451
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Gibbons RJ. Comparison of ESC and ACC/AHA guidelines for the diagnosis and management of patients with stable coronary heart disease: Are the differences clinically relevant? An American perspective. J Nucl Cardiol 2018; 25:516-520. [PMID: 29150751 DOI: 10.1007/s12350-017-1125-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Raymond J Gibbons
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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452
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Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation. Can J Cardiol 2018; 34:468-476. [DOI: 10.1016/j.cjca.2018.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/16/2017] [Accepted: 01/01/2018] [Indexed: 12/13/2022] Open
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453
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Parvand M, Rayner-Hartley E, Sedlak T. Recent Developments in Sex-Related Differences in Presentation, Prognosis, and Management of Coronary Artery Disease. Can J Cardiol 2018; 34:390-399. [DOI: 10.1016/j.cjca.2018.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 12/17/2022] Open
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454
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Pharmacologic Treatment of Patients With Myocardial Ischemia With No Obstructive Coronary Artery Disease. Am J Cardiol 2018; 121:888-895. [PMID: 29394999 DOI: 10.1016/j.amjcard.2017.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022]
Abstract
Half of women and 1/3 of men with angina and ischemia on stress testing have ischemia with no obstructive coronary artery disease (INOCA). These patients have quality of life (QoL) impairment comparable with patients with obstructive coronary artery disease. Clinicians generally treat INOCA with traditional antianginal agents despite previous studies demonstrating variable response to these medications. We performed a systematic review to evaluate the efficacy and safety of available pharmacologic therapies for INOCA. We systematically searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and the World Health Organization International Clinical Trials Registry Platform in July 2017 for randomized controlled trials (RCTs) evaluating pharmacologic agents for INOCA. The primary outcome of interest was QoL. Secondary outcomes included subjective and objective efficacy measures and safety outcomes. We included 35 RCTs from 333 identified studies. Interventions that improved QoL with moderate-quality evidence included angiotensin-converting enzyme (ACE) inhibitor (±statin) and ranolazine. Low-to-very-low-quality evidence also suggests that ACE inhibitors, β blockers, calcium-channel blockers, nicorandil, ranolazine, and statins may decrease angina frequency and delay ischemia on stress testing. Other interventions, most notably nitrates, did not significantly improve any outcome. In conclusion, evidence for pharmacologic treatment of INOCA is generally poor, and higher-quality RCTs using a standardized definition of INOCA are needed. Moderate-quality evidence suggests that ACE inhibitors and ranolazine improve QoL. Other interventions had low-quality evidence or no evidence of efficacy.
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455
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Ohanyan V, Sisakian H, Peketi P, Parikh A, Chilian W. A chicken and egg conundrum: coronary microvascular dysfunction and heart failure with preserved ejection fraction. Am J Physiol Heart Circ Physiol 2018; 314:H1262-H1263. [PMID: 29547025 DOI: 10.1152/ajpheart.00154.2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Vahagn Ohanyan
- Department of Integrative Medical Sciences, Northeastern Ohio Universities Colleges of Medicine, Rootstown OH 44272
| | - Hamayak Sisakian
- Departement of General and Invasive Cardiology, University Hospital 1, Yerevan State Medical University , Yerevan , Armenia
| | - Punita Peketi
- Department of Integrative Medical Sciences, Northeastern Ohio Universities Colleges of Medicine, Rootstown OH 44272
| | - Ankur Parikh
- Department of Integrative Medical Sciences, Northeastern Ohio Universities Colleges of Medicine, Rootstown OH 44272
| | - William Chilian
- Department of Integrative Medical Sciences, Northeastern Ohio Universities Colleges of Medicine, Rootstown OH 44272
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456
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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.
