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Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Objective

According to published studies, 16–82% of systemic lupus erythematosus (SLE) patients have abnormal findings on myocardial perfusion tests, but it has not been established whether these patients also have abnormal findings on coronary angiography. The aim of this study was to evaluate the frequency of abnormal findings on coronary angiography in SLE patients in whom myocardial perfusion scintigraphy revealed abnormalities.

Methods

Ninety female SLE patients (ages 20–55 years, disease duration >5 years, and current or previous steroid treatment for ≥1 year) underwent myocardial perfusion scintigraphy with single-photon–emission computed tomography using 99mTc-sestamibi. Images were taken while the patient was at rest and after dipyridamole-induced stress. Myocardial perfusion defects were identified in 30 patients (33%). Twenty-one of these patients (mean ± SD age 42 ± 9; mean ± SD disease duration 132 ± 66 months) agreed to undergo coronary angiography.

Results

Atherosclerotic plaques were identified by angiography in 8 of the 21 patients (38%). The majority of coronary abnormalities were localized in the anterior descending artery. The mean ± SD number of risk factors for coronary artery disease (CAD) was significantly higher in the subgroup with (4.5 ± 0.8) compared with the subgroup without (2.5 ± 1.9) abnormal angiographic findings (P = 0.006). Arterial hypertension and postmenopause status were significantly associated with abnormal angiographic findings. Of the patients with at least 4 risk factors for CAD, coronary stenosis was present in 67% (P = 0.005). The number of American College of Rheumatology (ACR) criteria for SLE and scores on the SLE Disease Activity Index and the Systemic Lupus International Collaborating Clinics/ACR damage index were also higher in the subgroup with coronary stenosis (P < 0.05).

Conclusion

This is the first study to examine coronary angiography results in SLE patients with abnormal findings on myocardial scintigraphy. Our data suggest that myocardial scintigraphy can be used to screen SLE patients and that all patients with abnormal findings plus at least 4 risk factors for CAD should undergo coronary angiography.

Several studies have shown that patients with systemic lupus erythematosus (SLE) have more frequent and more precocious atherosclerosis than the general population (1–3), but the etiology and pathophysiology of premature atherosclerosis in SLE are poorly understood (4). The mechanisms of atherosclerosis in SLE patients are probably multifactorial. Several possible mechanisms for ischemia, such as vasculitis, vasospasm, microvascular disease, and thrombosis with or without atherosclerosis, are potential causes of coronary events. Other identified risk factors for cardiovascular disease that may contribute to the coronary disease in SLE patients include circulating immune complexes, activated T cells, antiphospholipid antibodies, and hyperhomocysteinemia (2, 3, 5, 6).

Screening tests for coronary artery disease (CAD) are useful in high-risk patients (7). Detection of atherosclerosis in an early preclinical stage could avoid future cardiovascular events, since preventive interventions could be initiated in these patients (3). Moreover, the use of vascular imaging techniques in cardiovascular research could advance our understanding of the prevalence and mechanisms of CAD in patients with SLE (5).

Myocardial perfusion abnormalities have been reported in 16–82% of SLE patients (8–12). Patients in the general population who have traditional risk factors for CAD and abnormal findings on myocardial scintigraphy usually undergo coronary angiography. However, there have been no published studies of the angiographic evaluation of coronary arteries in SLE patients who have abnormal findings on myocardial scintigraphy.

The aim of this study was to evaluate findings on coronary artery angiography in SLE patients in whom myocardial scintigraphy revealed abnormalities. The secondary objective was to evaluate the possible association between the presence of atherosclerotic plaques on coronary angiography and the following parameters: traditional risk factors for CAD, the number of American College of Rheumatology (ACR) criteria met, the SLE Disease Activity Index (SLEDAI) score, and the Systemic Lupus International Collaborating Clinics/ACR (SLICC/ACR) damage index (DI) score.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Patients.

SLE patients who were receiving regular followup care at the Rheumatology Division of the Universidade Federal de São Paulo, Escola Paulista de Medicina, from September 1998 to September 2000 were invited to participate in this study. The study was approved by ethics committees of the university and the hospital, and all participants signed an informed consent form.

