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Heart Disease of the Small Arteries in Women and Men

This study is currently recruiting participants. (see Contacts and Locations)
Verified March 2017 by Cedars-Sinai Medical Center
Information provided by (Responsible Party):
Noel Bairey Merz, Cedars-Sinai Medical Center Identifier:
First received: December 12, 2007
Last updated: March 23, 2017
Last verified: March 2017

Women suffer disproportionately than men from Cardiac Syndrome X ( chest pain in the absence of flow limiting coronary artery stenosis). Coronary microvascular disease is hypothesized to mediate chest pain in this syndrome. This disorder of the small heart vessels (arterioles) compared to the large vessels (arteries) is not diagnosed during routine heart catheterization. This results in delays in diagnosis, missed opportunities for treatment, and likely contributes to the increased death rate from coronary heart disease in women compared to men.

Current testing for small vessel disease is performed in the cardiac catheterization laboratory using specialized testing and is not performed routinely. Accordingly, women with this condition are either falsely reassured, or misdiagnosed as another non-cardiac condition. Unnecessary healthcare costs related to re-hospitalization and repeat angiography are incurred, while women are often not initiated on appropriate lifesaving treatment. We and others have demonstrated in randomized controlled trials that therapies that target the endothelium, e.g. statins, ACE inhibitors, and exercise are effective in this condition.

Majority of women with Cardiac Syndorme X go undiagnosed. Recent studies have shown significant increased health care costs, morbidity and mortality related to this disease. It is becoming more important to further characterize this group of patients and we hope to do that with our study.

Condition Intervention
Heart Disease
Procedure: noninvasive tests

Study Type: Interventional
Study Design: Intervention Model: Single Group Assignment
Masking: No masking
Primary Purpose: Treatment
Official Title: Coronary Microvascular Disease and Endothelial Function in Women and Men

Resource links provided by NLM:

Further study details as provided by Cedars-Sinai Medical Center:

Primary Outcome Measures:
  • noninvasive Peripheral Artery Tonometry (PAT) testing and Cardiac Magnetic Resonance (CMR) imaging for the outcome of coronary endothelial dysfunction [ Time Frame: 120 minutes ]

Secondary Outcome Measures:
  • clinically indicated coronary angiography with adenosine coronary flow reserve measurement and acetylcholine provocative testing [ Time Frame: 60 minutes ]

Estimated Enrollment: 634
Study Start Date: November 2005
Estimated Study Completion Date: January 2020
Estimated Primary Completion Date: January 2020 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Single Arm
  1. fill out baseline demographic and health/medical history questionnaires, CV risk factors, reasons of diagnosis of ischemia, information of coronary artery, and medication use
  2. undergo clinically indicated coronary angiography with adenosine coronary flow reserve measurement and acetylcholine provocative testing in the cardiac catheterization laboratory (Appendix);
  3. undergo noninvasive Peripheral Artery Tonometry (PAT) testing (Appendix);
  4. undergo clinically indicated Cardiac Magnetic Resonance (CMR) imaging (Appendix) to detect subendocardial ischemia (if indicated and referred by the treating physician). The three tests (heart catheterization with adenosine coronary flow reserve testing, acetylcholine provocative vasomotor testing during heart catheterization, cardiac MRI) are performed for standard care.
  5. have blood and urine testing.
  6. fill out health questionnaires
  7. be followed prospectively 6-week, 6-month, and annually for clinical status
Procedure: noninvasive tests
clinically indicated coronary angiography with adenosine coronary flow reserve measurement and acetylcholine provocative testing in the cardiac catheterization laboratory; Peripheral Artery Tonometry (PAT) testing; Cardiac Magnetic Resonance (CMR) imaging.

Detailed Description:

Study Aims:

  1. To establish prevalence of microvascular disease in women and men with Cardiac Syndrome X
  2. To study the predictive value and utility of noninvasive tests like Peripheral Artery Tonometry (PAT) and Cardiac Magnetic Resonance (CMR) in diagnosing Cardiac Syndrome X.
  3. To establish prognosis in women and men with Cardiac Syndrome X.
  4. To elucidate the risk factors, clinical features, diagnostic methods, treatment, and prognosis of patients with microvascular angina (MVA).

With this research study, we want to specifically study a group of patients who have chest pain or other signs or symptoms suggestive of heart disease but don't have visible blockages in the large heart arteries. Patients with chest pain who undergo heart catheterization but have no blockages of large heart arteries will be consented and enrolled. Patients will be asked to fill out questionnaires about their medical history, including family, reproductive and, social histories. They will also be asked to undergo testing during heart catheterization that would test for abnormalities in their small heart arteries using medications, acetylcholine and adenosine. This testing is a standard of care procedure given at the discretion of the treating physician. Patients would receive this test whether they participate in the research or not. The test is performed by infusing acetylcholine and adenosine through the same catheter that is used for routine heart catheterization. This test may add an additional 15 minutes to the heart catheterization procedure.

