Citation Articles by Galli, M. Articles by Verna, E. Related Collections Cardiovascular imaging agents/Techniques Exercise testing Chronic ischemic heart disease

(Circulation. 1999;99:1774.)
© 1999 American Heart Association, Inc.

Images in Cardiovascular Medicine

Myocardial Ischemia and Occult Coronary Artery Disease

Michele Galli, MD; Claudio Marcassa, MD; Edoardo Verna, MD

From Fondazione Maugeri, Veruno, and Ospedale di Circolo, Varese (E.V.), Italy.

Correspondence to Michele Galli, MD, Cardiology Division, S. Maugeri Foundation, IRCCS, via Revislate 13, 28010 Veruno (NO), Italy.

	Introduction

 
A57-year-old postmenopausal woman was admitted to the hospital because of worsening angina pectoris. A diagnosis of syndrome X had been made 3 years earlier on the grounds of chest pain, positive exercise stress test, and angiographically normal coronary arteries. Angina persisted despite use of diltiazem, nitrates, simvastatin, and imipramine. Risk factors included hypertension, overweight, and hypercholesterolemia.

At treadmill testing, chest pain and 2-mm ST-segment depression developed after 5 minutes of exercise, and sestamibi myocardial tomoscintigraphy showed a reversible tracer uptake defect in the anterior region (Figure, panel A, arrows). Repeat coronary angiography did not show any "significant" stenosis (the left coronary artery is shown in panel B). However, intracoronary Doppler flow measurements at rest and after adenosine (panel C, top and bottom, respectively) showed a reduced maximal hyperemic flow velocity in the left anterior descending coronary artery (LAD) (LAD flow reserve, 2.4; left circumflex coronary artery flow reserve, 3.3). Intracoronary ultrasound imaging revealed an occult atherosclerotic plaque of the proximal LAD occupying 45% of the vessel area, with vessel remodeling (panel D: proximal LAD intravascular image is shown on the left and distal LAD on the right. pa indicates plaque area; diag, diagonal branch).

View larger version (86K): [in this window] [in a new window]   Figure 1.

The woman refused hormone-replacement therapy. A recommendation for more effective dietary modification and weight management was reinforced, and atenolol was added to the therapy. After 6 months, there was no improvement in symptoms, and overweight persisted.

	Footnotes

 
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, . . . [Full Text of this Article]