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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
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457
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Widmer RJ, Lerman LO, Lerman A. The Rho(ad)-kinase for individualized treatment of vasospastic angina. Eur Heart J 2018; 39:960-962. [PMID: 29293909 DOI: 10.1093/eurheartj/ehx757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R Jay Widmer
- Department of Cardiovascular, Mayo Clinic and College of Medicine, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular, Mayo Clinic and College of Medicine, Rochester, MN, USA
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458
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Taqueti VR, Solomon SD, Shah AM, Desai AS, Groarke JD, Osborne MT, Hainer J, Bibbo CF, Dorbala S, Blankstein R, Di Carli MF. Coronary microvascular dysfunction and future risk of heart failure with preserved ejection fraction. Eur Heart J 2018; 39:840-849. [PMID: 29293969 PMCID: PMC5939665 DOI: 10.1093/eurheartj/ehx721] [Citation(s) in RCA: 370] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/08/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023] Open
Abstract
Aims Coronary microvascular ischaemia, cardiomyocyte injury and stiffness may play an important role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). To date, the relationship between coronary flow reserve (CFR), myocardial injury, diastolic dysfunction, and future HFpEF risk is unknown. Methods and results Consecutive patients (n = 201) undergoing evaluation for suspected coronary artery disease (CAD) with stress myocardial perfusion positron emission tomography, serum troponin, and transthoracic echocardiography who did not have flow-limiting CAD or reduced left ventricular ejection fraction were identified. Patients were followed up (median 4.1 years) for cardiovascular death and hospitalization for non-fatal myocardial infarction or heart failure. Coronary flow reserve was quantified as stress/rest myocardial blood flow. Early diastolic flow (E) and relaxation (e') velocities were obtained via transmitral and tissue Doppler, respectively. Patients with impaired CFR (<2, n = 108) demonstrated linearly decreasing e' and increasing E/e' consistent with worsening diastolic function (P for trend <0.0001). A detectable troponin was associated with diastolic dysfunction only in the presence of impaired CFR (interaction P = 0.002). In adjusted analyses, impaired CFR was independently associated with diastolic dysfunction (E/e'septal > 15, adjusted OR 2.58, 95%CI 1.22-5.48) and composite cardiovascular outcomes or HFpEF hospitalization alone (adjusted HR 2.47, 95%CI 1.09-5.62). Patients with both impaired CFR and diastolic dysfunction demonstrated >five-fold increased risk of HFpEF hospitalization (P < 0.001). Conclusion In symptomatic patients without overt CAD, impaired CFR was independently associated with diastolic dysfunction and adverse events, especially HFpEF hospitalization. The presence of both coronary microvascular and diastolic dysfunctions was associated with a markedly increased risk of HFpEF events.
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Affiliation(s)
- Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amil M Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Osborne
- Cardiac MR/PET/CT Program, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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459
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Liu A, Wijesurendra RS, Liu JM, Forfar JC, Channon KM, Jerosch-Herold M, Piechnik SK, Neubauer S, Kharbanda RK, Ferreira VM. Diagnosis of Microvascular Angina Using Cardiac Magnetic Resonance. J Am Coll Cardiol 2018; 71:969-979. [PMID: 29495996 PMCID: PMC5835222 DOI: 10.1016/j.jacc.2017.12.046] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/01/2017] [Accepted: 12/26/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND In patients with angina and nonobstructive coronary artery disease (NOCAD), confirming symptoms due to coronary microvascular dysfunction (CMD) remains challenging. Cardiac magnetic resonance (CMR) assesses myocardial perfusion with high spatial resolution and is widely used for diagnosing obstructive coronary artery disease (CAD). OBJECTIVES The goal of this study was to validate CMR for diagnosing microvascular angina in patients with NOCAD, compared with patients with obstructive CAD and correlated to the index of microcirculatory resistance (IMR) during invasive coronary angiography. METHODS Fifty patients with angina (65 ± 9 years of age) and 20 age-matched healthy control subjects underwent adenosine stress CMR (1.5- and 3-T) to assess left ventricular function, inducible ischemia (myocardial perfusion reserve index [MPRI]; myocardial blood flow [MBF]), and infarction (late gadolinium enhancement). During subsequent angiography within 7 days, 28 patients had obstructive CAD (fractional flow reserve [FFR] ≤0.8) and 22 patients had NOCAD (FFR >0.8) who underwent 3-vessel IMR measurements. RESULTS In patients with NOCAD, myocardium with IMR <25 U had normal MPRI (1.9 ± 0.4 vs. controls 2.0 ± 0.3; p = 0.49); myocardium with IMR ≥25 U had significantly impaired MPRI, similar to ischemic myocardium downstream of obstructive CAD (1.2 ± 0.3 vs. 1.2 ± 0.4; p = 0.61). An MPRI of 1.4 accurately detected impaired perfusion related to CMD (IMR ≥25 U; FFR >0.8) (area under the curve: 0.90; specificity: 95%; sensitivity: 89%; p < 0.001). Impaired MPRI in patients with NOCAD was driven by impaired augmentation of MBF during stress, with normal resting MBF. Myocardium with FFR >0.8 and normal IMR (<25 U) still had blunted stress MBF, suggesting mild CMD, which was distinguishable from control subjects by using a stress MBF threshold of 2.3 ml/min/g with 100% positive predictive value. CONCLUSIONS In angina patients with NOCAD, CMR can objectively and noninvasively assess microvascular angina. A CMR-based combined diagnostic pathway for both epicardial and microvascular CAD deserves further clinical validation.
