ACUTE CORONARY SYNDROME WITH NONOBSTRUCTIVE CORONARY ARTERIES: THE SEVERITY OF CORONARY ATHEROSCLEROSIS AND MYOCARDIAL PERFUSION DISORDERS (PILOT STUDY)

Aim. To study the structural and functional status of coronary blood flow in patients with acute coronary syndrome with nonobstructive coronary arteries using multispiral computed tomography (MSCT) and single photon emission tomography (SPECT) and to compare data of MSCT and invasive coronary angiography (ICA).
Material and Methods. This study is a non-randomized, open-label, controlled clinical trial. The study is registered on ClinicalTrials.gov. The inclusion criteria are listed on the site. All patients underwent CT and SPECT.
Results. The study included 14 patients with MINOCA; the group comprised predominantly women (n=11, 78.6%); the average age was 61.1±14 years. The risk according to GRACE (Global Registry of Acute Coronary Events) risk score was moderate in 8 patients (57%) and high in 5 patients (35.7%). 85.7% of patients were admitted to hospital within the first six hours from onset of diseases. Three patients (21.4%) received thrombolytic therapy and it was effective in two of them (14%). Risk factors included hypertension (64.2%), dyslipidemia (50%), and burdened history (71.4). According to the results of invasive coronary angiography, intact coronary arteries were detected in 9 patients (64.3%); 5 patients (35.7%) had stenosis up to 50%. Coronary slow-flow phenomenon (TIMI 2) was detected in 11 patients (78.6%) including 8 patients (57.1%) who had coronary slow-flow phenomenon and intact coronary arteries. Severe coronary spasm was registered in 1 patient (7.1%) in the group with ST segment elevation acute coronary syndrome (STE ACS). According to MSCT data, the proportion of patients with intact coronary arteries decreased from 7 (50%) to 5 patients (35.7%) whereas the proportion of patients with nonstenosing atherosclerosis increased from 7 (50%) to 9 patients (64.3%). Twenty six atherosclerotic plaques were detected including eccentric (76%), circular (11.5%), and semi-circular plaques (11.5%). In regard to morphological structure, the atherosclerotic plaques were calcified (59.5%), mostly calcified (7.7%), and soft (29%). Normal myocardial perfusion (Summed Stress Score (SSS) and Summed Rest Score (SRS) <4) was detected in two patients (14.3%); 12 patients (85%) had transitory perfusion defects. The median score values were 7.5 (4; 13) for SSS, 4.7 (1.0; 9.0) for SRS, and 4.7 (3.0; 8.0) for SDS.
Conclusion. The introduction of MCTA and SPECT into the algorithm of the examination of patients with acute myocardial infarction and non-obstructive atherosclerosis of the coronary arteries was safe when additionally used during index hospitalization. These approaches provided new information about the structure and function of the coronary arteries. These data provide rationale for further study using a larger group of patients to determine a prognostic significance of detecting the atherosclerotic plaques with the signs of instability in this patient category.

1. Ibanez B., James S., Agewall S., Antunes M.J., Bucciarelli-Ducci C., Bueno H., et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur. Heart J. 2018 Jan. 7;39(2):119–177. DOI: 10.1093/eurheartj/ehx393.

2. Ryabov V.V., Gomboeva S.B., Shelkovnikova Т.A., Baev A.Е., Rebenkova М.S., Rogovskaya Y.V., Usov V.Y. Cardiac magnetic resonance imaging in differential diagnostics of acute coronary syndrome in patients with non-obstruction coronary atherosclerosis. Rossijskij kardiologicheskij zhurnal=Russian Journal of Cardiology. 2017;(12):47–54 (In Russ.). DOI: 10.15829/1560-4071-2017-12-47-54.

3. Ternovoy S.K., Shabanova M.S., Gaman S.A., Merkulova I.N., Shariya M.A. Role of computed tomography in detection of vulnerable coronary plaques in comparison with intravascular ultrasound. Rossijskij jelektronnyj zhurnal luchevoj diagnostiki=Russian Electronic Journal of Radiology. 2016;6(3):68–79 (In Russ.). DOI: 10.21569/2222-7415-2016-6-3-68-79.

4. Thomsen C., Abdulla J. Characteristics of high-risk coronary plaques identified by computed tomographic angiography and associated prognosis: a systematic review and meta-analysis. European Heart Journal – Cardiovascular Imaging. 2016/ Feb.;17(2):120-129. DOI: 10.1093/ehjci/jev325.

5. Voros S., Rinehart S., Qian Z., Joshi P., Vazquez G., Fischer C., et al. Coronary atherosclerosis imaging by coronary CT angiography: current status, correlation with intravascular interrogation and meta-analysis. JACC Cardiovascular Imaging. 2011;4(5):537–548. DOI: 10.1016/j.jcmg.2011.03.006.

