Elsevier

American Heart Journal

Volume 138, Issue 4, October 1999, Pages 731-739
American Heart Journal

Noninvasive determination of endothelium-mediated vasodilation as a screening test for coronary artery disease: Pilot study to assess the predictive value in comparison with angina pectoris, exercise electrocardiography, and myocardial perfusion imaging☆,☆☆

Presented in part at the 47th Annual Scientific Session of the American College of Cardiology, March 29 to April 1, 1998, Atlanta, Ga, and at the 20th Congress of the European Society of Cardiology, August 22 to 26, 1998, Vienna, Austria.
https://doi.org/10.1016/S0002-8703(99)70189-4Get rights and content

Abstract

Background Peripheral endothelial dysfunction (ED) quantified by the determination of flow-mediated dilation (FMD%) of the brachial artery with the use of high-resolution ultrasound is an early marker of atherosclerosis. Although a positive correlation with coronary artery disease (CAD) has been reported, the unanswered clinical question is the validity of FMD% as a screening test in patients with clinical suspicion of CAD. Thus the aim of this study was to determine the predictive value of FMD% compared with angina pectoris, exercise electrocardiography, and myocardial perfusion imaging. Methods and Results In this pilot study, we measured ED in 122 patients scheduled for coronary angiography by using high-resolution ultrasound (13 MHz). We defined ED as FMD% ≤4.5%. The presence of CAD was defined as angiographically detectable atherosclerotic vessel alterations of any degree. Exercise electrocardiography and myocardial perfusion imaging had been performed on an outpatient basis. Statistical analysis was conducted by analysis of variance and Mantel-Haenszel chi-square test. Patients with CAD (n = 101) had a significantly lower FMD% than patients without CAD (n = 21; 3.7% ± 4.1% vs 7.01% ± 3.5%, P < .001). A sensitivity of 71%, a specificity of 81% with a positive predictive value of 0.95 (72 of 76), and a negative predictive value of 0.41 (17 of 46) was calculated. In comparison to angina pectoris (sensitivity 95%, specificity 47.6%), exercise electrocardiography (sensitivity 82.4%, specificity 57.1%) and myocardial perfusion imaging (sensitivity in our study group 100%) had the best specificity, and a high sensitivity for FMD% was found. Conclusions The determination of ED was found to be a sensitive and specific screening test to predict the presence of CAD. Because this is a noninvasive, nonradioactive, and cost-effective approach, it warrants further evaluation to determine its value in daily clinical practice as an additional screening test in the diagnosis of CAD. (Am Heart J 1999;138:731-9.)

Section snippets

Subjects and study protocol

In this prospective pilot study we included 122 consecutive patients without prior invasive coronary diagnostics who were scheduled for coronary angiography because of the clinical suspicion of CAD (typical or atypical angina pectoris and/or positive exercise electrocardiography/myocardial perfusion imaging). All patients gave their informed consent to participate in this study. The study was performed according to the principles of the declaration of Helsinki and was approved by the local

Ultrasound studies and CAD

In 101 patients, the presence of CAD was diagnosed by coronary angiography, and in 21 patients CAD was excluded. As shown in Table II , patients without CAD had significantly better endothelium-dependent vasodilation (FMD%) in response to reactive hyperemia (7.01% ± 3.51% vs 3.77% ± 4.11%, P < .001).

. Results of ultrasound measurements in determination of FMD%

Empty CellCADNo CADP value
n10121
Baseline diameter (mm)4.61 (0.73)4.37 (0.77).177
FMD diameter (mm)4.77 (0.73)4.65 (0.72).510
FMD%3.73 (4.11)7.01 (3.51)

Discussion

Our study underlines the close relation between the presence of CAD and impaired peripheral flow-mediated vasodilation, as already shown by Neunteufl et al.18

The new findings of the current study are (1) the noninvasive determination of endothelial dysfunction was found to be a sensitive and specific screening test in patients with clinical suspicion of CAD; (2) the extent of measurable endothelial dysfunction does not correlate with the severity of CAD; and (3) by defining a low cutoff point

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    ☆

    Reprint requests: Stephen Schroeder, MD, Division of Cardiology, University of Tuebingen, Otfried-Mueller-Str 10, D-72076, Tuebingen, Germany. E-mail: [email protected]

    ☆☆

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