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Affiliation(s)
- Alexander Liu
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rohan S Wijesurendra
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Joanna M Liu
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John C Forfar
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Keith M Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Stefan K Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rajesh K Kharbanda
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Vanessa M Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
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460
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Aggarwal NR, Bond RM, Mieres JH. The role of imaging in women with ischemic heart disease. Clin Cardiol 2018; 41:194-202. [PMID: 29505091 DOI: 10.1002/clc.22913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 12/24/2022] Open
Abstract
Substantial advances and insights in medical technology and treatment strategies, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, ischemic heart disease (IHD) remains the leading cause of cardiovascular morbidity and mortality of women in the Western world. Advances in cardiovascular imaging, over the past 4 decades, have significantly improved the evaluation and management of the full spectrum of coronary atherosclerosis, which contributes to ischemic heart disease. The development of contemporary and novel diagnostic imaging techniques and tools have assumed an expanded role in the evaluation of symptomatic women to detect not only flow-limiting epicardial coronary stenosis and nonobstructive atherosclerosis, but also ischemia resulting from microvascular dysfunction. IHD is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies in women. In this article, we review the available evidence on the role of contemporary diagnostic imaging techniques in the evaluation of women with suspected IHD.
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Affiliation(s)
| | - Rachel M Bond
- Zucker School of Medicine at Hofstra Northwell, New York
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461
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Pacheco Claudio C, Quesada O, Pepine CJ, Noel Bairey Merz C. Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease). Clin Cardiol 2018; 41:185-193. [PMID: 29498752 DOI: 10.1002/clc.22894] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/05/2018] [Indexed: 12/19/2022] Open
Abstract
The syndromes of myocardial infarction/myocardial ischemia with No Obstructive Coronary Artery Disease (MINOCA/INOCA) are increasingly evident. A majority of these patients have coronary microvascular dysfunction. These patients have elevated risk for a cardiovascular event (including acute coronary syndrome, myocardial infarction, stroke, and repeated cardiovascular procedures) and appear to be at higher risk for development of heart failure with preserved ejection fraction. Terminology such as coronary artery disease or coronary heart disease is often synonymous with obstructive atherosclerosis in the clinician's mind, leaving one at a loss to recognize or explain the phenomenon of MINOCA and INOCA with elevated risk. We review the available literature regarding stable and unstable ischemic heart disease that suggests that use of the ischemic heart disease (IHD) terminology matters for women, and should facilitate recognition of risk to provide potential treatment targets and optimized health.
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Affiliation(s)
| | - Odayme Quesada
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, Florida
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
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462
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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: 1] [Impact Index Per Article: 0.2] [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.
