Persistent angina: highly prevalent and associated with long-term anxiety, depression, low physical functioning, and quality of life in stable angina pectoris

Living with stable angina: patients' pathway and needs in angina

AIMS

There is evidence that stable angina patients may suffer from emotional disorders that further impair their quality of life. However, the emotional experience of living with stable angina from the patient's perspective still has to be explored. Thus, the main aim of this study was to explore patients' emotional experience of having stable angina and their reported needs during the pathway from the first symptoms, through the process of diagnosis, to management and related lifestyle changes.

METHODS

A survey was conducted in 75 chronic ischemic heart disease patients with angina (Brazil, China, Romania, Russia, and Turkey) using a 75-min, face-to-face in-depth interview.

RESULTS AND CONCLUSION

Patients' responses highlighted the need to increase individuals' awareness on the first signs and symptoms of the disease. The survey also showed that chronic stable angina patients need constant emotional support to overcome stress, anxiety, and depression. Finally, this study suggests the need to offer greater space for dialogue with healthcare professionals to get more comprehensive and 'patient-friendly' information.

Novel experimental model for studying the spatiotemporal electrical signature of acute myocardial ischemia: a translational platform

Myocardial ischemia is one of the most common cardiovascular pathologies and can indicate many severe and life threatening diseases. Despite these risks, current electrocardiographic detection techniques for ischemia are mediocre at best, with reported sensitivity and specificity ranging from 50%-70% and 70%-90%, respectively.

OBJECTIVE

To improve this performance, we set out to develop an experimental preparation to induce, detect, and analyze bioelectric sources of myocardial ischemia and determine how these sources reflect changes in body-surface potential measurements.

APPROACH

We designed the experimental preparation with three important characteristics: (1) enable comprehensive and simultaneous high-resolution electrical recordings within the myocardial wall, on the heart surface, and on the torso surface; (2) develop techniques to visualize these recorded electrical signals in time and space; and (3) accurately and controllably simulate ischemic stress within the heart by modulating the supply of blood, the demand for perfusion, or a combination of both.

MAIN RESULTS

To achieve these goals we designed comprehensive system that includes (1) custom electrode arrays (2) signal acquisition and multiplexing units, (3) a surgical technique to place electrical recording and myocardial ischemic control equipment, and (4) an image based modeling pipeline to acquire, process, and visualize the results. With this setup, we are uniquely able to capture simultaneously and continuously the electrical signatures of acute myocardial ischemia within the heart, on the heart surface, and on the body surface.

SIGNIFICANCE

This novel experimental preparation enables investigation of the complex and dynamic nature of acute myocardial ischemia that should lead to new, clinically translatable results.

Pre-diabetes, diabetes and predictors of incident angina among older women and men in the Cardiovascular Health Study

Diabetes mellitus and angina pectoris are important conditions in older persons. The utility of pre-diabetes mellitus, diabetes mellitus and other risk factors as predictors of incident angina pectoris among older adults has not been characterized. We examined incident angina pectoris rates by sex and diabetes mellitus status in 4511 adults aged ⩾65 years without coronary heart disease at baseline from the Cardiovascular Health Study. Cox regression examined predictors of incident angina pectoris, including pre-diabetes mellitus or diabetes mellitus adjusted for sociodemographic characteristics and other risk factors, over 12.2 ± 6.9 years of follow-up. Overall, 39.1% of participants had pre-diabetes mellitus, 14.0% had diabetes mellitus and 532 (11.8%) had incident angina pectoris. Incident angina pectoris rates per 1000 person-years in those with neither condition, pre-diabetes mellitus, and diabetes mellitus were 7.9, 9.0 and 12.3 in women and 10.3, 11.2 and 14.5 in men, respectively. Pre-diabetes mellitus and diabetes mellitus were not independently associated with incident AP; however, key predictors of AP were male sex, low-density lipoprotein-cholesterol, triglycerides, systolic blood pressure, antihypertensive medication and difficulty performing at least one instrumental activity of daily living (all p < 0.05 to p < 0.01). In our cohort of older adult participants, while the incidence of AP is greater in those with diabetes mellitus, neither diabetes mellitus nor pre-diabetes mellitus independently predicted incident angina pectoris.