Ninety SLE patients who met the inclusion and exclusion criteria agreed to undergo myocardial scintigraphy. The inclusion criteria were as follows: presence of SLE according to the ACR criteria (13, 14), female sex, ages 20–55 years, disease duration >5 years, and current or previous steroid treatment for ≥1 year. Patients were excluded for any of the following features: ineligibility for the dipyridamole protocol (15), current or previous confirmed coronary disease (such as acute myocardial infarction), coronary interventions (percutaneous transluminal coronary angioplasty or coronary artery bypass surgery), pregnancy, and breastfeeding.

Clinical assessments.

The standard protocol included assessment and recording of demographic data, traditional risk factors for CAD at the time of study, SLE disease-related risk factors, signs and symptoms suggestive of angina pectoris, and physical evaluation. Blood and urine samples were obtained, and standard laboratory tests and assessments for diabetes mellitus, dyslipidemia, menopause status, and components of the SLEDAI were performed (16). The protocol also included clinical chart reviews to collect clinical and serologic data and to calculate the SLICC/ACR DI score (17, 18).

The following traditional risk factors for CAD were examined: arterial hypertension (blood pressure ≥140/90 mm Hg or treatment with antihypertensive drugs), diabetes mellitus (fasting glucose ≥126 mg/dl or treatment with insulin or oral hypoglycemic agents), dyslipidemia (high-density lipoprotein [HDL] cholesterol <35 mg/dl, low-density lipoprotein [LDL] cholesterol ≥130 mg/dl, or triglycerides ≥200 mg/dl), postmenopause status, current smoker, obesity (body mass index [BMI] ≥30 kg/m2), and family history of premature CAD (definite acute myocardial infarction or sudden death before the age of 55 years in first-degree male relatives and before the age of 65 years in first-degree female relatives) (19–23).

Myocardial perfusion scintigraphy.

Myocardial perfusion scintigraphy was performed using single-photon–emission computed tomography (SPECT) with 99mTc-sestamibi as the radiotracer. A 2-phase 1-day protocol was used, with images captured under resting conditions and after dipyridamole-induced stress.

A resting 12-lead electrocardiogram (EKG) was performed. Patients then received 8 mCi of 99mTc-sestamibi (Cardiolite; DuPont Merck Pharmaceuticals, Boston, MA), administered as an intravenous bolus while the patient was at rest. After 1 hour, myocardial images were acquired. Two hours after acquisition of the SPECT images under resting conditions, pharmacologic cardiac stress was induced with dipyridamole (Persantin; Boehringer Ingelheim, Buenos Aires, Argentina), at a dose of 0.56 mg/kg of body weight, which was infused over a period of 4 minutes. Seven minutes after the dipyridamole infusion, 24 mCi of 99mTc-sestamibi was injected as an intravenous bolus. During and after pharmacologic stress, the patient's heart rate, blood pressure, EKG, and physical symptoms were monitored at 1-minute intervals. After 1 hour, myocardial images were acquired.

A cardiologist was in attendance to supervise the pharmacologic stress test. The test was terminated immediately if any of the following occurred: grade 2 or 3 atrioventricular blockade, systolic hypotension of ≤80 mm Hg, a ≥2-mm decrease in the ST segment, angina, headache, hyperventilation, and/or gastrointestinal symptoms (15). Patients with cardiac or vascular symptoms were given 120 mg of aminophylline (Aminofilina; Novartis Biociências, Sao Paulo, Brazil) (24).

Patients prepared for the myocardial perfusion study by abstaining from smoking, alcohol, and caffeine for 24 hours before the test. Calcium-channel blockers, beta-blockers, and medications containing methylxanthine (aminophylline, pentoxifylline, theophylline) were discontinued 48 hours before the procedure (25). To improve the quality of the cardiac images (minimizing radiopharmacologic activity in the bowel), patients were given a fat-rich meal and were instructed to walk for a few minutes; the SPECT images were acquired thereafter.

A tomographic gamma camera (APEX SPX-4/4HR; Elscint, Haifa, Israel) was used to acquire the myocardial scintigraphy images. Data were acquired as 60 frames, with 20 seconds per frame, according to the current conventional clinical protocol. Myocardial perfusion images obtained during the resting 99mTc-sestamibi and dipyridamole-induced stress procedures were reconstructed using routine clinical protocols. Perfusion images were displayed as short-axis, vertical long-axis, and horizontal long-axis tomograms for assessment of perfusion defects. Three expert observers who were blinded to the patients' clinical histories and CAD risk factors performed the visual analyses of the images.

