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Objective Negative emotional states, such as anger and anxiety, are associated with the onset of myocardial infarction and other acute clinical manifestations of ischemic heart disease. The likelihood of experiencing these short-term negative emotions has been associated with long-term psychological background factors such as depression, generalized anxiety, and personality factors. We examined the association of acute emotional states preceding cardiac stress testing (CST) with inducibility of myocardial ischemia and to what extent psychological background factors account for this association. Methods Emotional states were assessed in patients undergoing CST (n = 210; mean [standard deviation] age = 66.9 [8.2] years); 91 (43%) women) using self-report measures and video recordings of facial emotion expression. Video recordings were analyzed for expressed anxiety, anger, sadness, and happiness before CST. Psychological background factors were assessed with validated questionnaires. Single-photon emission computed tomography was used to evaluate inducibility of ischemia. Results Ischemia occurred in 72 patients (34%). Emotional states were not associated with subsequent inducibility of ischemia during CST (odds ratio between 0.93 and 1.04; p values > .50). Psychological background factors were also not associated with ischemia (odds ratio between 0.96 and 1.06 per scale unit; p values > .20) and did not account for the associations of emotional states with ischemia. Conclusions Emotional states immediately before CST and psychological background factors were not associated with the inducibility of ischemia. These findings indicate that the well-documented association between negative emotions with acute clinical manifestations of ischemic heart disease requires a different explanation than a reduced threshold for inducible ischemia.

Background Negative emotions have been linked to ischemic heart disease, but existing research typically involves self-report methods and little is known about non-verbal facial emotion expression. The role of ischemia and anginal symptoms in emotion expression was examined. Methods Patients undergoing cardiac stress testing (CST) using bicycle exercise or adenosine with myocardial perfusion imaging were included (N = 256, mean age 66.8 ± 8.7 year., 43% women). Video images and emotion expression (sadness, anxiety, anger, and happiness) were analyzed at baseline, initial CST , maximal CST, recovery. Nuclear images were evaluated using SPECT. Results Ischemia (N = 89; 35%) was associated with higher levels of sadness (p = .017, d = 0.34) and lower happiness (p = .015, d = 0.30). During recovery, patients with both ischemia and anginal symptoms had the highest sadness expression (F (3,254) = 3.67, p = .013, eta2 = 0.042) and the lowest happiness expression (F (3, 254) = 4.19, p = .006, eta2 = .048). Conclusion Sadness and reduced happiness were more common in patients with ischemia. Also, anginal symptoms were associated with more negative emotions.

Background Patients with myocardial ischemia in the absence of obstructive coronary artery disease (CAD) often experience anginal complaints and are at risk of cardiac events. Stress-related psychological factors and acute negative emotions might play a role in these patients with suspect coronary microvascular dysfunction (CMD). Methods and Results 295 Patients (66.9 ± 8.7 years, 46% women) undergoing myocardial perfusion single-photon-emission computed tomography (MPI-SPECT), were divided as follows: (1) a non-ischemic reference group (n = 136); (2) patients without inducible ischemia, but with a history of CAD (n = 62); (3) ischemia and documented CAD (n = 52); and (4) ischemia and suspect CMD (n = 45). These four groups were compared with regard to psychological factors and acute emotions. Results revealed no differences between the groups in psychological factors (all P > .646, all effect sizes d P = .029). The groups did not differ in the association of psychological factors or emotions with anginal complaints (all P values > .448). Conclusion Suspect CMD was not associated with more negative psychological factors compared to other groups. State sadness was significantly higher for patients with suspect CMD, whereas no differences in state anxiety and other psychological factors were found.

