ArticleThe international journal of cardiovascular imaging2026
Paradoxical ST-segment depression at high blood flow in ANOCA: a hypothesis-generating analysis.
Article in The international journal of cardiovascular imaging, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundAngina with non-obstructive coronary arteries (ANOCA) is increasingly recognized as a common cause of chest pain.
objectiveWe observed that some ANOCA patients undergoing dipyridamole rubidium-82 positron emission tomography (PET)/computed tomography (CT) myocardial perfusion imaging (MPI) develop ST-segment depression despite preserved or elevated stress myocardial blood flow (MBF). This study sought to characterize this phenomenon.
methodsWe analyzed patients referred for rubidium-82 PET/CT MPI without obstructive coronary artery disease for evaluation of microvascular function between 2017 and 2023 (ANOCA) and a propensity-matched control group at very low likelihood of obstructive disease. Stress MBF was categorized as low (< 2.0 mL/min/g), normal (2.0-3.5 mL/min/g), or high (> 3.5 mL/min/g). ST-segment depression was defined as ≥ 1 mm horizontal or downsloping depression in two contiguous leads.
resultsThe final cohort comprised 136 ANOCA patients and 533 controls. A total of 37 (5.5%) patients presented ST-segment depression, 25 (4.7%) in the control group and 12 (8.8%) in the ANOCA group; all were female. Its prevalence was significantly higher among patients with high vs. normal stress MBF in both the ANOCA group (37.5% vs. 6.1%, p = 0.0016) and the Control group (16.7% vs. 3.4%, p < 0.0001). At any given stress MBF, ANOCA patients had a higher probability of developing ST-segment depression compared with controls (p = 0.0037). In multivariable analyses, ST-segment depression was significantly associated with high stress MBF in ANOCA patients (OR:4.85, 95%CI:1.07-21.93).
conclusionsVasodilator-induced ST-segment depression was observed more frequently at higher stress MBF, particularly in ANOCA, raising the possibility of a paradoxical "high-flow ischemia" phenotype. These observations are hypothesis-generating and highlight the need for further studies to clarify underlying mechanisms and prognostic relevance.
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