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. 2017 Oct 13;104(4):284–292. doi: 10.1136/heartjnl-2017-311446

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© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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Clinical case demonstrating the utility of non-invasive and invasive diagnostic tests for coronary artery function. A 73-year-old woman presented with a 2-year history of typical Canadian cardiovascular society (CCS) class 2 angina. The patient had type 2 diabetes mellitus, an elevated body mass index and had previously been documented to have a normal invasive coronary angiogram 8 years previously. Invasive coronary angiography (A,B) demonstrated unobstructed epicardial coronary arteries. In the left anterior descending artery, the fractional flow reserve (FFR) value was 0.95, consistent with no epicardial flow-limiting stenosis (C). The coronary flow reserve (CFR) was reduced (1.3, normal >2.0), and the index of microcirculatory resistance (IMR) was elevated (33 units, normal <25), indicative of impaired epicardial and microvascular vasodilation and increased microvascular resistance respectively (C). Coronary endothelial function assessment using graded intracoronary acetylcholine infusion revealed mild vasoconstriction (dashed line) consistent with endothelial dysfunction (D) compared with endothelial-independent function testing with intracoronary glyceryl trinitrate (E). There was inducible coronary vasospasm using 100 µg acetylcholine bolus over 20 s (not shown). The patient subsequently underwent adenosine stress perfusion CMR, which demonstrated an inducible circumferential subendocardial perfusion defect in the basal short axis slice (arrows) with adenosine stress (F), compared with the corresponding rest perfusion imaging (G). A pixel-wide fully quantitative myocardial blood flow analysis confirmed markedly reduced myocardial blood flow in the subendocardium with adenosine stress (H) compared with the corresponding rest perfusion image (I). A diagnosis of coronary microvascular dysfunction was made. The patient was symptomatically improved at 3-month follow-up after treatment with nebivolol, statin and ACE inhibitors was started. The CMR methods were provided by Andrew Arai and Li-Yueh Hsu, National Institutes of Health, MD.