Background The prevalence of myocardial ischemia is associated with anxiety. State and trait anxiety are more common in younger women compared to men, and high anxiety levels could affect hemodynamic reactivity during cardiac stress testing. The aim is to examine whether anxiety plays a role in gender differences in patients ≤ 65 and > 65 years in hemodynamic reactivity and ischemia during cardiac stress testing. Methods and results Included were 291 patients (66.8 ± 8.7 years, 45% women) with suspect ischemia undergoing myocardial perfusion single-photon emission computed tomography (MPI-SPECT). Primary outcomes were semi-quantitative summed difference score (SDS) and summed stress score (SSS), as continuous indicators of myocardial ischemia. Analyses were stratified by age. Trait anxiety was measured using a validated questionnaire (GAD-7) and state anxiety using facial expression analyses software. Overall, trait and state anxiety were not associated with the prevalence of ischemia (N = 107, 36%). A significant interaction was found between gender and trait anxiety in women ≤ 65 years for SDS (F(1,4) = 5.73, P = .019) and SSS (F(1,10) = 6.50, P = .012). This was not found for state anxiety. Conclusion SDS and SSS were significantly higher in women younger than 65 years with high trait anxiety. This interaction was not found in men and women over 65 years.

Background: In cardiac syndrome X, which is a syndrome defined as chest pain, positive exercise stress testing and/or reversible myocardial perfusion defects during myocardial scintigraphy and normal coronary angiograms, the ischemic origin is still debated. No previous study compared the myocardial perfusion in stress first-pass cardiac magnetic resonance (CMR) versus stress single-photon emission computed tomography (SPECT) in cardiac syndrome X. Methods: We performed stress SPECT and CMR imaging for 20 syndrome X patients. Perfusion analysis of the CMR was done by using the normalized upslope of myocardial signal enhancement to derive the myocardial perfusion index (MPI) and the myocardial perfusion reserve index (MPRI). The SPECT images were visually scored by 3 observers using a seg- mental model. Results: An MPRI of  1.2 was found for 31 (9%) of the 335 segments, indicating local ischemia. SPECT indicated re- versible perfusion defects for 39 (12%) of the 335 segments. However, the combination of both an MPRI  1.2 and a re- versible perfusion defect was detected in only 3 segments. Conclusions: Our data show about 10% stress-induced myocardial perfusion abnormalities on CMR and SPECT, suggest- ing local ischemia. However, only in 1% of the segments there was concordance for the presence of myocardial ischemia with both exams. This result may be evidence for the variability over time of the mechanisms responsible for coronary microvascular dysfunction.

Aims: On the basis of an MRI study it has been suggested that subendocardial hypoperfusion is present in patients with cardiac syndrome X. However, further work is required to test whether these findings can be generalized. Methods and results: MRI was used to visually and semi-quantitatively assess subendocardial and subepicardial perfusion, at rest and during an infusion of adenosine, in 20 patients with angina pectoris and normal coronary angiograms. A myocardial perfusion index (MPI) was calculated using the normalized upslope of myocardial signal enhancement. An index for myocardial perfusion reserve (MPRI) was calculated by dividing the MPI values at maximal vasodilatation by the values at rest. The MPI in our study population increased significantly during adenosine infusion in both the subendocardium (from 0.091 ± 0.020 to 0.143 ± 0.030; P < 0.001) and the subepicardium (from 0.074 ± 0.017 to 0.135 ± 0.03; P < 0.001). The overall MPRI was 1.83 ± 0.50. Conclusion: The results show that patients with chest pain and normal coronary angiograms had significant perfusion responses to adenosine in both the subendocardium and subepicardium. In the present study we found no evidence for subendocardial hypoperfusion in these patients. © The European Society of Cardiology 2007. All rights reserved.

Objective: In myocardial perfusion single-photon emission computed tomography (SPECT), abdominal activity often interferes with the evaluation of perfusion in the inferior wall, especially after pharmacological stress. In this randomized study, we examined the effect of carbonated water intake versus still water intake on the quality of images obtained during myocardial perfusion images (MPI) studies. Methods: A total of 467 MIBI studies were randomized into a carbonated water group and a water group. The presence of intestinal activity adjacent to the inferior wall was evaluated by two observers. Furthermore, a semiquantitative analysis was performed in the adenosine subgroup,using a count ratio of the inferior myocardial wall and adjacent abdominal activity. Results: The need for repeated SPECT in the adenosine studies was 5.3 % in the carbonated water group versus 19.4 % in the still water group (p = 0.019). The inferior wall-to-abdomen count ratio was significantly higher in the carbonated water group compared to the still water group (2.11 ± 1.00 vs. 1.72 ± 0.73, p\0.001). The effect of carbonated water during rest and after exercise was not significant. Conclusions: This randomized study showed that carbonated water significantly reduced the interference of extra-cardiac activity in adenosine SPECT MPI. Keywords: Extra-cardiac radioactivity, Myocardial SPECT, Image quality enhancement, Carbonated water

