Clinical studies
Coronary flow reserve, esophageal motility, and chest pain in patients with angiographically normal coronary arteries

https://doi.org/10.1016/0002-9343(90)90145-4Get rights and content

Abstract

purpose and methods: To ascertain the relative prevalence of abnormalities of coronary flow reserve and esophageal function in patients with chest pain despite angiographically normal coronary arteries, 87 patients underwent invasive study of coronary flow reserve and, during the same week, esophageal testing.

results: Sixty-three of the 87 patients (72%) demonstrated abnormalities of coronary flow reserve, as evidenced by an increase in coronary resistance during the stress of rapid atrial pacing after administration of ergonovine 0.15 mg intravenously (1.33 ± 0.36 mm Hg·minute/mL), compared with pacing at the same heart rate before ergonovine administration (1.10 ± 0.33 mm Hg·minute/mL). This higher coronary vascular resistance occurred in the absence of significant epicardial coronary artery luminal narrowing. Fifty-seven of these 63 patients (90%) with a coronary vasoconstrictor response to ergonovine described their typical chest pain during pacing stress, compared with only six of 24 patients (25%) who demonstrated no coronary flow abnormality (p <0.001). After administration of dipyridamole 0.5 to 0.75 mg/kg intravenously to 65 patients, the 48 patients with ergonovine-induced vasoconstriction had a significantly higher minimum coronary resistance, compared with the 17 patients without a coronary vasoconstrictor response to ergonovine (0.65 ± 0.21 versus 0.47 ± 0.13 mm Hg·minute/mL, p <0.03).

Twenty of 87 patients (23%) had abnormal esophageal motility [nutcracker esophagus (11), nonspecific motility disorder (seven), and diffuse esophageal spasm (two)], including 16 of the 63 patients (25%) with abnormal coronary flow reserve.

Twenty-four (28%) patients experienced their typical chest pain during motility testing, but only five of these patients met criteria for abnormal esophageal motility. Nine of 75 patients tested (12%) had their typical chest pain during Bernstein testing, and 18 of 38 patients (47%) tested had their typical chest pain provoked by intraesophageal balloon distention.

conclusion: Seventy-one of 87 patients (82%) with anginal-like chest pain and normal epicardial vessels in our series had a disorder of either coronary flow reserve, esophageal motility, and/or reproduction of typical chest pain during acid infusion. Of interest, chest pain was commonly encountered during cardiac and esophageal testing (85% of patients), regardless of the ability to demonstrate an abnormality of coronary flow reserve or abnormal esophageal function. This suggests that pain experienced by these patients may be a consequence of myocardial ischemia, esophageal dysfunction, abnormal visceral nociception, or a combination of any or all of these entities.

References (32)

  • DH Schmidt et al.

    Ergonovine/dipyridamole-induced changes in regional myocardial perfusion in patients with angina and normal coronary arteries

    Circulation

    (1984)
  • KS Virtanen

    Evidence of myocardial ischemia in patients with chest pain syndromes and normal coronary angiograms

    Acta Med Scand

    (1984)
  • RO Cannon et al.

    Limited coronary flow reserve after dipyridamole in patients with ergonovine-induced coronary vasoconstriction

    Circulation

    (1987)
  • MA Greenberg et al.

    Impaired coronary vasodilator responsiveness as a cause of lactate production during pacing-induced ischemia in patients with angina pectoris and normal coronary arteries

    J Am Coll Cardiol

    (1987)
  • AS Bortone et al.

    Abnormal coronary vasomotion during exercise in patients with normal coronary arteries and reduced coronary flow reserve

    Circulation

    (1989)
  • DL Brand et al.

    Esophageal manometrics in patients with angina-like chest pain

    Am J Dig Dis

    (1977)
  • Cited by (0)

    View full text