169 Quantitative Perfusion CMR in ANOCA METHODS Study population This sub-study is part of the MICORDIS study, a single-center observational cohort study assessing patients with ANOCA, defined as those with long-standing angina, documented non-obstructive coronary artery disease (CAD), and lack of response to medical therapy. The MICORDIS study design has been published.12 In short, 28 adult ANOCA patients were recruited, along with a control group of 28 participants one-toone matched for sex and age. The control group was recruited through posters and local media, and selected to match the patients in sex and age. They underwent screening through transthoracic echocardiography, ECG, and laboratory tests to exclude individuals with heart disease and impaired renal function. The inclusion and exclusion criteria are presented in Supplementary Table 1. Subjects included in the MICORDIS study were eligible for this sub-study if they had completed the full QP CMR protocol. The study protocol was approved by the institutional ethics committee on human research of the Amsterdam UMC and is registered (ICTRP Search Portal (who.int), unique identifier NLOMON23861). Individual data were collected and anonymously stored in a fully compliant cloud-based clinical data platform (Castor EDC, Amsterdam, The Netherlands). CMR imaging acquisition All subjects underwent adenosine stress perfusion CMR imaging performed on a wholebody 3 Tesla scanner (Magnetom Vida, Siemens, Healthcare, Erlangen Germany), after abstaining from caffeine and xanthine for 24 h. Furthermore, patients were instructed to withhold from calcium channel blockers, β-blockers, and long-acting nitrates for 2 days prior to the study day. Myocardial perfusion images were acquired using a dual-bolus protocol.12, 13 Stress arterial input function (AIF) and perfusion images were acquired using a saturation recovery turbo spoiled gradient echo sequence for at least 50 heart beats in basal, mid and apical levels, following a constant intravenous infusion of adenosine (140 μg/kg/min) for at least 3 min. Proton density-weighted images were obtained at each level to correct surface-coil signal intensity inhomogeneity. The myocardial perfusion images had a typical in-plane resolution of 2.25 × 2.25 mm2, with a slice thickness of 8 mm (repetition time 2.64 ms, echo time 1.18 ms, inversion time 125 ms, Gauss pulse α = 12˚, matrix size 160 × 120). A twofold acceleration was implemented using GRAPPA/T-pat. In cases where heart rates exceeded 90 BPM, each set of perfusion images was acquired over two heart beats. Rest AIF and perfusion images were acquired at least 10 min post-adenosine infusion, using identical scanning parameters. Intravenous administration of GBCA (DOTAREM®, Guerbet, Villepinte, France 0.05 mmol/ml) included a pre-bolus at 0.0075 mmol/kg, infused at 3 ml/s and flushed with 20 ml of saline for AIF images. Perfusion images used a main bolus of 0.075 mmol/kg, infused at 3 ml/s and flushed with 20 ml of saline. 8
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