Effects of a Cardiac Rehabilitation Program Versus Usual Care on Cardiopulmonary Function in Patients With Cardiac Syndrome X

PURPOSE

Because of uncertainty in the pathophysiological process, the treatment of cardiac syndrome X (CSX) is still under study. Addressing the effects of cardiac rehabilitation (CR) can help promote the prescription of this modality as an adjuvant therapy for these patients.

METHODS

This study was performed on 30 patients with effort-induced angina pectoris using a positive exercise test and/or myocardial perfusion scan in the absence of obvious stenosis or a stenosis of <50% on coronary angiography. The patients were divided into the CR and usual care (UC) groups and underwent cardiopulmonary exercise testing with gas exchange analysis before and after the study. The Duke Treadmill Score was used to compare prognosis and survival estimates of patients.

RESULTS

An increase in peak oxygen uptake ((Equation is included in full-text article.)O2) was significantly higher in the CR group than in the control group (P = .017). Resting (Equation is included in full-text article.)O2 was also increased in the CR group, but its difference with the UC group was not statistically significant. Resting O2 pulse was increased in the CR group, which significantly differed between groups (P = .041). Exercise test duration and the Duke Treadmill Score significantly increased in the CR group as compared with the UC group (P = .003 and P = .002, respectively). Also, recovery heart rate in the first minute was significantly improved in CR group.

CONCLUSION

Adding a 4-wk course of CR to UC for patients with CSX not only increased the Duke Treadmill Score and exercise test duration but also improved the resting O2 pulse, peak (Equation is included in full-text article.)O2, and first-minute recovery heart rate.

Health-related quality of life and its associated factors among patients with angina in Jordan

BACKGROUND

Despite the negative impact of angina and its worsening symptoms on the quality of life of the affected patients, little research has evaluated the factors associated with poor health-related quality of life (HRQOL) among patients with angina.

OBJECTIVE

The study aim was to evaluate HRQOL and to explore factors associated with poor HRQOL in patients with angina in Jordan.

SETTING

The present study used data collected for patients attending the cardiology clinic at the Royal Medical Services (RMS) Hospital in Amman.

METHODS

In addition to collecting sociodemographic and clinical data, the EQ-5D questionnaire was used to assess HRQOL in outpatients with angina in the present study. Multiple linear regression analysis was conducted to build a model with variables that are significantly and independently associated with poor HRQOL.

MAIN OUTCOME MEASURE

HRQOL quantified using the EQ-5D.

RESULTS

The mean of the total EQ-5D score of the 500 participants was 0.392. Most of the patients reported 'some problems' through the five dimensions, with the highest percentage (66.6%) related to mobility domain. Regression analysis identified female gender (B = - 0.232; P < 0.05) elevated fasting blood sugar (FBS) (P < 0.05; B = - 0.219), and low high density lipoprotein (HDL) (B = - 0.183; P < 0.05) as being significantly associated with poor HRQOL.

CONCLUSIONS

The HRQOL has considerable scope for improvement for patients with angina in Jordan. Female gender, elevated FBS, and decreased HDL levels were significantly associated with poor HRQoL in the present study.

Experimental Validation of Image-Based Modeling of Torso Surface Potentials During Acute Myocardial Ischemia

INTRODUCTION

Myocardial ischemia is an early clinical indicator of several underlying cardiac pathologies, including coronary artery disease, Takatsobu cardiomyopathy, and coronary artery dissection. Significant progress has been made in computing body-surface potentials from cardiac sources by solving the forward problem of electrocardiography. However, the lack of in vivo studies to validate such computations from ischemic sources has limited the translational potential of such models.

METHODS

To resolve this need, we have developed a large-animal experimental model that includes simultaneous recordings within the myocardium, on the epicardial surface, and on the torso surface during episodes of acute, controlled ischemia. Following each experiment, magnetic resonance images were obtained of the anatomy and electrode locations to create a subject-specific model for each animal. From the electrical recordings of the heart, we identified ischemic sources and used the finite element method to solve a static bidomain equation on a geometric model to compute torso surface potentials.

RESULTS

Across 33 individual heartbeats, the forward computed torso potentials showed only moderate agreement in both pattern and amplitude with the measured values on the torso surface. Qualitative analysis showed a more encouraging pattern of elevations and depressions shared by computed and measured torso potentials. Pearson's correlation coefficient, root mean squared error, and absolute error varied significantly by heartbeat (0.1642 ± 0.223, 0.10 ± 0.03mV, and 0.08 ± 0.03mV, respectively).