The results were defined as normal if there was no regional hypoconcentration in the 2 series of images (at rest and after dipyridamole stress). Abnormalities were classified as reversible (suggestive of ischemia) or fixed (suggestive of fibrosis). Some patients had more than 1 type of myocardial perfusion defect.

All patients who had abnormal findings on myocardial perfusion tests were invited to undergo coronary angiography. This procedure was considered important for determining the clinical management of these patients. Twenty-one of the patients agreed to undergo the procedure and signed a specific informed consent form. Nine patients refused the procedure. The results of coronary angiography were considered abnormal when there was >30% stenosis of the vascular lumen.

Statistical analysis.

Descriptive data are presented as the mean ± SD. Comparisons of qualitative variables between the subgroups were performed with the chi-square test, the Pearson's chi-square test, and Fisher's exact test. The Mann-Whitney U test was used to analyze quantitative variables. P values less than 0.05 were considered statistically significant (26).

RESULTS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Findings in the SLE patients who underwent myocardial scintigraphy.

Ninety female SLE patients were evaluated. Sixty percent were white. Their mean ± SD age at the time of study was 38 ± 10 years, and their mean ± SD disease duration was 128 ± 59 months. Mean (±SD) scores on the SLEDAI and the SLICC/ACR DI were 6 ± 5 and 2 ± 2, respectively. Their age at the time of diagnosis was 27 ± 9 years (mean ± SD).

During the evolution SLE, malar rash occurred in 82 patients (91%), discoid rash in 21 (23%), photosensitivity in 81 (90%), oral ulcers in 34 (38%), arthritis in 79 (88%), serositis in 33 (37%), renal disorder in 44 (49%), neurologic disorder in 10 (11%), hematologic disorder in 78 (87%), immunologic disorder in 74 (82%), and antinuclear antibodies in 89 (99%). At the time of study, 76 patients (84%) had at least 1 risk factor for CAD, and 20 patients (22%) had at least 4. The more frequent CAD risk factors were arterial hypertension (44%), higher LDL cholesterol level (34%), and postmenopause status (31%).

Myocardial perfusion abnormalities were found in 30 of the 90 SLE patients (33%). Three patients had more than 1 defect, yielding a total of 33 perfusion defects that were identified. Nineteen of the 33 defects (58%) were reversible, 6 (18%) were fixed, and 8 (24%) were reversible and fixed. Sixty-one percent of the myocardial perfusion defects were localized to the anterior wall of the ventricle. Forty-three percent of the patients with abnormal scintigraphic results and 12% of the patients with normal results had at least 4 risk factors for CAD (P = 0.002). Angina pectoris was reported by 8 of the 90 SLE patients (9%). Seven of the 8 patients with angina (88%) and 23 of the 81 patients without angina (28%) had abnormal findings on myocardial perfusion scintigraphy (P = 0.003).

Findings in the SLE patients who underwent coronary angiography.

Twenty-one SLE patients with myocardial perfusion abnormalities (62% white, mean ± SD age 42 ± 9 years, and mean ± SD disease duration 132 ± 66 months) underwent coronary angiography. Sixty-two percent of the defects identified in these patients were reversible. Nine patients (44% white, mean age 35 ± 8 years, and mean disease duration 121 ± 59 months) with abnormal scintigraphic findings refused to undergo angiography. Seventy-eight percent of their perfusion defects were reversible.

In 8 of the 21 patients (38%), stenosis was identified on coronary angiography. Eighty-seven percent of these lesions were localized to the descending coronary artery, corresponding to the area of hypoperfusion detected on myocardial scintigraphy. Patients with abnormal angiographic results had significantly more CAD risk factors (mean ± SD 4.5 ± 0.8, median 4) than did patients without abnormal results (2.5 ± 1.9, median 2) (P = 0.006). In 67% of the patients who had at least 4 CAD risk factors, coronary stenosis was identified angiographically (P = 0.005). Figure 1 shows the mean ± SD number of CAD risk factors (with 95% confidence intervals) in patients with normal and abnormal coronary angiographic results.

thumbnail image

Figure 1. Number of risk factors for coronary artery disease (CAD) in systemic lupus erythematosus patients with normal and abnormal findings on coronary angiography. Values are the mean ± SD, with 95% confidence intervals.