In addition, patients will be asked to undergo a non-invasive test called Peripheral Arterial Tonometry or PAT for research purposes and in some cases, if clinically indicated a Cardiac Magnetic Resonance (CMR) imaging test as a standard of care. Patients will be followed up using phone questionnaires at 6 months and than annually thereafter. It is proposed that problems with the function of the large and small arteries may be responsible for giving some patients their symptoms of chest pain and put them at risk for heart attacks. PAT may help us more easily and non-invasively measure this function by testing the arteries in the arm. Selected patients will also undergo CMR imaging that may be useful to detect abnormalities in the inner layer of the heart muscle resulting from the abnormal function of the large and small heart arteries. These non-invasive tests will be corroborated with results from invasive testing during heart catheterization, which is considered the gold standard for testing for function of the large and the small heart arteries.

The three tests (heart catheterization with adenosine coronary flow reserve testing, acetylcholine provocative vasomotor testing during heart catheterization, cardiac MRI) are performed for standard care.

Blood and urine collection have been added to this protocol as a secondary outcome for future tests and for testing whether impaired Endothelial Progenitor Cell (EPC) number is related to the presence and severity of microvascular disease.

Results from our study will help confirm the need to test patients with chest pain and open large arteries during heart catheterizations for abnormalities in the function of the large and small heart arteries, and to validate the usefulness of using non-invasive techniques like PAT and CMR for detecting this problem. The study will also help confirm the increased risk of heart attack associated with the abnormal function in the large and small arteries in these patients.

Subjects will be asked if they are interested in receiving information on Pro00015124 (repository/collection). If they are interested, they will be consented under Pro00015124. No specimens collected as part of this study will be forwarded to Pro00015124.


Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Women and men with signs and symptoms of myocardial ischemia and angina or angina equivalent (chest pain, abnormal stress testing, abnormal noninvasive testing) or microvascular angina (MVA) which is defined as angina and ischemic ECG changes without organic obstructive stenosis or epicardial spasm of the coronary arteries
  2. No obstructive coronary artery disease performed within the previous 24 months (<50% luminal obstruction in one or more coronary arteries on angiography).
  3. Age > 18 years old
  4. Competent to give informed consent

Exclusion Criteria:

  1. Obstructive CAD ≥ 50% luminal diameter stenosis in ≥ 1 epicardial coronary artery,
  2. Acute coronary syndrome (defined by the ACC/AHA criteria, Braunwald 2000),
  3. Primary valvular heart disease clearly indicating the need for valve repair or replacement;
  4. Patients with concurrent cardiogenic shock or requiring inotropic or intra-aortic balloon support;
  5. Prior or planned percutaneous coronary intervention or CABG or prior acute MI in prior 30 days;
  6. Prior non-cardiac illness with an estimated life expectancy <4 years;
  7. Unable to give informed consent;
  8. Chest pain with a non-ischemic etiology (e.g.,pericarditis, pneumonia, esophageal spasm);
  9. Contraindications to adenosine or Regadenoson (Lexiscan)
  10. Women and men with intermediate coronary stenoses (>20% but <50% luminal diameter stenosis assessed visually at the time of angiography) will undergo clinically indicated IVUS testing based on the judgment of the operator; those determined to have flow FFR or obstructing stenosis will be excluded from the overall study.
  11. Heart failure (NYHA Class III or IV on treatment)
  12. LV dysfunction (ejection fraction <40%)
  13. Documented obstructive myocardiopathy
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its identifier: NCT00573027

Contact: Ying Mou, PhD 310-248-7669
Contact: Sophie Yoo, MS 424-315-4306

United States, California
Cedars-Sinai Women's Heart Center Recruiting
Los Angeles, California, United States, 90048
Contact: Ying Mou, PhD    310-248-7669   
Contact: Sophie Yoo, MS    424-315-4306   
Principal Investigator: Noel Bairey-Merz, MD         
Sub-Investigator: Saibal Kar, MD         
Sub-Investigator: Raj Makkar, MD         
Sub-Investigator: Dan Berman, MD         
Sub-Investigator: Leslee Shaw, MD         
Sub-Investigator: Louise Thompson, MBChB         
Sub-Investigator: Rola Saouf, MD         
Sponsors and Collaborators
Cedars-Sinai Medical Center
Principal Investigator: C.Noel Bairey-Merz, MD Cedars-Sinai Medical Center
  More Information

Responsible Party: Noel Bairey Merz, Director, Cedars-Sinai Medical Center Identifier: NCT00573027     History of Changes
Other Study ID Numbers: IRB 8221
Study First Received: December 12, 2007
Last Updated: March 23, 2017
Individual Participant Data  
Plan to Share IPD: Undecided

Keywords provided by Cedars-Sinai Medical Center:
microvascular dysfunction

Additional relevant MeSH terms:
Heart Diseases
Cardiovascular Diseases
Vasodilator Agents
Cholinergic Agonists
Cholinergic Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action
Physiological Effects of Drugs
Sensory System Agents
Peripheral Nervous System Agents
Anti-Arrhythmia Agents
Purinergic P1 Receptor Agonists
Purinergic Agonists
Purinergic Agents processed this record on May 25, 2017