DISCUSSION

We speculate several sources of error in our computation including noise within torso surface recordings, registration of electrode and anatomical locations, assuming a homogeneous torso conductivities, and imposing a uniform "transition zone" between ischemic and non-ischemic tissues. Further studies will focus on characterizing these sources of error and understanding how they effect the study results.

Social Support, Unstable Angina, and Stroke as Predictors of Depression in Patients With Coronary Heart Disease

BACKGROUND

Depression is known to adversely affect coronary heart disease patients in western countries; however, no study of social support and depression has been conducted in the Chinese population.

OBJECTIVE

The aim of this study was to investigate the predictors of depression in patients with coronary heart disease.

METHODS

Between January and December 2015, a cross-sectional sample of 105 Taiwanese patients from cardiology units completed a demographic and clinical characteristics questionnaire, Enhancing Recovery in Coronary Heart Disease Social Support Inventory, and Patient Health Questionnaire-9.

RESULTS

Thirty-nine percent of the participants reported low social support, and 61.0% had depression symptoms. Eight factors predicted depression. Social support was significantly and adversely correlated with depression (r = -.481, P < .01). The other 7 factors were positively correlated with depression: age (r = .212, P < .05), reported monthly income of less than US $600 (F = 4.98, P = .001), lack of exercise (F = 3.75, P = .027), history of stroke (t = -2.45, P = .016) and kidney disease (t = -2.41, P = .018), unstable angina (F = 3.56, P = .031), and groin puncture (F = 3.27, P = .042). A hierarchical regression model explained 43.7% of the variance in depression.

CONCLUSION

Social support, unstable angina, and stroke may be important predictors of depression in patients with coronary heart disease. These findings help clinical staff to understand physical and mental health problems in cardiovascular patients. Thus, we suggest that early depression prediction and sufficient social support can help patients to face their disease and thus improve depression and health care quality.

Women with coronary microvascular dysfunction and no obstructive coronary artery disease have reduced exercise capacity

BACKGROUND

Both coronary microvascular dysfunction (CMD) and reduced exercise capacity are associated with adverse cardiovascular prognosis. The association between CMD and cardiopulmonary exercise testing (CPET) derived exercise capacity in symptomatic individuals without obstructive coronary artery disease (CAD) is not clear. We investigated whether exercise capacity was reduced in women with angina, CMD and no obstructive CAD compared with sex-matched controls. Furthermore, we assessed the association between CMD and other CPET-derived variables.

METHODS

All participants underwent transthoracic Doppler echocardiography of the left anterior descending artery with dipyridamole-induced vasodilation and CPET using ergometer cycle with an incremental test protocol.

RESULTS

We included 99 women with angina and no obstructive CAD (patients) and 27 asymptomatic women (controls), age (mean ± standard deviation) 61 ± 10 and 58 ± 10 years, respectively. Patients had a higher burden of risk factors compared with controls, while the weekly physical activity level was comparable between the groups (p = 0.72). CMD was present in 27 (27%) patients and 5 (19%) controls. Peak VO₂ was significantly reduced in patients with CMD compared with controls with normal coronary microvascular function ((median (IQR) 17.3 (15.5-21.3) vs. 27.3 (21.6-30.8) ml/kg/min; age-adjusted p = 0.001), independent of cardiovascular risk factors (p = 0.041). Presence of CMD in symptomatic women was also associated with diminished heart rate reserve (p < 0.001) and blunted heart rate recovery.

CONCLUSIONS

Women with angina, CMD and no obstructive CAD have markedly reduced exercise capacity compared with sex-matched controls. Moreover, combination of angina and CMD is associated with impaired heart rate response and heart rate recovery.

Overlap between angina without obstructive coronary artery disease and left ventricular diastolic dysfunction with preserved ejection fraction

Background

A link between angina with no obstructive coronary artery disease (CAD) and heart failure with preserved left ventricular ejection fraction has been proposed, but evidence in support of this is lacking. In a cross-sectional study, we investigated whether left ventricular diastolic function in women with angina pectoris and no obstructive CAD differed from a reference population.

