Detecting occult coronary disease in a high-risk asymptomatic population

Background - Exercise stress testing alone or with perfusion imaging is the standard screening method to determine the presence of obstructive coronary artery disease (CAD) in people with chest pain. In asymptomatic individuals with a family history of premature CAD, it is unclear whether abnormalities on these functional exercise tests represent significant coronary disease. Methods and Results - An abnormal exercise test, thallium scan, or both occurred in 153 (21%) of 734 asymptomatic siblings of persons with documented CAD, of whom 105 underwent coronary angiography with quantitative analysis of stenosis severity. Overall, 95% had coronary atherosclerosis, but only 39% had 1 or more stenoses with ≳50% narrowing. Of 30 siblings in whom the exercise test and perfusion scan were both abnormal, 70% had ≳50% stenoses. The mean stenosis in arteries that fed perfusion defects was only 43±31%, and 68% of such stenoses were <50%. However, in 71% of all defects, the location matched arteries with the most severe stenoses. Conclusions - In asymptomatic persons with a family history of CAD, abnormal exercise scintigraphy identifies predominantly mild coronary atherosclerosis. Perfusion defects may be caused by coronary vasomotor dysfunction in addition to atherosclerotic plaque.