Diastolic Dysfunction in Women with Signs and Symptoms of Ischemia in the Absence of Obstructive Coronary Artery Disease: A Hypothesis-Generating Study

Signs and symptoms of ischemia in the absence of obstructive coronary artery disease (CAD) represent an important clinical problem, especially for women. Indeed, women with signs and symptoms of ischemia, but without obstructive CAD, are at increased risk for adverse cardiovascular events compared with asymptomatic community-based women 1. Moreover, symptom-driven health care is costly, with average lifetime cost estimates of over $750 000 2. The Women’s Ischemia Syndrome Evaluation (WISE), designed to investigate new and innovative techniques for the detection of ischemic heart disease in women 3, described an abnormal metabolic response to mild stress testing using 31P magnetic resonance spectroscopy in women with signs and symptoms of ischemia but no obstructive CAD 4. We, and others, have subsequently found this abnormality to be related to abnormal coronary reactivity 5, 6, microvascular coronary dysfunction (MCD) 7, 8, and plaque erosion/distal microembolization 9, 10. Despite this background, it remains unclear whether these abnormalities manifest into actual changes in ventricular function. Accordingly, we incorporated MR tissue tagging into our standard MR imaging protocol to assess LV systolic and diastolic function. MR tissue tagging is an accurate non-invasive imaging technique that provides detailed quantitative information about myocardial tissue deformation 11, 12. Application of this technique to a variety of different diseases has allowed for the early detection of subclinical LV dysfunction 13, 14, and more recently, for the assessment of diastolic function 15, 16. We hypothesized that women with angina in the absence of obstructive CAD would have impaired diastolic function, but preserved systolic function, compared to a group of age-matched reference controls.