Methods

We included 956 women with angina and <50% coronary artery stenosis at invasive coronary angiography. Women with cardiovascular risk factors, but no history of chest pain or cardiac disease served as controls (n = 214). Left ventricular diastolic function was assessed by transthoracic echocardiography.

Results

The women with angina were slightly older, had higher body mass index, higher heart rate, and more had diabetes compared with controls while systolic blood pressure was lower. In age-adjusted analyses, angina patients had significantly lower E/A (Estimated difference -0.13, 95% CI: -0.17; -0.08), higher left ventricular mass index (5.73 g/m², 95% CI: 3.71; 7.75), left atrial volume index (2.34 ml/m², 95% CI: 1.23; 3.45) and E/e’ (0.68, 95% CI: 0.30; 1.05) and a larger proportion had higher estimated left ventricular filling pressure (17% versus 6%, p = 0.001). No between group differences were seen for e’ or deceleration time. After adjustment for known cardiovascular risk factors, between group differences for echocardiographic parameters remained statistically significant.

Conclusions

Patients with angina and no obstructive CAD had a more impaired left ventricular diastolic function compared with an asymptomatic reference population. This suggests some common pathophysiological pathway between the two syndromes.

Clarifying the Concept of Depression in Women With Coronary Heart Disease

The concept of depression in women with coronary heart disease has been poorly defined for several reasons: numerous widely variable instruments that operationalize the concept, divergent proposed instrument cutoff scores, and continued lack of female participants and data analysis by gender in coronary heart disease research. In the forty articles from 1990 to 2018 evaluating depression in women with coronary heart disease, the concept is defined by specific somatic and cognitive symptoms, preceded by particular physiological and psychosocial vulnerabilities, and leads to poorer outcomes. Concept clarification is necessary for accurate diagnosis of depression, leading to more timely and appropriate interventions for women.

Identifying Myocardial Ischemia due to Coronary Microvascular Dysfunction in the Emergency Department: Introducing a New Paradigm in Acute Chest Pain Evaluation

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.

Guanxinjing capsule in the treatment of chronic stable angina: study protocol for a randomized controlled trial

Background

Stable angina is a common cardiovascular disease with high mortality and a poor prognosis. Although there are various interventions against stable angina, none are able to significantly reduce the mortality rate. Guanxinjing capsule (GXJ) is made from the classical Chinese prescription Xuefuzhuyutang (血府逐瘀汤). Both basic research and clinical studies have shown that GXJ can relieve the symptoms of angina, but currently, the effects of GXJ lack high-quality clinical evidence. The aim of this study was to evaluate the clinical effectiveness and safety of GXJ compared with placebo.

Methods/design

This multicentre, blinded, randomized trial will be conducted with a total of 120 participants diagnosed with chronic stable angina (Qi deficiency and blood stasis syndrome). Using a central randomization system, participants will be randomized (1:1) into groups receiving either GXJ or placebo for 8 weeks. After a 2-week run-in period, eligible patients will receive either GXJ or placebo (4 pills, three times daily) for 8 weeks in addition to conventional treatment. The primary outcomes include changes in the total exercise time on exercise tolerance tests and changes in the integral scores of angina symptoms. The secondary outcome measures include changes in the maximal estimated workload, changes in time to a 1 mm ST-segment depression or raise, changes in the time to onset of angina during exercise tolerance testing, changes in the total score of traditional Chinese medicine syndrome, and changes in the total score of the Generalized Anxiety Disorder 7-item assessment between baseline and week 8. Other outcome measures will also be assessed. All exercise tolerance tests use a standard Bruce multistage exercise test protocol. Adverse events will be monitored throughout the trial.

Discussion

This study will investigate whether GXJ can alleviate clinical symptoms, increase the angina-free walking time, and improve quality of life in patients with chronic stable angina (Qi deficiency and blood stasis syndrome). The results of this study will provide clinical evidence for the application of GXJ to the treatment of stable angina.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800014258. Registered on 2 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2950-7) contains supplementary material, which is available to authorized users.

