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Dr. Mete ALPASLAN
Coronary Slow Flow Phenomenon - Syndrome Y
Definition
Delayed opacification of distal coronary vasculature in patients with normal or near-normal epicardial coronary arteries.
Delayed opacification is present if at least 3 or more cardiac cycles are needed to opacify the coronary distal vasculature.
Clinical findings
Most patients present with rest angina.
Some patients may present as acute coronary syndrome.
Male smokers are affected more.
ECG abnormalities suggestive of ischemia may be seen.
Coronary slow flow has been observed in 1-7% of subjects undergoing coronary angiography.
Pathogenesis
The pathogenesis has not been fully elucidated.
ECG signs of ischemia are frequent but there is no pathognomonic ECG sign.
Increased resting peripheral (coronary) resistances caused by structural microvascular abnormalities have been suggested.
In contrast to coronary syndrome X, coronary flow reserve in response to vasodilators appears to be intact in these "syndrome Y" patients.
Abnormal ECG findings in patients with coronary slow flow phenomenon
ST segment elevation (pain-free).
ST segment depression (pain-free).
T wave inversion.
Peaked T waves.
Higher prevalance of positive (abnormal) exercise test.
References
Int J Cardiol 2006;112:e1-e4.
Angiology 2001;52:507-514.
Int J Cardiol 2011;146:457-458.
Int J Cardiol 2012;156:84-91.
Int J Cardiol 2008;127:358-361.
Cardiology 2002;97:197-202.
Int J Cardiol 2009;137:308-310.
Korean Circ J 2013;43:196-198.
Journal of Electrocardiology 2012;45:277-279.
ECG 1. The ECG above belongs to a 68 years-old woman with coronary slow flow phenomenon.
Widespread T wave negativity imitates ECG signs of myocardial ischemia.
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ECG 2. The ECG above belongs to a 45 years-old man with coronary slow flow phenomenon.
There are q waves in leads V1 to V3. However the patient did not have previous myocardial infarction.
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ECG 3. The ECG above belongs to a 53 years-old man with coronary slow flow phenomenon.
Negative T waves in leads V1-V2, and non-specific T wave changes are seen in leads V3-V4.
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ECG 4. The ECG above belongs to a 64 years-old woman with coronary slow flow phenomenon.
Chest leads show asymmetrically negative T waves and biphasic T waves with terminal negativity.
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ECG 5. The ECG above belongs to a 56 years-old woman with coronary slow flow phenomenon.
Non-specific T wave changes are seen in chest leads.
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ECG 6. The ECG above belongs to a 58 years-old man with coronary slow flow phenomenon.
Chest leads show peaked T waves.
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ECG 7. The ECG above belongs to a 75 years-old man with coronary slow flow phenomenon.
Non-specific T wave changes are seen in leads V4-V5.
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ECG 8. The ECG above belongs to a 76 years-old hypertensive man with coronary slow flow phenomenon.
Left bundle branch block, first degree AV block and Chapman's sign are seen.
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ECG 9. The ECG above belongs to a 67 years-old man with coronary slow flow phenomenon.
Leads II and aVF show minimal ST segment elevation.
Leads V2 to V5 show relatively tall T waves when compared to the preceding QRS complexes.
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ECG 10. The ECG above belongs to a 44 years-old man with coronary slow flow phenomenon.
Leads V4 to V6 show biphasic T waves: not typical for myocardial ischemia or strain pattern.
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ECG 11. The ECG above belongs to a 64 years-old woman slow flow in the LAD coronary artery.
Leads V3 to V6 show negative T waves: not typical for myocardial ischemia or strain pattern.
Asymmetrically negative T waves are not typical for myocardial ischemia.
Isolated left ventricular strain pattern does not involve leads V3 and V4.
In addition, no sign of increased voltage for left ventricular hypertrophy is seen.
Click here for a more detailed ECG
ECG 12. The compact ECG above, belongs to a 50 years-old man with coronary artery ectasia and coronary slow flow
phenomenon. Leads V2 to V6 show negative T waves. Obesity increases the risk for coronary slow flow phenomenon.