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463
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Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and meta-analysis. Int J Cardiol 2018; 254:1-9. [DOI: 10.1016/j.ijcard.2017.10.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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464
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Zorach B, Shaw PW, Bourque J, Kuruvilla S, Balfour PC, Yang Y, Mathew R, Pan J, Gonzalez JA, Taylor AM, Meyer CH, Epstein FH, Kramer CM, Salerno M. Quantitative cardiovascular magnetic resonance perfusion imaging identifies reduced flow reserve in microvascular coronary artery disease. J Cardiovasc Magn Reson 2018; 20:14. [PMID: 29471856 PMCID: PMC5822618 DOI: 10.1186/s12968-018-0435-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 02/05/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preliminary semi-quantitative cardiovascular magnetic resonance (CMR) perfusion studies have demonstrated reduced myocardial perfusion reserve (MPR) in patients with angina and risk factors for microvascular disease (MVD), however fully quantitative CMR has not been studied. The purpose of this study is to evaluate whether fully quantitative CMR identifies reduced MPR in this population, and to investigate the relationship between epicardial atherosclerosis, left ventricular hypertrophy (LVH), extracellular volume (ECV), and perfusion. METHODS Forty-six patients with typical angina and risk factors for MVD (females, or males with diabetes or metabolic syndrome) who had no obstructive coronary artery disease by coronary angiography and 20 healthy control subjects underwent regadenoson stress CMR perfusion imaging using a dual-sequence quantitative spiral pulse sequence to quantify MPR. Subjects also underwent T1 mapping to quantify ECV, and computed tomographic (CT) coronary calcium scoring to assess atherosclerosis burden. RESULTS In patients with risk factors for MVD, both MPR (2.21 [1.95,2.69] vs. 2.93 [2.763.19], p < 0.001) and stress myocardial perfusion (2.65 ± 0.62 ml/min/g, vs. 3.17 ± 0.49 ml/min/g p < 0.002) were reduced as compared to controls. These differences remained after adjusting for age, left ventricular (LV) mass, body mass index (BMI), and gender. There were no differences in native T1 or ECV between subjects and controls. CONCLUSIONS Stress myocardial perfusion and MPR as measured by fully quantitative CMR perfusion imaging are reduced in subjects with risk factors for MVD with no obstructive CAD as compared to healthy controls. Neither myocardial hypertrophy nor fibrosis accounts for these differences.
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Affiliation(s)
- Benjamin Zorach
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
| | | | - Jamieson Bourque
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
- Department of Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA USA
| | - Sujith Kuruvilla
- Department of Medicine, Philadelphia VA Medical Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA USA
| | - Pelbreton C. Balfour
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
| | - Yang Yang
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA USA
| | - Roshin Mathew
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
| | - Jonathan Pan
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
| | - Jorge A. Gonzalez
- Division of Cardiovascular Disease, Scripps Clinic, Division of Cardiology, Cardiovascular Imaging, Division of Radiology, La Jolla, San Diego, CA USA
| | - Angela M. Taylor
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
| | - Craig H. Meyer
- Department of Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA USA
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA USA
| | - Frederick H. Epstein
- Department of Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA USA
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA USA
| | - Christopher M. Kramer
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
- Department of Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA USA
| | - Michael Salerno
- Department of Medicine, Cardiology Division, University of Virginia Health System, Charlottesville, VA USA
- Department of Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA USA
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA USA
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465
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Wei J, Bakir M, Darounian N, Li Q, Landes S, Mehta PK, Shufelt CL, Handberg EM, Kelsey SF, Sopko G, Pepine CJ, Petersen JW, Berman DS, Thomson LEJ, Bairey Merz CN. Myocardial Scar Is Prevalent and Associated With Subclinical Myocardial Dysfunction in Women With Suspected Ischemia But No Obstructive Coronary Artery Disease: From the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction Study. Circulation 2018; 137:874-876. [PMID: 29459474 PMCID: PMC5823279 DOI: 10.1161/circulationaha.117.031999] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - May Bakir
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - Navid Darounian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - Quanlin Li
- Biostatistics and Bioinformatics Research Center (Q.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sofy Landes
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - Puja K Mehta
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (P.K.M.)
| | - Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - Eileen M Handberg
- Division of Cardiology, University of Florida, Gainesville (E.M.H., C.J.P., J.W.P.)
| | - Sheryl F Kelsey
- Graduate School of Public Health, University of Pittsburgh, PA (S.F.K.)
| | - George Sopko
- National Heart, Lung, and Blood Institute, Bethesda, MD (G.S.)
| | - Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville (E.M.H., C.J.P., J.W.P.)
| | - John W Petersen
- Division of Cardiology, University of Florida, Gainesville (E.M.H., C.J.P., J.W.P.)
| | - Daniel S Berman
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - Louise E J Thomson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute (J.W., M.B., N.D., S.L., C.L.S., D.S.B., L.E.J.T., C.N.B.M.)