Cardiac Rehabilitation and Exercise Prescription in Symptomatic Patients with Non-Obstructive Coronary Artery Disease-a Systematic Review

Purpose of review

Non-obstructive coronary artery disease (NOCAD) on coronary angiography is a common finding in patients with stable angina. Angina in NOCAD patients is thought to be caused by endothelial dysfunction of the epicardial coronary arteries and/or the microvasculature. Treatment is empiric, and 30% of patients remain symptomatic in spite of therapy. It is well known that physical exercise can improve endothelial function. The goal of this review was to assess the current literature on effects of physical exercise in NOCAD patients with angina. Therefore, a literature search was conducted to March 13, 2018 using the following search terms: syndrome X, microvascular angina, non-obstructive coronary artery disease and exercise training, cardiac rehabilitation, endothelial function. All original publications were included which examined the effect of a cardiac rehabilitation (CR) program or exercise training (ET) on patients with angina and NOCAD.

Recent findings

Eight studies, of which four were randomized controlled studies, examined 218 participants, 162 in an intervention and 56 in control groups. Most patients were women (97.7%). Exercise programs varied from 8 weeks to 4 months at moderate intensity and some included relaxation therapy. The studies examined the effect of CR on exercise capacity, quality of life (QoL), and perfusion defects. CR increased exercise capacity, oxygen uptake, symptom severity, and QoL. Myocardial perfusion improved.

Summary

CR appears to be beneficial in symptomatic patients with NOCAD, improving exercise capacity and QoL and reducing severity of symptoms and myocardial perfusion defects. Data is limited to a small number of predominantly female patients. Further larger trials are warranted to determine the optimal rehabilitation protocols and define its long-term benefits.

Clinical care for patients with recurrent myocardial ischemia in Germany-the VOICES trial

Background

Chronic ischemic heart disease is frequent and represents the most common cause of death in western countries. Angina pectoris, the clinical symptom of myocardial ischemia, is associated with increased morbidity and mortality also in patients without obstructive coronary artery disease. The aim of this study was to investigate the current care of patients with recurrent myocardial ischemia after ruling out significant coronary stenosis in the setting of outpatient care.

Methods

Data were obtained by a detailed and structured survey. German cardiologists in outpatient care were interviewed about the management and treatment of outpatients with recurrent angina pectoris after ruling out significant stenoses by coronary angiography. Items were analysed using rating scales [1-10] by means of descriptive methods. Absolute and relative frequency distribution was calculated for the characterisation of qualitative data and multiple-choice questions.

Results

The interviews of 731 cardiologic experts could be included in this analysis. The main results showed that history taking seems to be one major problem in those patients-more than 10% of the expert cardiologists admit that they do not perform a detailed history taking of patients with recurrent angina pectoris. While a classification of the symptoms by means of the CCS classification is rated as important such a classification is not used on a regular basis. Extra-cardiac causes are frequently not excluded before performing coronary angiography (>10% of the cases). A significant fraction (20%) of German cardiologists does not consider the initiation of a specific, antianginal medical treatment as their objective.

Conclusions

The trial revealed deficiencies in the history taking, the proper classification of the symptoms, and the initiation of an adequate drug therapy in patients with recurrent angina pectoris after exclusion of significant coronary stenoses.

Rationale and design of the British Heart Foundation (BHF) Coronary Microvascular Angina (CorMicA) stratified medicine clinical trial

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.

A multicenter trial of extracorporeal cardiac shock wave therapy for refractory angina pectoris: report of the highly advanced medical treatment in Japan