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Arterial hypertension was present in all SLE patients with abnormal angiographic findings and in 54% of those with normal findings (P = 0.046). Eighty-seven percent of the patients with abnormal angiographic findings and 31% of those with normal findings were postmenopausal (P = 0.024). Seven patients with a history of angina pectoris underwent coronary angiography. Three of them (43%) had normal angiographic results and 4 (57%) had abnormal results (P > 0.05).

There were no significant differences in the levels of total, HDL, LDL, and VLDL cholesterol or the BMI between patients with and those without abnormal angiographic results (Table 1). However, triglyceride levels and Castelli I and Castelli II indexes (total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol, respectively) were significantly higher in patients with abnormal angiographic findings.

Table 1. Traditional coronary risk factors in 21 SLE patients who underwent coronary angiography*
Risk factorAll SLE patients (n = 21)Coronary angiography findingsP
Normal (n = 13)Abnormal (n = 8)
  • *

    SLE = systemic lupus erythematosus; HDL = high-density lipoprotein; LDL = low-density lipoprotein; VLDL = very low-density lipoprotein; Castelli I index = total cholesterol/HDL cholesterol; Castelli II index = LDL cholesterol/HDL cholesterol.

  • P values were determined by Mann-Whitney U test. Values less than 0.05 were considered significant.

Total cholesterol, mg/dl    
 Mean ± SD211 ± 67188 ± 41250 ± 84 
 Median (minimum/maximum)191 (110/371)188 (110/295)234 (134/371)0.055
HDL cholesterol, mg/dl    
 Mean ± SD51 ± 1554 ± 1545 ± 12 
 Median (minimum/maximum)51 (27/80)52 (30/80)49 (27/60)0.261
LDL cholesterol, mg/dl    
 Mean ± SD120 ± 6795 ± 43160 ± 82 
 Median (minimum/maximum)111 (29/281)106 (29/176)166 (46/281)0.820
VLDL cholesterol, mg/dl    
 Mean ± SD41 ± 2139 ± 1745 ± 28 
 Median (minimum/maximum)36 (13/88)37 (13/67)29 (21/88)0.885
Triglycerides, mg/dl    
 Mean ± SD141 ± 81113 ± 65186 ± 88 
 Median (minimum/maximum)118 (35/304)94 (35/250)136 (107/304)0.043
Castelli I index    
 Mean ± SD4.4 ± 1.53.7 ± 1.45.5 ± 1.0 
 Median (minimum/maximum)4.2 (2.4/7.0)3.5 (2.4/7.0)5.6 (3.9/7.0)0.008
Castelli II index    
 Mean ± SD2.6 ± 1.52.0 ± 1.33.5 ± 1.5 
 Median (minimum/maximum)2.2 (0.7/5.2)1.9 (0.7/4.8)3.8 (1.0/5.2)0.020
Body mass index, kg/m2    
 Mean ± SD29 ± 629 ± 630 ± 7 
 Median (minimum/maximum)30 (19/39)26 (20/38)30 (19/39)0.828

The mean age and disease duration at the time of study and the mean age at the time of SLE diagnosis were not significantly different between the patients with normal angiographic findings and those with abnormal findings (Table 2). However, the number of ACR criteria, the SLEDAI score, and the SLICC/ACR DI score, which could be considered SLE-related risk factors for CAD, were statistically significantly higher in patients with abnormal angiographic results than in patients with normal results.

Table 2. Age-related and SLE-related risk factors for coronary artery disease in 21 SLE patients who underwent coronary angiography*
Risk factorAll SLE patients (n = 21)Coronary angiography findingsP
Normal (n = 13)Abnormal (n = 8)
  • *

    SLE = systemic lupus erythematosus; SLEDAI = SLE Disease Activity Index; ACR = American College of Rheumatology; SLICC/ACR = Systemic Lupus International Collaborating Clinics/ACR; DI = damage index.

