451
|
Identifying Myocardial Ischemia due to Coronary Microvascular Dysfunction in the Emergency Department: Introducing a New Paradigm in Acute Chest Pain Evaluation. Clin Ther 2018; 40:1920-1930. [PMID: 30458932 DOI: 10.1016/j.clinthera.2018.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 12/20/2022]
Abstract
Chest pain stands as one of the most frequent patient presentations in the emergency department (ED). Despite established diagnostic algorithms for identifying several important causes of chest pain, such as acute myocardial infarction (AMI), aortic dissection, and pulmonary embolism, guidance on managing patients with recurrent chest pain, one of the top 3 reasons for repeated hospitalization in the United States, is less defined. The assessment of symptoms, serial ECG, and necrosis biomarkers plays a major role in patient management. Notably, the recently introduced high-sensitivity troponin T (hs-TnT) assay is helping to identify ischemia in patients previously undiagnosed by conventional testing. In Europe, with the use of this assay for over a decade, the identification of patients with AMI has substantially increased, particularly of patients with type 2 AMI, which is seen in the absence of atherosclerotic obstruction of the epicardial coronaries on angiography. Use of hs-TnT is in particular relevant in women, in whom the use of a sex-specific threshold for elevated hs-TnT has almost doubled the diagnosis of AMI. With the advent of the hs-TnT assay in the United States in 2017, a similar phenomenon is expected. Thus, it is important to learn from the European experience and to develop sex-specific nuanced algorithms for the evaluation of additional causes of myocardial ischemia/necrosis, such as coronary artery vasomotor disorders and coronary microvascular dysfunction. The latter has a high prevalence among symptomatic women presenting to the ED, a group in whom recurrent chest pain is common. This commentary describes the tools available for diagnosing epicardial- and non-epicardial-related myocardial ischemia in patients with recurrent chest pain in the ED setting. A sex-specific, nuanced approach applied to select groups of patients being observed in the ED has the potential to reduce admissions and to allow for the initiation of timely, appropriate medical treatment and outpatient follow-up in an at-risk population. The costs and availability of advanced diagnostics may pose some limitation to the widespread adoption of such protocols.
Collapse
|
452
|
|
453
|
Ford TJ, Corcoran D, Oldroyd KG, McEntegart M, Rocchiccioli P, Watkins S, Brooksbank K, Padmanabhan S, Sattar N, Briggs A, McConnachie A, Touyz R, Berry C. Rationale and design of the British Heart Foundation (BHF) Coronary Microvascular Angina (CorMicA) stratified medicine clinical trial. Am Heart J 2018; 201:86-94. [PMID: 29803987 PMCID: PMC6018570 DOI: 10.1016/j.ahj.2018.03.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 03/15/2018] [Indexed: 01/09/2023]
Abstract
Background Coronary angiography is performed to assess for obstructive coronary artery disease (CAD), but “nonobstructive CAD” is a common finding. Microvascular or vasospastic angina may be relevant, but routine confirmatory testing is not evidence based and thus rarely performed. Aim The aim was to assess the effect of stratified medicine guided by coronary function testing on the diagnosis, treatment, and well-being of patients with angina and nonobstructive CAD. Design The BHF CorMicA trial is a prospective, multicenter, randomized, blinded, sham-controlled trial of stratified medicine (NCT03193294). All-comers referred for elective coronary angiography for investigation of suspected CAD will be screened. Following informed consent, eligible patients with angina and nonobstructive CAD will be randomized 1:1 immediately in the catheter laboratory to either coronary artery function–guided diagnosis and treatment (intervention group) or not (control group). Coronary function will be assessed using a pressure-temperature–sensitive guidewire and adenosine followed by pharmacological testing with intracoronary acetylcholine. Patients will be stratified into endotypes with linked therapy. The primary outcome is change in Seattle Angina Questionnaire score at 6 months. Secondary outcomes include safety, feasibility, diagnostic utility (impact on diagnosis and diagnostic certainty), and clinical utility (impact on treatment and investigations). Health status is a key secondary outcome assessed according to the following domains: quality of life, treatment satisfaction, illness perception, physical activity, and anxiety-depression score. Patients with obstructive disease who are not randomized will form a registry group who will be followed up as a comparator for secondary outcomes including health status. Health and economic outcomes will be evaluated in the longer term using electronic health record linkage. Value CorMicA is a proof-of-concept clinical trial of a disruptive stratified intervention with potential benefits to patients and health care providers.