We have previously demonstrated that cardiac shock wave therapy (CSWT) effectively improves myocardial ischemia through coronary neovascularization both in a porcine model of chronic myocardial ischemia and in patients with refractory angina pectoris (AP). In this study, we further addressed the efficacy and safety of CSWT in a single-arm multicenter study approved as a highly advanced medical treatment by the Japanese Ministry of Health, Labour and Welfare. Fifty patients with refractory AP [mean age 70.9 ± 12.6 (SD) years, M/F 38/12] without the indications of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were enrolled in 4 institutes in Japan. Ischemic myocardial regions in the left ventricle (LV) were identified by drug-induced stress myocardial perfusion imaging (MPI). Shock waves (200 shots/spot at 0.09 mJ/mm²) were applied to 40-60 spots in the ischemic myocardium 3 times in the first week. The patients were followed up for 3 months thereafter. Forty-one patients underwent CSWT and completed the follow-up at 3 months. CSWT markedly improved weekly nitroglycerin use [from 3.5 (IQR 2 to 6) to 0 (IQR 0 to 1)] and the symptoms [Canadian Cardiovascular Society functional class score, from 2 (IQR 2 to 3) to 1 (IQR 1 to 2)] (both P < 0.001). CSWT also significantly improved 6-min walking distance (from 384 ± 91 to 435 ± 122 m, P < 0.05). There were no significant changes in LV ejection fraction evaluated by echocardiography and LV stroke volume evaluated by cardiac magnetic resonance imaging (from 56.3 ± 14.7 to 58.8 ± 12.8%, P = 0.10, and from 52.3 ± 17.4 to 55.6 ± 15.7 mL, P = 0.15, respectively). Percent myocardium ischemia assessed by drug-induced stress MPI tended to be improved only in the treated segments (from 16.0 ± 11.1 to 12.1 ± 16.2%, P = 0.06), although no change was noted in the whole LV. No procedural complications or adverse effects related to the CSWT were noted. These results of the multicenter trial further indicate that CSWT is a useful and safe non-invasive strategy for patients with refractory AP with no options of PCI or CABG.

Chest Pain and Mental Stress-Induced Myocardial Ischemia: Sex Differences

BACKGROUND

Mental stress-induced myocardial ischemia is a frequent phenomenon in patients with coronary artery disease. Women with coronary artery disease tend to have more mental stress-induced myocardial ischemia and more chest pain/anginal symptoms than men, but whether the association between mental stress-induced myocardial ischemia and angina burden differs in women and men is unknown.

METHODS

This was a cross-sectional study with experimental manipulation of 950 individuals with stable coronary artery disease. Chest pain/angina frequency in the previous 4 weeks was assessed with the Seattle Angina Questionnaire's angina-frequency subscale. Mental stress-induced myocardial ischemia was assessed with myocardial perfusion imaging during mental stress (standardized public speaking task). Presence of mental stress-induced myocardial ischemia was based on expert readers and established criteria. A conventional (exercise or pharmacologic) stress test was used as a control condition.

RESULTS

Overall, 338 individuals (37%) reported angina; 112 (12%) developed mental stress-induced myocardial ischemia, and 256 (29%) developed conventional stress ischemia. Women who reported angina had almost double the probability to develop mental stress-induced myocardial ischemia (19% vs 10%, adjusted prevalence rate ratio, 1.90; 95% confidence interval, 1.04-3.46), whereas there was no such difference in men (11% vs 11%, adjusted prevalence rate ratio, 1.09; 95% confidence interval, 0.66-1.82). No association was found between angina symptoms and conventional stress ischemia for women or men. Results for ischemia as a continuous variable were similar.

CONCLUSIONS

In women, but not in men, anginal symptoms may be a marker of vulnerability toward ischemia induced by psychologic stress. These results highlight the psychosocial origins of angina in women and may have important implications for the management and prognosis of women with angina.

The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease

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.

Ventricular repolarization alterations in women with angina pectoris and suspected coronary microvascular dysfunction

OBJECTIVES

CMD could be the explanation of angina pectoris with no obstructive CAD and may cause ventricular repolarization changes. We compared T-wave morphology and QTc interval in women with angina pectoris with a control group as well as the associations with CMD.

METHODS

Women with angina pectoris and no obstructive coronary artery disease (n=138) and age-matched controls were compared in regard to QTc interval and morphology combination score (MCS) based on T-wave asymmetry, flatness and presence of T-wave notch. CMD was assessed as a coronary flow velocity reserve (CFVR) by transthoracic echocardiography.

RESULTS

Women with angina pectoris had significantly longer QTc intervals (429±20ms) and increased MCS (IQR) (0.73 [0.64-0.80]) compared with the controls (419±20ms) and (0.63 [(0.53-0.73]), respectively (both p<0.001). CFVR was associated with longer QTc interval (p=0.02), but the association was attenuated after multivariable adjustment (p=0.08).

CONCLUSION

This study suggests that women with angina pectoris have alterations in T-wave morphology as well as longer QTc interval compared with a reference population. CMD might be an explanation.

Chest pain and shortness of breath in cardiovascular disease: a prospective cohort study in UK primary care

OBJECTIVE

To determine characteristics associated with monthly chest pain and shortness of breath (SoB) during activity in cardiovascular disease (CVD) and trajectories of these symptoms over 10 months.