  • P values were determined by Mann-Whitney U test. Values less than 0.05 were considered significant.

Age at the time of study, years    
 Mean ± SD42 ± 939 ± 1047 ± 4 
 Median (minimum/maximum)45 (23/52)42 (23/51)42 (41/52)0.064
SLE duration, months    
 Mean ± SD132 ± 66125 ± 64142 ± 74 
 Median (minimum/maximum)120 (61/312)127 (61/302)120 (62/312)0.664
Age at SLE diagnosis, years    
 Mean ± SD31 ± 1029 ± 1035 ± 8 
 Median (minimum/maximum)33 (13/45)27 (13/45)34 (18/44)0.128
Number of ACR criteria    
 Mean ± SD7 ± 26 ± 18 ± 1 
 Median (minimum/maximum)7 (4/10)6 (4/9)8 (6/10)0.018
SLEDAI    
 Mean ± SD6 ± 54 ± 311 ± 3 
 Median (minimum/maximum)6 (0/18)4 (0/12)10 (6/18)0.010
SLICC/ACR DI    
 Mean ± SD2 ± 21 ± 14 ± 1 
 Median (minimum/maximum)2 (0/6)1 (0/5)3 (2/6)0.003

During followup of the patients with abnormalities identified on coronary angiography, 1 patient experienced an extensive acute myocardial infarction complicated by a cerebrovascular accident. This patient died. Three patients underwent angioplasty, with placement of a stent in the right coronary artery in 1 patient and in the anterior descending artery in the other 2 patients. One patient underwent revascularization surgery, and the remaining 3 patients were maintained with conservative therapy.

DISCUSSION

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

In the present study, we found that 33% of 90 SLE patients with disease duration of >5 years had abnormal findings on myocardial scintigraphy. This is the first study in which coronary angiography was performed in SLE patients in whom abnormalities were identified on myocardial scintigraphy. We found that in 38% of the patients with abnormal scintigraphic features, coronary lesions were identified by angiography. In 67% of the SLE patients with abnormal scintigraphic findings and at least 4 risk factors for CAD, coronary angiography revealed the presence of stenosis.

In the general population, the measurement of subclinical disease provides an approach to identifying individuals who may be at high risk of developing clinical cardiovascular events (27). In the literature, there is no consensus about the best diagnostic method for evaluating subclinical CAD in SLE patients. Coronary angiography is too invasive and would be unethical to use for the initial evaluation of SLE patients with CAD risk factors. Coronary artery scanning by electron beam computed tomography (EBCT) has been used to measure noninvasively the deposition of calcium in the coronary artery walls. EBCT may be able to detect premature atherosclerosis in SLE patients (5, 28). However, this method is not widely available, and it is a very expensive procedure. Measurement of carotid artery intima-media thickness by B-mode ultrasound is a noninvasive method of predicting the future incidence of coronary disease in the general population (29). Potentially modifiable risk factors, including traditional coronary risk factors, SLE-related factors, and inflammation markers, have been found to be associated with vascular disease detected by this method (30, 31). No study has demonstrated the usefulness of this method for selecting SLE patients to undergo more invasive coronary tests.

Previous studies have demonstrated the prognostic value of myocardial perfusion scintigraphy with pharmacologically induced stress (dipyridamole infusion) performed with SPECT images using 99mTc-sestamibi in patients with CAD risk factors (32–34). This noninvasive tool shows high sensitivity (95–100%) and variable specificity (75–100%) (35). Hypoperfusion observed on myocardial scintigraphy suggests the presence of ischemia in the case of reversible perfusion defects and fibrosis in the case of fixed defects (36, 37). However, correlation between myocardial hypoperfusion and CAD is not perfect. The sensitivity of cardiac scintigraphy increases with an increasing number of injured vessels (37), and its predictive value depends on the population being tested (38).

