Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease

Estrada, André; Sousa, André Silveira; Mesquita, Claudio Tinoco; Villacorta, Humberto

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Original Article • Arq. Bras. Cardiol. 119 (6) • Dec 2022 • https://doi.org/10.36660/abc.20210787 copy

Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia.

Objective

To assess the association between CorT and myocardial ischemia.

Methods

Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level.

Results

A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021).

Conclusion

This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

Coronary Vessels; Ischemia; Myocardial Ischemia

Characteristic	Value
Demographics
Age (years), mean ± SD	58.3 ±8.8
Female sex	40 (70.2%)
Body mass index (Kg/m2), mean ± SD	29 ±5.2
Creatinine Clearance (mL/min)*	93.6±29.4
Presenting symptoms
Angina CCS I	14 (24.6%)
Angina CCS II	21 (36.8%)
Angina CCS III	20 (31.5%)
Angina CCS IV	2 (3.5%)
Dyspnea	32 (56.1%)
Cardiovascular risk factors
Smoking	8 (14%)
Sedentarism	47 (82.5%)
Hyperlipidemia	27 (47.4%)
Diabetes	17 (29.8%)
Hypertension	51 (89.5%)
Left ventricular ejection fraction (%), mean ± SD	66.5 (10.2)
Medication
Beta-blocker or calcium channel blockers	42 (73.7%)
Nitrates or trimetazidine	34 (59.6%)
Statins	30 (52.6%)
Aspirin	48 (84.2%)
Myocardial perfusion SPECT
Abnormal SPECT	37 (64.9%)
If abnormal, myocardial impairment (%), mean ± SD	5.9 (3.3)
Abnormal SPECT in LAD territory	25 (43.9%)
Abnormal SPECT in LCX territory	19 (33.3%)
Abnormal SPECT in RCA territory	13 (22.8%)
Invasive Coronary Angiography
Subjects with CorT	16 (28,1%)
LAD CorT	10 (17,5%)
LCX CorT	10 (17,5%)
RCA CorT	4 (7%)

Characteristics	CorT (n = 16)	No CorT (n = 41)	p value
Age (years)	62.2 ± 7.5	56.8 ± 8.9	0.042
Female	13 (81.3%)	27 (65.9%)	0.26
BMI (kg/m²)	29.2 ± 5.0	28.9 ± 5.3	0.84
Acetylsalicylic acid	14 (87.5%)	34 (82.9%)	0.67
Statin	8 (50.0%)	22 (53.7%)	0.80
Beta-blocker/ calcium channel blocker	13 (81.3%)	29 (70.7%)	0.42
Nitrate/ trimetazidine	8 (50.0%)	26 (63.4%)	0.36
Angina CCS I	2 (12.5%)	12 (29.3%)
Angina CCS II	7 (43.8%)	14 (34.1%)	0.22
Angina CCS III/IV	7 (43.8%)	15 (36.6%)	0.25
Dyspnea	9 (56.3%)	23 (56.1%)	0.99
Hypertension	15 (93.8%)	36 (87.8%)	0.52
Diabetes	5 (31.3%)	12 (29.3%)	0.88
Dyslipidemia	6 (37.5%)	21 (51.2%)	0.35
Sedentarism	13 (81.3%)	34 (82.9%)	0.88
Smoker	2 (13%)	6 (14.6%)	0.84

	Ischemia			No Ischemia			p value

	N	Median	Range	N	Median	Range
LAD
most severe bend angle during diastole (degrees)	25	114	82-135	32	108	78.5-136	0.6
number of bend angles <90° during diastole	25	0	0-1	32	0.0	0-1	0.89
most severe bend angle during systole (degrees)	25	78	59.5-112	32	74.5	61.3-117	0.92
number of bend angles <90° during systole	25	1	0-2.5	32	1	0-3	0.9
LCX
most severe bend angle during diastole (degrees)	19	79	58-109	38	102	74.3-120	0.083
number of bend angles <90° during diastole	19	1	0-3	38	0	0-1	0.025
most severe bend angle during systole (degrees)	19	55	46-96	38	97	52.5-121	0.077
systole number of bend angles <90° during systole	19	3.0	0-3	38	0	0-2	0.005
RCA
most severe bend angle during diastole (degrees)	13	88	59.5-106.5	44	104	74.8-121	0.16
number of bend angles <90° during diastole	13	1	0-1.5	44	0	0-1	0.31
most severe bend angle during systole (degrees)	13	71	44-93	44	94	57.5-112	0.14
number of bend angles <90° during systole	13	1	0-2	44	0	0-1	0.24

Angiographic parameters	Ischemia (n =57)		No Ischemia (n = 114)		p value

	median	Range	median	range
most severe bend angle during diastole (degrees)	92	67-118	105	76-122	0.3
number of bend angles <90° during diastole	0	0-2.5	0	0-1	0.1
most severe bend angle during systole (degrees)	73	48.5-107	85.5	56.5-115	0.074
number of bend angles <90° during systole	1.5	0-3	1	0-2	0.021

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