Many patients suffer from persistent angina due to coronary vasospasm despite optimal medical treatment. We treated a 46-year-old patient with severe and treatment-resistant coronary vasospasm with the endothelin-receptor antagonist bosentan. Using oxygen-15-labelled water in conjunction with oxygen 15-labelled carbon monoxide positron emission tomography (PET), we measured an impaired coronary flow reserve (CFR) in 6 out of 13 segments directly before the start of bosentan therapy. A repeated PET measurement after 16 weeks of bosentan revealed a completely normalized CFR in this patient. Furthermore, the patient reported less frequent and less severe chest pain. Our data suggest a potential role of endothelin-receptor antagonists for patients with severe coronary vasospasms.

Aims Follow-up studies of patients with cardiac syndrome X (CSX) generally report good prognosis. However, some recent studies report an adverse outcome for women. Methods and results Structured literature search and meta-analysis for studies regarding prognosis of cardiac syndrome X patients. We identified 85 studies, ultimately selecting 16 for inclusion. Meta-analysis yielded a pooled major cardiac event percentage of 1.5% per 5 years and a pooled vascular event percentage of 4.8% per 5 years (n = 16 studies, n = 1694 patients). Fourteen studies reported upon the recurrence rate of angina pectoris: the pooled percentage of angina recurrence was 55% (n = 1336 patients). Conclusion The present review of recent archival literature demonstrates an overall major cardiac event rate of 1.5% per 5 years. Although this is an excellent prognosis for CSX patients, the quality of life is impaired because of the high recurrence rate of angina pectoris (55%).

Positron emission tomography (PET) enables robust and reproducible measurements of myocardial blood flow (MBF). However, the relatively limited resolution of PET till recently prohibited distinction between the subendocardial and the subepicardial layers in non-hypertrophied myocardium. Recent developments in hard- and software, however, have enabled to identify a transmural gradient difference in animal experiments. The aim of this study is to determine the feasibility of subendocardial and subepicardial MBF in normal human hearts assessed with (15)O-labeled water PET.Twenty-seven healthy subjects (mean age 41 ± 13 years; 11 men) were studied with (15)O-labeled water PET to quantify resting and hyperaemic (adenosine) MBF at a subendocardial and subepicardial level. In addition, cardiac magnetic resonance imaging was performed to determine left ventricular (LV) volumes and function.Mean rest MBF was 1.46 ± 0.49 in the subendocardium, and 1.14 ± 0.342 mL · min(-1) · g(-1) in the subepicardium (P .001). MBF during vasodilation was augmented to a greater extent at the subepicardial level (subendocardium vs subepicardium: 3.88 ± 0.86 vs 4.14 ± 0.88 mL · min(-1) · g(-1), P = .013). The endocardial-to-epicardial MBF ratio decreased significantly during hyperaemia (1.35 ± 0.23 to 1.12 ± 0.20, P .001). Hyperaemic transmural MBF was inversely correlated with left ventricular end-diastolic volume index (LVEDVI) (r (2) = 0.41, P = .0003), with greater impact however at the subendocardial level.(15)O-labeled water PET enables MBF measurements with distinction of the subendocardial and subepicardial layers in the normal human heart and correlates with LVEDVI. This PET technique may prove useful in evaluating patients with signs of ischaemia due to coronary artery disease or microvascular dysfunction.

There is no consensus regarding the definition of cardiac syndrome X (CSX). We systematically reviewed recent literature using a standardized search strategy. We included 57 articles. A total of 47 studies mentioned a male/female distribution. A meta-analysis yielded a pooled proportion of females of 0.56 (n = 1,934 patients, with 95% confidence interval: 0.54–0.59). As much as 9 inclusion criteria and 43 exclusion criteria were found in the 57 articles. Applying these criteria to a population with normal coronary angiograms and treated in 1 year at a general hospital, the attributable CSX incidence varied between 3 and 11%. The many inclusion and exclusion criteria result in a wide range of definitions of CSX and these have large effects on the incidence. This shows the need for a generally accepted definition of CSX.