Collapse
Affiliation(s)
- Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; University of New South Wales, Sydney, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Katriona Brooksbank
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Sandosh Padmanabhan
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Andrew Briggs
- Centre for Population and Health Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Rhian Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
| |
Collapse
|
454
|
|
455
|
Scalone G, Niccoli G, Crea F. Editor's Choice- Pathophysiology, diagnosis and management of MINOCA: an update. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:54-62. [PMID: 29952633 DOI: 10.1177/2048872618782414] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a syndrome with different causes, characterised by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. Its prevalence ranges between 5% and 25% of all myocardial infarction. The prognosis is extremely variable, depending on the cause of MINOCA. The key principle in the management of this syndrome is to clarify the underlying individual mechanisms to achieve patient-specific treatments. Clinical history, electrocardiogram, cardiac enzymes, echocardiography, coronary angiography and left ventricular angiography represent the first level diagnostic investigations to identify the causes of MINOCA. Regional wall motion abnormalities at left ventricular angiography limited to a single epicardial coronary artery territory identify an 'epicardial pattern'whereas regional wall motion abnormalities extended beyond a single epicardial coronary artery territory identify a 'microvascular pattern'. The most common causes of MINOCA are represented by coronary plaque disease, coronary dissection, coronary artery spasm, coronary microvascular spasm, Takotsubo cardiomyopathy, myocarditis, coronary thromboembolism, other forms of type 2 myocardial infarction and MINOCA of uncertain aetiology. This review aims at summarising the diagnosis and management of MINOCA, according to the underlying physiopathology.
Collapse
Affiliation(s)
- Giancarla Scalone
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
| | - Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
| |
Collapse
|
456
|
Shaw JL, Nelson MD, Wei J, Motwani M, Landes S, Mehta PK, Thomson LEJ, Berman DS, Li D, Bairey Merz CN, Sharif B. Inverse association of MRI-derived native myocardial T1 and perfusion reserve index in women with evidence of ischemia and no obstructive CAD: A pilot study. Int J Cardiol 2018; 270:48-53. [PMID: 30041981 DOI: 10.1016/j.ijcard.2018.06.086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND It has recently been shown that magnetic resonance (MR) "native T1" mapping is capable of characterizing abnormal microcirculation in patients with obstructive coronary artery disease (CAD). In studies involving women with signs and symptoms of ischemia and no obstructive CAD (INOCA), however, the potential role of native T1 as an imaging marker and its association with indices of diastolic function or vasodilator-induced myocardial ischemia have not been explored. We investigated whether native T1 in INOCA is associated with reduced myocardial perfusion reserve index (MPRI) or with diastolic dysfunction. METHODS Twenty-two female patients with INOCA and twelve female reference controls with matching age and body-mass index were studied. The patients had evidence of vasodilator-induced ischemia without obstructive CAD or any prior infarction. All 34 subjects underwent stress/rest MR including native T1 mapping (MOLLI 5(3)3) at 1.5-Tesla. RESULTS Compared with controls, patients had similar morphology/function. As expected, MPRI was significantly reduced in patients compared to controls (1.78 ± 0.39 vs. 2.49 ± 0.41, p < 0.0001). Native T1 was significantly elevated in patients (1040.1 ± 29.3 ms vs. 1003.8 ± 18.5 ms, p < 0.001) and the increased T1 showed a significant inverse correlation with MPRI (r = -0.481, p = 0.004), but was not correlated with reduced diastolic strain rate. CONCLUSIONS Symptomatic women with INOCA have elevated native T1 compared to matched reference controls and there is a significant association between elevated native T1 and impaired MPRI, considered a surrogate measure of ischemia severity in this cohort. Future studies in a larger cohort are needed to elucidate the mechanism underlying this inverse relationship.
Collapse
Affiliation(s)
- Jaime L Shaw
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Bioengineering, University of California Los Angeles, CA, United States
| | - Michael D Nelson
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Janet Wei
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Manish Motwani
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sofy Landes
- Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Puja K Mehta
- Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Louise E J Thomson
- Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States; Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Daniel S Berman
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, CA, United States
| | - Debiao Li
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Bioengineering, University of California Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, CA, United States
| | - C Noel Bairey Merz
- Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, CA, United States
| | - Behzad Sharif
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Bioengineering, University of California Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, CA, United States.
