MI Scar Often Seen in Women With Chest Pain, No Obstructive CAD in WISE-CVD Study

March 02, 2018

The prevalence of myocardial scar by cardiac magnetic resonance (CMR) imaging was 8% in a prospective study of women presenting with angina-like chest pain but in whom prior clinically driven angiography had not shown obstructive coronary disease.

Such scar defined by late gadolinium enhancement at CMR is a sign of prior myocardial infarction (MI), yet a third of women with the sign had no prior MI diagnosis.

Moreover, about 1% of the cohort showed new scar at CMR a year later. That was only two patients in this series, but in neither case was an MI diagnosed during the follow-up, report investigators from the Women's Ischemia Syndrome Evaluation–Coronary Vascular Dysfunction (WISE-CVD) study.

The findings add to abundant evidence that an MI diagnosis is missed in many women with suggestive symptoms but no obstructive CAD by angiography, observed Janet Wei, MD, Cedars-Sinai Heart Institute, Los Angeles, California, for theheart.org | Medscape Cardiology.

They also underscore the need for additional testing in such cases. "If a woman has persistent symptoms, especially if she's had an actual myocardial infarction, just stopping at a 'normal' angiogram doesn't actually give you any answers," said Wei, who is lead author on the WISE-CVD analysis published February 19 in Circulation.

Previously in the primary WISE observational study, "We found that over half of these women who have symptoms of ischemia and no obstructive coronary disease do have coronary microvascular dysfunction."

In addition, the symptom pattern of myocardial ischemia in women can be different from that in men, and not recognized as due to ischemia. In such cases, women may be told their pain is noncardiac or perhaps due to anxiety, Wei said.

"If they are felt to be low risk because they may have previously undergone testing that showed no obstructive coronary disease, they're often told their heart is fine, so they may not actually receive optimal testing," she said.

"It is a mind set that we need to overcome. This is a large proportion of the population, and these patients do unfortunately have worse outcomes, so we can't just take no for an answer."

CMR imaging with late-gadolinium enhancement disclosed myocardial scar in 26 of the 340 women with angina-like symptoms but negative angiograms, the report notes. 

Of those 26 women, 18 had a confirmed history of acute MI but only 2 had electrocardiographic Q waves consistent with prior MI.

Also, the 26 with scar shown by imaging showed functional signs of myocardial remodeling, with significantly lower LV ejection fraction and higher end-diastolic and end-systolic volumes.

There was no significant difference in myocardial perfusion reserve index (MPRI), a predictor of coronary microvascular dysfunction, between women with vs those without scar.

Table. Functional Parameters of CMR Imaging by Presence of Scar by Late Gadolinium Enhancement

Endpoints No Scar (n = 314) Scar (n = 26) P Value
LVEF (%) 68 63 .004
LV end-diastolic volume (mL) 122 136 .01
LV end-systolic volume (mL) 39 51 .002
LV mass (g) 93 96 .42
MPRI 1.84 2.00 .12


Among 179 women in the series who were prospectively followed by CMR imaging at 1 year, 2 (about 1.1%) showed a presence of new scar in myocardium that had not previously shown late gadolinium enhancement.

Both of those two women with new scar, Wei said, had been hospitalized for angina during the year-long follow-up, but neither was diagnosed with MI.

Wei reports no conflicts of interest. Disclosures for the other authors are in the report.

Circulation. Published online February 19, 2018. Abstract

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