Abnormal myocardial scintigraphic findings with normal coronary angiographic findings may occur in cases in which angiography cannot identify coronary disease because of inadequate projections, the presence of the diaphragm overlying the vessels, congenital anomalies of coronary arteries, and intra- and interobserver differences (37). False-positive results on myocardial scintigraphy could occur in patients with mitral valve prolapse, myocardial bridge, Chagas' disease, aortic stenosis, left bundle branch block, Wolff-Parkinson-White syndrome, breast and diaphragm attenuation, motion artifacts, and reconstruction artifacts (37, 39). In the present study, we tried to reduce factors that could potentially impair the scintigraphic results, as described in Patients and Methods. Moreover, none of our patients had Wolff-Parkinson-White syndrome, Chagas' disease, or significant valve disease that could cause abnormal scintigraphic results. The frequency of abnormal findings on myocardial scintigraphy in our study is consistent with those from other studies of SLE patients (8–12).

In recent years, several studies in the general population have focused on the role of the endothelium in regulating epicardial coronary artery vasomotor tone and in modulating coronary microvascular function (40, 41). Coronary microvascular endothelial dysfunction is a possible explanation for chest pain symptoms in patients with normal findings on coronary angiography or with minimal coronary atherosclerosis (42, 43). Moreover, severe endothelial dysfunction in the absence of obstructive CAD has been associated with an increased frequency of cardiac events (44). CAD risk factors that include the presence of arterial hypertension and hypercholesterolemia, the total number of CAD risk factors, and age >50 years have been associated with impairment of endothelial vasoactive function in coronary arteries (45–47). Lima et al (48) used a high-resolution ultrasound technique to measure brachial artery diameter at rest and after flow-induced dilation, and demonstrated that endothelial function is impaired in SLE patients even in the absence of traditional risk factors for CAD. SLE-related risk factors, such as inflammatory and immunologic factors, may be important triggers in the induction of the early stages of vascular disease.

The absence of detectable lesions on angiography in many of our SLE patients with abnormal myocardial scintigraphic findings does not exclude the possibility that atherosclerosis is present in an early/subclinical stage. Hasdai et al (41) showed that coronary endothelial dysfunction may be temporally associated with myocardial perfusion defects, which supports the role of coronary epicardial and microcirculation endothelium in regulating myocardial perfusion. Vessels that are apparently normal on angiography could be affected by an endothelial dysfunction that may be considered an early atherosclerotic process. Endothelial dysfunction may account for normal angiographic results in our patients with abnormal scintigraphic results (41–44). Indeed, in a recent study using a high-resolution ultrasound technique (49), we observed a significant association between myocardial perfusion defects and endothelial dysfunction in the brachial artery.

Although some studies have shown that assessment of the angiographic severity of coronary stenosis may be inadequate to accurately predict the time or location of a subsequent coronary occlusion associated with acute myocardial infarction (50–52), the value of coronary angiography remains unquestioned, and this procedure is considered the gold standard technique for defining the anatomy of coronary vessels and determining whether conservative or invasive treatment is the best approach.

In our study, the presence of CAD risk factors was associated with abnormal scintigraphic results. Performing coronary angiography in 21 SLE patients with abnormal myocardial scintigraphic results, we found that angiographic abnormalities were associated with the presence of at least 4 risk factors for CAD. We also found a significant association between the presence of angiographic abnormalities and arterial hypertension and postmenopause status, confirming the importance of traditional risk factors for CAD in the development of atherosclerosis in SLE patients and showing the necessity of developing strategies to better control these factors in SLE patients.

This is the first study in which angiography was performed to evaluate abnormal myocardial scintigraphic findings in SLE patients. Despite the relative limitation of the small number of patients in whom coronary angiography was performed, our study showed that 38% of patients with abnormal findings on myocardial scintigraphy had coronary lesions detected on angiography. Patients with abnormal myocardial scintigraphic findings and at least 4 risk factors for CAD had a higher risk of abnormal findings on coronary angiography. These data suggest that myocardial scintigraphy can be used to screen SLE patients and that all patients with abnormal scintigraphic findings and at least 4 risk factors for CAD should undergo coronary angiography.

Acknowledgements

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

We are grateful for the financial support by the FAPESP. We thank Wagner A. Leite, MD, and Japy A. Oliveira Filho, MD, PhD (Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina), for performing the dipyridamole-induced stress tests. We also thank the members of the Invasive Cardiology Division for performing the coronary angiographies and Gilberto Alonso, MD, PhD, and Marta M. Sevillano, MD, for performing the analyses of the myocardial scintigraphy images.

REFERENCES

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES
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