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466
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Giannopoulos AA, Gaemperli O. Hybrid Imaging in Ischemic Heart Disease. ACTA ACUST UNITED AC 2018; 71:382-390. [PMID: 29329818 DOI: 10.1016/j.rec.2017.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/22/2017] [Indexed: 01/21/2023]
Abstract
Hybrid imaging for ischemic heart disease refers to the fusion of information from a single or usually from multiple cardiovascular imaging modalities enabling synergistic assessment of the presence, the extent, and the severity of coronary atherosclerotic disease along with the hemodynamic significance of lesions and/or with evaluation of the myocardial function. A combination of coronary computed tomography angiography with myocardial perfusion imaging, such as single-photon emission computed tomography and positron emission tomography, has been adopted in several centers and implemented in international coronary artery disease management guidelines. Interest has increased in novel hybrid methods including coronary computed tomography angiography-derived fractional flow reserve and computed tomography perfusion and these techniques hold promise for the imminent diagnostic and management approaches of patients with coronary artery disease. In this review, we discuss the currently available hybrid noninvasive imaging modalities used in clinical practice, research approaches, and exciting potential future technological developments.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Gaemperli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
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467
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Abstract
Cardiovascular disease remains the leading cause of morbidity and mortality for both women and men. Emerging evidence supports that ischemic heart disease (IHD) may manifest differently in women and men, in ways ranging from the clinical presentation, diagnosis, and management of disease to the basic biology and biomechanics of cardiomyocyte function and the coronary circulation. Women consistently present with a higher burden of symptoms and comorbidities as compared with men and experience worse outcomes. These data have proved perplexing given the decreased likelihood of women to demonstrate obstructive coronary artery disease (CAD) on coronary angiography. Reported sex differences have long been influenced by the practice of defining heart disease primarily as obstructive CAD, but obstructive plaque is now recognized as neither necessary nor sufficient to explain symptoms of IHD, and it is no longer adequate to tailor diagnostic and treatment strategies only to this subset of patients. To date, women remain underrepresented in guideline-changing heart disease research and trials, creating important limitations in the evidence base for cardiovascular medicine. Smaller epicardial coronary arteries in women as compared to men, coupled with differences in shear stress and inflammatory mediators over the life span, may modify the development of CAD in susceptible patients into a diffuse pattern with more contribution from coronary vasomotor dysfunction than focal obstruction. Newer studies corroborate that symptomatic women are more likely than men to present with nonobstructive CAD and coronary microvascular dysfunction. When present, these processes increase cardiovascular risk in both women and men but may constitute an especially malignant phenotype in a subset of severely affected women, with implications for the management of not only CAD but also heart failure with preserved ejection fraction. This represents a state-of-the-art review of sex differences in the coronary system, with an eye toward how diverse pathophysiological processes may contribute to IHD phenotypes prevalent in women and men. Beyond providing women and men with equitable optimal care according to current paradigms, understanding the pathophysiology of IHD beyond a conventional focus on obstructive CAD is needed to address what is likely a combination of biological as well as environmental determinants of their prognosis.
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Affiliation(s)
- Viviany R Taqueti
- Heart and Vascular Center; Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology (Nuclear Medicine and Molecular Imaging), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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468
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Reusch JEB, Kumar TR, Regensteiner JG, Zeitler PS. Identifying the Critical Gaps in Research on Sex Differences in Metabolism Across the Life Span. Endocrinology 2018; 159:9-19. [PMID: 29300998 PMCID: PMC5761606 DOI: 10.1210/en.2017-03019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/13/2017] [Indexed: 12/12/2022]
Abstract
The National Institutes of Health (NIH) Office of Research in Women's Health now functions under a mandate calling for the systematic inclusion of both female and male cells, animals, and human subjects in all types of research, so that sex as a biological variable is understood in health and disease. Sex-specific data can improve disease prevention, diagnosis, and treatment as well as reduce inequities. Inclusion of women in research studies has modestly improved over the last 20 years, yet preclinical research is still primarily done using male animal models and male-derived cells, with the result that many conclusions are made based on incomplete and sex-biased data. There are important, yet poorly studied, sex differences in cardiometabolic disease. To begin to address these sex differences, the Center for Women's Health Research at the University of Colorado held its inaugural National Conference, "Sex Differences Across the Lifespan: A Focus on Metabolism," in September 2016 (cwhr@ucdenver.edu). Research to address the important goal of understanding key sex differences in cardiometabolic disease across the life span is lacking. The goal of this article is to discuss the current state of research addressing sex differences in cardiometabolic health across the life span, to outline critical research gaps that must be addressed in response to NIH mandates, and, importantly, to develop strategies to address sex as a biological variable to understand disease mechanisms as well as develop diagnostic and therapeutic modalities.