ECG 13. The compact ECG above, belongs to a 40 years-old man with coronary artery ectasia and significant slow flow in the
LAD coronary artery. He was complaining of retrosternal severe chest pain but he was found to have no coronary stenosis.
Peaked T waves and ST elevation in anterior leads may suggest anterior myocardial infarction at first glance.
ECG 14. The above ECG is from a 65 years-old woman with prominent slow flow in her coronary arteries.
All leads except lead aVR show negative T waves.
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ECG 15. The above ECG is from a 73 years-old hypertensive woman with prominent slow flow in her right coronary artery.
Extensive ST segment depression is seen. No obstructive coronary artery disease was detected at coronary angiography.
ECG 16. The above ECG is from a 59 years-old man with hypertension and prominent slow flow in his coronary arteries.
Limb leads show low voltage. There is interatrial block. PR interval is also prolonged (1st degree AV block).
Leads V1 to V4 show negative T waves and minimal ST segment depression.
Despite the absence of beta blocker or non-dihydropyridine type calcium channel blockers, his heart rate is low.
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ECG 17. The ECG above belongs to a 62 years-old woman with systemic arterial hypertension.
Her coronary angiogram showed only slow flow.
Leads V3 to V6 show ST segment depression. This patient is not taking Digoxin.
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ECG 18. The ECG above belongs to a 56 years-old hypertensive man with a normal ECHOcardiogram.
His coronary angiogram showed only slow flow.
Right precordial leads show asymmetrically negative T waves.
Chest leads also show minimal ST segment depression.
Click here for a more detailed ECG
ECG 19a. The ECG above belongs to a 44 years-old woman with systemic arterial hypertension.
Her coronary angiogram showed slow flow.
Leads V3 to V6 show ST segment depression.
Click here for a more detailed ECG
ECG 19b. The ECG above belongs to the same woman and was recorded 3 days later.
No ST segment depression is seen now.
Click here for a more detailed ECG
Delayed opacification of distal coronary vasculature in patients with normal or near-normal epicardial coronary arteries.
Delayed opacification is present if at least 3 or more cardiac cycles are needed to opacify the coronary distal vasculature.
Clinical findings
Most patients present with rest angina.
Some patients may present as acute coronary syndrome.
Male smokers are affected more.
ECG abnormalities suggestive of ischemia may be seen.
Coronary slow flow has been observed in 1-7% of subjects undergoing coronary angiography.
Pathogenesis
The pathogenesis has not been fully elucidated.
ECG signs of ischemia are frequent but there is no pathognomonic ECG sign.
Increased resting peripheral (coronary) resistances caused by structural microvascular abnormalities have been suggested.
In contrast to coronary syndrome X, coronary flow reserve in response to vasodilators appears to be intact in these "syndrome Y" patients.
Abnormal ECG findings in patients with coronary slow flow phenomenon
ST segment elevation (pain-free).
ST segment depression (pain-free).
T wave inversion.
Peaked T waves.
Higher prevalance of positive (abnormal) exercise test.
References
Int J Cardiol 2006;112:e1-e4.
Angiology 2001;52:507-514.
Int J Cardiol 2011;146:457-458.
Int J Cardiol 2012;156:84-91.
Int J Cardiol 2008;127:358-361.
Cardiology 2002;97:197-202.
Int J Cardiol 2009;137:308-310.
Korean Circ J 2013;43:196-198.
Journal of Electrocardiology 2012;45:277-279.
ECG 1. The ECG above belongs to a 68 years-old woman with coronary slow flow phenomenon.
Widespread T wave negativity imitates ECG signs of myocardial ischemia.
Click here for a more detailed ECG
ECG 2. The ECG above belongs to a 45 years-old man with coronary slow flow phenomenon.
There are q waves in leads V1 to V3. However the patient did not have previous myocardial infarction.
Click here for a more detailed ECG
ECG 3. The ECG above belongs to a 53 years-old man with coronary slow flow phenomenon.
