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European Heart Journal Advance Access originally published online on September 4, 2007
European Heart Journal 2007 28(19):2416-2417; doi:10.1093/eurheartj/ehm318
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Role of delayed enhancement MRI in patients with acute coronary syndrome and unobstructed coronary arteries

Michele Coceani

CNR Institute of Clinical Physiology
Via Moruzzi 1
56124 Pisa Italy

Antonio L'Abbate

CNR Institute of Clinical Physiology
Via Moruzzi 1
56124 Pisa
Italy

Tel: +39 050 3152731 Fax: +39 050 3152166 E-mail address: michecoc{at}ifc.cnr.it

We read with interest the paper by Assomull et al.1 on the use of magnetic resonance imaging (MRI) in patients with acute chest pain, raised cardiac troponin, and angiographically normal coronary arteries. A diagnosis of myocarditis and cardiomyopathy was made in 50 and 3.4% of cases, respectively. Somewhat unexpectedly, only 11.6% of the population showed myocardial infarction, although it is conceivable that, among patients with a normal MRI scan, myocardial ischaemia might have caused a small increase in circulating troponin.

The authors, however, do not provide any detail on the underlying cause of myocardial damage in patients with myocardial infarction and in those without delayed enhancement at MRI. Was any additional test performed to identify non-obstructive coronary atherosclerosis, vasospasm, or microcirculatory dysfunction? Because therapeutic measures vary between these conditions, their discrimination is extremely important. Indeed, the authors should have qualified more concisely the definition of ‘unobstructed coronary artery’. Did the coronary arteries appear homogenously smooth at angiography, or rather, did they present an irregular contour, pointing to potentially instable atherosclerotic plaques?

Pathophysiology cannot be inferred, though, from coronary ‘lumenography’ alone, and additional indicators must be sought with other imaging modalities. Combined positron emission tomography/computed tomography, for example, could become the gold standard for this analysis,2 notwithstanding its drawbacks due to cost, radiation exposure, and lack of general availability. MRI, on the other hand, is not as limiting. However, in patients with ischaemic heart disease and normal coronary arteries, delayed enhancement MRI alone provides insufficient information on the pathogenesis of myocardial damage and, by extension, is hardly able to guide therapy. In conclusion, myocardial ischaemia needs always to be qualified in its underlying pathophysiology, especially considering that the absence of obstructive coronary atherosclerosis does not necessarily entail a benign long-term prognosis.3

References

  1. Assomull RG, Lyne JC, Keenan N, Gulati A, Bunce NH, Davies SW, Pennell DJ, Prasad SK. The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries. Eur Heart J (2007) 28:1242–1249.[Abstract/Free Full Text]
  2. Namdar M, Hany TF, Koepfli P, Siegrist PT, Burger C, Wyss CA, Luscher TF, von Schulthess GK, Kaufmann PA. Integrated PET/CT for the assessment of coronary artery disease: a feasibility study. J Nucl Med (2005) 46:930–935.[Abstract/Free Full Text]
  3. Bugiardini R, Bairey Merz CN. Angina with ‘normal’ coronary arteries: a changing philosophy. JAMA (2005) 293:477–484.[Abstract/Free Full Text]

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This Article
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28/19/2416-a    most recent
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