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Affiliation(s)
- Jane E. B. Reusch
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
- Veterans Administration Eastern Colorado Health Care System, Denver, Colorado 80220
| | - T. Rajendra Kumar
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Judith G. Regensteiner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Philip S. Zeitler
- Department of and Pediatrics, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - on Behalf of the Conference Participants
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
- Veterans Administration Eastern Colorado Health Care System, Denver, Colorado 80220
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado 80045
- Department of and Pediatrics, University of Colorado School of Medicine, Aurora, Colorado 80045
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469
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Bekendam MT, Kop WJ, Barzilay S, Widdershoven JW, Aarnoudse W, Denollet J, Mommersteeg PMC. The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease. J Psychosom Res 2018; 104:108-114. [PMID: 29275779 DOI: 10.1016/j.jpsychores.2017.11.003] [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: 07/03/2017] [Revised: 10/25/2017] [Accepted: 11/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with non-obstructive coronary artery disease (NOCAD) continue to experience disabling symptoms. Positive affect (PA) has shown a cardioprotective potential. Type D personality has previously been shown to have a deleterious effect on adverse outcomes in diverse cardiac populations. Little is known about the predictive value of PA and Type D personality for long-term outcomes in NOCAD patients. The aim was to investigate the effect of PA and Type D personality on clinical outcomes. METHODS 547 patients (mean age 61 years±9, 48% male) who underwent a coronary angiography or CT-scan between January 2009 and February 2013 answered questionnaires concerning PA (GMS) and Type D personality (DS14). Cox proportional hazards analyses were performed. RESULTS When analyzed dichotomously, PA was a significant predictor of need for repeat cardiac testing (HR=0.64, 95% CI: 0.41-0.99), but not emergency department (ED) admissions (HR=0.83, 95% CI: 0.52-1.32) after adjustment for age, sex, education, diagnosis by group, BMI and hypertension. Analyzed continuously, the predictive value of PA was non-significant for both repeat testing (HR=0.85, 95% CI: 0.69-1.06) and ED admissions (HR=0.98, 95% CI: 0.77-1.23). Type D personality, both continuously and dichotomously, was not significantly associated with the outcomes. Findings were also examined for men and women separately. CONCLUSION Although Type D personality was not predictive of adverse events in this sample, PA is an interesting and important variable to take into account in NOCAD patients. Research on psychosocial factors in NOCAD patients should consider the importance of choices of endpoint, given the heterogeneity of NOCAD patients.
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Affiliation(s)
- Maria T Bekendam
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Willem J Kop
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Simone Barzilay
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Jos W Widdershoven
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands; The Department of Cardiology, TweeSteden Hospital, Tilburg, The Netherlands
| | - Wilbert Aarnoudse
- The Department of Cardiology, TweeSteden Hospital, Tilburg, The Netherlands
| | - Johan Denollet
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Paula M C Mommersteeg
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.