Negative T waves in leads V1-V2, and non-specific T wave changes are seen in leads V3-V4.
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a 64 years-old woman with coronary slow flow phenomenon.
Chest leads show asymmetrically negative T waves and biphasic T waves with terminal negativity.
Click here for a more detailed ECG
ECG 5. The ECG above belongs to a 56 years-old woman with coronary slow flow phenomenon.
Non-specific T wave changes are seen in chest leads.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a 58 years-old man with coronary slow flow phenomenon.
Chest leads show peaked T waves.
Click here for a more detailed ECG
ECG 7. The ECG above belongs to a 75 years-old man with coronary slow flow phenomenon.
Non-specific T wave changes are seen in leads V4-V5.
Click here for a more detailed ECG
ECG 8. The ECG above belongs to a 76 years-old hypertensive man with coronary slow flow phenomenon.
Left bundle branch block, first degree AV block and Chapman's sign are seen.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a 67 years-old man with coronary slow flow phenomenon.
Leads II and aVF show minimal ST segment elevation.
Leads V2 to V5 show relatively tall T waves when compared to the preceding QRS complexes.
Click here for a more detailed ECG
ECG 10. The ECG above belongs to a 44 years-old man with coronary slow flow phenomenon.
Leads V4 to V6 show biphasic T waves: not typical for myocardial ischemia or strain pattern.
Click here for a more detailed ECG
ECG 11. The ECG above belongs to a 64 years-old woman slow flow in the LAD coronary artery.
Leads V3 to V6 show negative T waves: not typical for myocardial ischemia or strain pattern.
Asymmetrically negative T waves are not typical for myocardial ischemia.
Isolated left ventricular strain pattern does not involve leads V3 and V4.
In addition, no sign of increased voltage for left ventricular hypertrophy is seen.
Click here for a more detailed ECG
ECG 12. The compact ECG above, belongs to a 50 years-old man with coronary artery ectasia and coronary slow flow
phenomenon. Leads V2 to V6 show negative T waves. Obesity increases the risk for coronary slow flow phenomenon.
ECG 13. The compact ECG above, belongs to a 40 years-old man with coronary artery ectasia and significant slow flow in the
LAD coronary artery. He was complaining of retrosternal severe chest pain but he was found to have no coronary stenosis.
Peaked T waves and ST elevation in anterior leads may suggest anterior myocardial infarction at first glance.
ECG 14. The above ECG is from a 65 years-old woman with prominent slow flow in her coronary arteries.
All leads except lead aVR show negative T waves.
Click here for a more detailed ECG
ECG 15. The above ECG is from a 73 years-old hypertensive woman with prominent slow flow in her right coronary artery.
Extensive ST segment depression is seen. No obstructive coronary artery disease was detected at coronary angiography.
ECG 16. The above ECG is from a 59 years-old man with hypertension and prominent slow flow in his coronary arteries.
Limb leads show low voltage. There is interatrial block. PR interval is also prolonged (1st degree AV block).
Leads V1 to V4 show negative T waves and minimal ST segment depression.
Despite the absence of beta blocker or non-dihydropyridine type calcium channel blockers, his heart rate is low.
Click here for a more detailed ECG
ECG 17. The ECG above belongs to a 62 years-old woman with systemic arterial hypertension.
Her coronary angiogram showed only slow flow.
Leads V3 to V6 show ST segment depression. This patient is not taking Digoxin.
Click here for a more detailed ECG
ECG 18. The ECG above belongs to a 56 years-old hypertensive man with a normal ECHOcardiogram.
His coronary angiogram showed only slow flow.
Right precordial leads show asymmetrically negative T waves.
Chest leads also show minimal ST segment depression.
Click here for a more detailed ECG
ECG 19a. The ECG above belongs to a 44 years-old woman with systemic arterial hypertension.
Her coronary angiogram showed slow flow.
Leads V3 to V6 show ST segment depression.
Click here for a more detailed ECG
ECG 19b. The ECG above belongs to the same woman and was recorded 3 days later.
No ST segment depression is seen now.
Click here for a more detailed ECG