| |
Collapse
|
457
|
Ong P, Camici PG, Beltrame JF, Crea F, Shimokawa H, Sechtem U, Kaski JC, Noel Bairey Merz C. Response to letter from Picichè: The microvascular network connecting extracardiac arteries to the heart. Int J Cardiol 2018; 259:56. [PMID: 29579613 DOI: 10.1016/j.ijcard.2018.02.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/22/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | |
Collapse
|
458
|
Picichè M. The microvascular network connecting extracardiac arteries to the heart. Int J Cardiol 2018; 259:55. [DOI: 10.1016/j.ijcard.2018.01.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 11/15/2022]
|
459
|
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality in people with type 2 diabetes mellitus (T2DM), yet a significant proportion of the disease burden cannot be accounted for by conventional cardiovascular risk factors. Hypertension occurs in majority of people with T2DM, which is substantially more frequent than would be anticipated based on general population samples. The impact of hypertension is considerably higher in people with diabetes than it is in the general population, suggesting either an increased sensitivity to its effect or a confounding underlying aetiopathogenic mechanism of hypertension associated with CVD within diabetes. In this contribution, we aim to review the changes observed in the vascular tree in people with T2DM compared to the general population, the effects of established anti-diabetes drugs on microvascular outcomes, and explore the hypotheses to account for common causalities of the increased prevalence of CVD and hypertension in people with T2DM.
Collapse
Affiliation(s)
- W David Strain
- Diabetes and Vascular Medicine Research Centre, NIHR Exeter Clinical Research Facility and Institute of Biomedical and Clinical Science, University of Exeter Medical School, Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5AX, UK.
| | | |
Collapse
|
460
|
Safdar B, D’Onofrio G, Dziura J, Russell RR, Johnson C, Sinusas AJ. Prevalence and characteristics of coronary microvascular dysfunction among chest pain patients in the emergency department. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018. [DOI: 10.1177/2048872618764418] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aims: Coronary microvascular dysfunction (CMD) is common in patients with non-obstructive coronary arteries but has not been described in low-risk symptomatic patients. We therefore assessed the prevalence and characteristics of CMD in low to moderate risk patients with chest pain in an emergency department. Methods and results: We used three-dimensional Rb82 cardiac positron emission tomography/computed tomography to diagnose coronary artery disease (known or new regional defect, any coronary calcification) and CMD (low coronary flow reserve without coronary artery disease) in chest pain patients after being ruled out for acute myocardial infarction. Exclusions included age 30 years or less, acute myocardial infarction, hemodynamic instability, heart failure and dialysis. Among 195 participants undergoing cardiac positron emission tomography/computed tomography, 42% had CMD, 36% had coronary artery disease and 22% had normal flows; 70% were women and 84% were obese. Patients with CMD and coronary artery disease had significantly lower coronary flow reserve than normal patients (mean coronary flow reserve 1.6 and 1.9 vs. 2.6, respectively, P<0.05). However, CMD patients were younger (mean age 51 vs. 61 years), and had fewer traditional cardiac risk factors ( P<0.05) than patients with coronary artery disease. Nearly one third (31%) of patients had a prior emergency department visit for chest pain within three years of index presentation. Women were four times as likely to have CMD as men (adjusted odds ratio 4.2; 95% confidence interval 1.8, 9.6) after controlling for age, race, hypertension, diabetes, smoking, dyslipidemia, obesity and family history of coronary artery disease. Conclusions: Despite their low-risk profile, nearly one half of symptomatic and mostly obese emergency department patients without evidence of myocardial infarction or coronary artery disease had CMD. The results could explain the high rates of return visits associated with chest pain, although their application to the general emergency department population require validation.
Collapse
Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, USA
| | - James Dziura
- Department of Emergency Medicine, Yale University School of Medicine, USA
- Yale Center for Analytical Sciences, USA
| | - Raymond R Russell
- Department of Internal Medicine (Section of Cardiovascular Medicine), Warren Alpert Medical School Brown University, USA
| | - Caitlin Johnson
- Department of Emergency Medicine, Yale University School of Medicine, USA
| | - Albert J Sinusas
- Department of Internal Medicine (Section of Cardiovascular Medicine), Yale University School of Medicine, USA
| |
Collapse
|
461
|
Beltrame JF. The emergence of the coronary vasomotor dysfunction era. Int J Cardiol 2018; 254:43-44. [PMID: 29407125 DOI: 10.1016/j.ijcard.2017.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 11/28/2017] [Indexed: 01/09/2023]
Affiliation(s)
- John F Beltrame
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; Central Adelaide Local Health Network, Adelaide, Australia; Basil Hetzel Institute for Translational Health Research, Adelaide, Australia.
| |
Collapse
|