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470
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Affiliation(s)
- Joshua D Mitchell
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - David L Brown
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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471
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Aziz A, Hansen HS, Sechtem U, Prescott E, Ong P. Sex-Related Differences in Vasomotor Function in Patients With Angina and Unobstructed Coronary Arteries. J Am Coll Cardiol 2017; 70:2349-2358. [PMID: 29096805 DOI: 10.1016/j.jacc.2017.09.016] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 09/04/2017] [Accepted: 09/06/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Coronary vasomotor dysfunction is an important mechanism for angina in patients with unobstructed coronary arteries. OBJECTIVES The purpose of this study was to determine sex differences in the prevalence and clinical presentation of vasomotor dysfunction in a European population and to examine sex differences in the dose of acetylcholine leading to a positive acetylcholine provocation test (ACH test). METHODS Between 2007 and 2014, we included 1,379 consecutive patients with stable angina, unobstructed coronaries and ACH test performed for epicardial vasospasm or coronary microvascular dysfunction (CMD) due to microvascular spasm. The predictive value of sex, risk factors, symptoms, and noninvasive test results was analyzed by means of logistic regression. RESULTS The mean patient age was 62 years, and 42% were male. There were 813 patients (59%) with a pathological ACH test, 33% for CMD and 26% for epicardial vasospasm. A pathological test was more common in females (70% vs. 43%; p < 0.001). In a multivariable logistic regression model the sex difference was statistically significant with a female-male odds ratio for CMD and epicardial vasospasm of 4.2 (95% confidence interval: 3.1 to 5.5; p < 0.001) and 2.3 (95% confidence interval: 1.7 to 3.1; p < 0.001), respectively. Effort-related symptoms, but neither risk factors nor noninvasive stress tests, contributed to predicting a pathological test. Female patients were more sensitive to acetylcholine with vasomotor dysfunction occurring at lower ACH doses compared with male patients. CONCLUSIONS Vasomotor dysfunction is frequent in patients with angina and unobstructed coronaries in a European population. Female patients have a higher prevalence of vasomotor dysfunction (especially CMD) compared with male patients. A pathological ACH test was observed at lower ACH doses in women compared with men.
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Affiliation(s)
- Ahmed Aziz
- Department of Cardiology, Robert Bosch Krankenhaus, Stuttgart, Germany; Department of Cardiology, Odense University Hospital, Odense, Denmark.
| | | | - Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus, Stuttgart, Germany
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Ong
- Department of Cardiology, Robert Bosch Krankenhaus, Stuttgart, Germany
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472
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Bienvenu LA, Morgan J, Reichelt ME, Delbridge LM, Young MJ. Chronic in vivo nitric oxide deficiency impairs cardiac functional recovery after ischemia in female (but not male) mice. J Mol Cell Cardiol 2017; 112:8-15. [DOI: 10.1016/j.yjmcc.2017.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/24/2017] [Accepted: 08/26/2017] [Indexed: 12/29/2022]
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473
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Schuijf JD, Ko BS, Di Carli MF, Hislop-Jambrich J, Ihdayhid AR, Seneviratne SK, Lima JAC. Fractional flow reserve and myocardial perfusion by computed tomography: a guide to clinical application. Eur Heart J Cardiovasc Imaging 2017; 19:127-135. [DOI: 10.1093/ehjci/jex240] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/21/2017] [Indexed: 12/13/2022] Open
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474
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Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. HEART (BRITISH CARDIAC SOCIETY) 2017; 104:284-292. [PMID: 29030424 PMCID: PMC5861393 DOI: 10.1136/heartjnl-2017-311446] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/13/2022]
Abstract
The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,University of New South Wales, Sydney, NSW, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
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475
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Abstract
Well into the 21st century, we still triage acute myocardial infarction on the basis of the presence or absence of ST-segment elevation, a century-old technology. Meanwhile, we have learned a great deal about the pathophysiology and mechanisms of acute coronary syndromes (ACS) at the clinical, pathological, cellular, and molecular levels. Contemporary imaging studies have shed new light on the mechanisms of ACS. This review discusses these advances and their implications for clinical management of the ACS for the future. Plaque rupture has dominated our thinking about ACS pathophysiology for decades. However, current evidence suggests that a sole focus on plaque rupture vastly oversimplifies this complex collection of diseases and obscures other mechanisms that may mandate different management strategies. We propose segmenting coronary artery thrombosis caused by plaque rupture into cases with or without signs of concomitant inflammation. This distinction may have substantial therapeutic implications as direct anti-inflammatory interventions for atherosclerosis emerge. Coronary artery thrombosis caused by plaque erosion may be on the rise in an era of intense lipid lowering. Identification of patients with of ACS resulting from erosion may permit a less invasive approach to management than the current standard of care. We also now recognize ACS that occur without apparent epicardial coronary artery thrombus or stenosis. Such events may arise from spasm, microvascular disease, or other pathways. Emerging management strategies may likewise apply selectively to this category of ACS. We advocate this more mechanistic approach to the categorization of ACS to provide a framework for future tailoring, triage, and therapy for patients in a more personalized and precise manner.