6. Ito T., Terashima M., Kaneda H., Nasu K., Matsuo H., Ehara M., et al. Comparison of in vivo assessment of vulnerable plaque by 64-slice multislice computed tomography versus optical coherence tomography. 2011. May 1;107(9):1270–1277. DOI: 10.1016/j.amjcard.2010.12.036.

7. Sergienko V.B., Ansheles A.A. Tomographic methods in the assessment of myocardial perfusion. Vestnik rentgenologii i radiologii=Journal of Radiology and Nuclear Medicine. 2010;3:10–14 (In Russ.).

8. Henzlova M.J., Duvall W.L., Einstein A.J., Travin M.I., Verberne H.J. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J. Nucl. Cardiol. 2016;23(3):606–639. DOI: 10.1007/s12350-015-0387-x.

9. Xiu J., Cui K., Wang Y., Zheng H., Chen G., Feng Q., Bin J., et al. Prognostic value of myocardial perfusion analysis in patients with coronary artery disease: a meta-analysis. J. Am. Soc. Echocardiogr. 2017 Mar.;30(3):270–281. DOI: 10.1016/j.echo.2016.11.015.

10. Peix A., Macides Y., Rodríguez L., Cabrera L.O., Padrón K., Heres F., et al. Stress-rest myocardial perfusion scintigraphy and adverse cardiac events in heart failure patients. MEDICC Review. 2015 Apr.;17(2):33–38.

11. Sharif-Yakan A., Divchev D., Trautwein U., Nienaber Ch.A. The coronary slow flow phenomena or «cardiac syndrome Y». Reviews in Vascular Medicine. 2014 Dec.;2(4):118–122. DOI: 10.1016/j.rvm.2014.07.001

12. Zavadovsky K.V., Gulya M.O., Saushkin V.V., Saushkina Y.V., Lishmanov Y.B. Superimposed single-photon emission computed tomography and X-ray computed tomography of the heart: Methodical aspects. Journal of radiology and nuclear medicine. 2016;97(4):235–242 (In Russ.). DOI: 10.20862/0042-4676-2016-97-4-8-15.

13. Pasupathy S., Air T., Dreyer R.P., Tavella R., Beltrame J.F. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861–870.

14. Tornvall P., Gerbaud E., Behaghel A., Chopard R., Collste O., Laraudogoitia E., et al. Myocarditis or “true” infarction by cardiac magnetic resonance in patients with a clinical diagnosis of myocardial infarction without obstructive coronary disease. Atherosclerosis. 2015 Jul.;241(1):87–91. DOI: 10.1016/j.atherosclerosis.2015.04.816.

15. Task Force Members, Montalescot G., Sechtem U., Achenbach S., Andreotti F., Arden C., et al. ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur. Heart J. 2013 Oct.;34(38):2949–3003. DOI: 10.1093/eurheartj/eht296.

16. Obaid D.R., Calvert P.A., Gopalan D., Parker R.A., Hoole S.P., West N.E., et al. Atherosclerotic plaque composition and classification identified by coronary computed tomography: assessment of computed tomography-generated plaque maps compared with virtual histology intravascular ultrasound and histology. Cardiovascular Imaging. 2013 Sep.;6(5):655–664. DOI: 10.1161/CIRCIMAGING.112.000250.

17. Puchner S.B., Lu M.T., Mayrhofer T., Liu T., Pursnani A., Ghoshhajra B.B., et al. High-risk plaque detected on coronary ct angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II Trial. JACC. 2014 Aug. 19;64(7):684–692. DOI: 10.1016/j.jacc.2014.05.039.

18. Lindahl B., Baron T., Erlinge D., Hadziosmanovic N., Nordenskjöld A., Gard A., Jernberg T. Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation. 2017 Apr. 18;135(16):1481–1489. DOI: 10.1161/CIRCULATIONAHA.116.026336.

19. Wang X., Nie S.P. The coronary slow flow phenomenon: Characteristics, mechanisms and implications. Cardiovascular Diagnosis and Therapy. 2011 Dec.;1(1):37–43. DOI: 10.3978/j.issn.2223-3652.2011.10.01.

20. Goldkorn R., Naimushin A., Beigel R., Naimushin E., Narodetski M., Matetzky S. Evaluation of patients with acute chest pain using SPECT myocardial perfusion imaging: prognostic implications of mildly abnormal scans. Israel Medical Association Journal. 2017 Jun.;19(6): 368–371.

21. Zavadovsky K.V., Saushkin V.V., Grakova E.V., Gulya M.O., Mochula A.V. Myocardial perfusion pattern in patients with different degrees of coronary artery stenosis. REJR. 2017; 7(4): 39–54 (In Russ.). DOI: 10.21569/2222-7415-2017-7-4-39-54.