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Affiliation(s)
- Filippo Crea
- From Department of Cardiovascular and Thoracic Sciences, Catholic University, Rome, Italy (F.C.); and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.L.)
| | - Peter Libby
- From Department of Cardiovascular and Thoracic Sciences, Catholic University, Rome, Italy (F.C.); and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.L.).
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476
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AlBadri A, Wei J, Mehta PK, Shah R, Herscovici R, Gulati M, Shufelt C, Bairey Merz N. Sex differences in coronary heart disease risk factors: rename it ischaemic heart disease! Heart 2017; 103:1567-1568. [PMID: 28931566 PMCID: PMC6728076 DOI: 10.1136/heartjnl-2017-311921] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | | | - Romana Herscovici
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
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477
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Taqueti VR, Dorbala S, Wolinsky D, Abbott B, Heller GV, Bateman TM, Mieres JH, Phillips LM, Wenger NK, Shaw LJ. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations. J Nucl Cardiol 2017; 24:1402-1426. [PMID: 28585034 PMCID: PMC5942593 DOI: 10.1007/s12350-017-0926-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.
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Affiliation(s)
- Viviany R Taqueti
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Wolinsky
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Brian Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Cardiovascular Institute, The Miriam and Newport Hospitals, Providence, RI, USA
| | - Gary V Heller
- Gagnon Cardiovascular Center, Morristown Medical Center, Morristown, NJ, USA
| | - Timothy M Bateman
- Saint Luke's Health System, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, USA
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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478
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Berry C. Stable Coronary Syndromes: The Case for Consolidating the Nomenclature of Stable Ischemic Heart Disease. Circulation 2017; 136:437-439. [PMID: 28760869 DOI: 10.1161/circulationaha.117.028991] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Colin Berry
- From British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
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479
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Affiliation(s)
- Angela Hem Maas
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
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480
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Innovative Clinical Trial Designs for Precision Medicine in Heart Failure with Preserved Ejection Fraction. J Cardiovasc Transl Res 2017; 10:322-336. [PMID: 28681133 DOI: 10.1007/s12265-017-9759-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 06/13/2017] [Indexed: 12/17/2022]
Abstract
A major challenge in the care of patients with heart failure and preserved ejection fraction (HFpEF) is the lack of proven therapies due to disappointing results from randomized controlled trials (RCTs). The heterogeneity of the HFpEF syndrome and the use of conventional RCT designs are possible reasons underlying the failure of these trials. There are several factors-including the widespread adoption of electronic health records, decreasing costs of obtaining high-dimensional data, and the availability of a wide variety of potential therapeutics-that have evolved to enable more innovative clinical trial designs in HFpEF. Here, we review the current landscape of HFpEF RCTs and present several innovative RCT designs that could be implemented in HFpEF, including enrichment trials, adaptive trials, umbrella trials, basket trials, and machine learning-based trials (including examples for each). Our hope is that the description of the aforementioned innovative trial designs will stimulate new approaches to clinical trials in HFpEF.
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481
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Abstract
OPINION STATEMENT Despite continued advances in the field, cardiovascular disease remains the leading cause of death in women in the USA with an annual mortality rate that has remained higher for women as compared to men. The factors leading to this sex difference remain incompletely understood. Likely contributors include atypical symptoms at presentation and lack of recognition of cardiovascular risk by women and their providers alike. In addition, women have a higher burden of comorbidities at the time of disease diagnosis and can have differential pathophysiological mechanisms of their acute events. Women also can develop unique cardiovascular risk factors such as preeclampsia and hypertensive disorders of pregnancy. As a result, when women present with symptoms, even atypical, healthcare providers should increase their index level of suspicion for cardiovascular disease. Even after diagnosis, women are less likely to receive guideline-directed medical therapies and be referred for coronary angiography or cardiac rehabilitation. Thus, greater awareness of and research into the aspects of coronary disease that remain unique to women is critical, as women presenting with coronary disease continue to receive disparate care as compared to men. Improvements in awareness and care and new research avenues may reduce the incidence and complications of cardiovascular disease among women.
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