STUDY DESIGN AND SETTING

Baseline questionnaire was sent to patients aged ≥40 years from 10 UK general practices. Responders were sent monthly questionnaires for 10 months. For patients with CVD (ischaemic heart disease and heart failure), the association of sociodemographic characteristics, pain elsewhere and anxiety and depression with monthly reports of chest pain and SoB during activity were determined using multilevel, multinomial logistic regression. Common symptom trajectories were determined using dual trajectory latent class growth analysis.

RESULTS

661 patients with CVD completed at least 5 monthly questionnaires. Multiple other pain sites (relative risk ratio: 4.03; 95% CI 1.64 to 9.91) and anxiety or depression (relative risk ratio: 3.31; 95% CI 1.89 to 5.79) were associated with reporting weekly chest pain. Anxiety or depression (relative risk ratio: 4.10; 95% CI 2.72 to 6.17), obesity (relative risk ratio: 2.53; 95% CI 1.49 to 4.30), older age (80+: relative risk ratio: 2.51; 95% CI 1.19 to 5.26), increasing number of pain sites (4+: relative risk ratio: 4.64; 95% CI 2.35 to 9.18) and female gender (relative risk ratio: 1.81; 95% CI 1.20 to 2.75) were associated with reporting weekly SoB. Eight symptom trajectories were identified, with SoB symptoms more common than chest pain.

CONCLUSIONS

Potentially modifiable characteristics are associated with the experience of chest pain and SoB. Identified symptom trajectories may facilitate tailored care to improve outcomes in patients with CVD.

Quality of Life in Patients with Coronary Artery Disease and Panic Disorder: A Comparative Study

OBJECTIVES

The quality of life (QOL) of patients with coronary artery disease (CAD) is known to be impaired. Non-cardiac chest pain referrals are often under-diagnosed and untreated, and there are hardly any studies comparing the QOL of CAD and panic disorder related (non-cardiac) chest pain referrals (PDRC).

METHODS

We assessed the psychiatric morbidity and QOL of patients newly diagnosed with CAD (n = 40) at baseline and six weeks post-treatment and compared their QOL with patients with PDRC (n = 40) and age- and gender-matched healthy controls (n = 57). Psychiatric morbidity in the CAD group was assessed using the General Health Questionnaire (GHQ12) item, Hamilton Anxiety Scores (HAM-A), and Hamilton Depression Scores (HAMD). QOL measures were determined by the World Health Organization QOL questionnaire (brief) and Seattle Angina Questionnaire. The CAD group was treated with anti-ischemic drugs (nitrates, betablockers), antiplatelet drugs (acetylsalicylsalicylic acid), anticoagulants (low molecular weight heparin, clopidogrel), and managed for risk factors. The PDRC group was treated with selective serotonin reuptake inhibitors and anxiolytics.

RESULTS

Patients with panic disorder had a worse QOL than those with CAD and healthy controls in the physical domain and psychological domain (PDRC vs. CAD vs. healthy controls, p < 0.001). In the CAD group, smoking was associated with change in angina stability (p = 0.049) whereas other tobacco products were associated with change in angina frequency (p = 0.044). Psychiatric morbidity was present in 40.0% of patients with CAD. In the PDRC group, a significant correlation of HAM-A scores was noted in the physical (p = 0.000), psychological (p = 0.001), social (p = 0.006), and environment (p = 0.001) domains of QOL. Patients with panic disorder had a significant improvement in anxiety scores after treatment compared to baseline (HAM-A scores difference 21.0 [16.5-25.6]; p < 0.001).

CONCLUSIONS

Patients in the PDRC group had a worse QOL than those in the CAD and healthy control groups. This highlights the need for careful diagnosis and prompt treatment of panic disorder in these patients to improve their QOL. Additionally, smoking, the use of other tobacco products, and hypercholesterolemia were associated with angina symptoms in patients with CAD.

Women with Stable Angina Pectoris and No Obstructive Coronary Artery Disease: Closer to a Diagnosis

A large proportion of women with chest pain have no obstructive coronary artery disease. Recent studies have demonstrated that these women continue to have symptoms and are at increased risk of cardiovascular morbidity and mortality. Coronary microvascular dysfunction (CMD) leads to an impairment of blood flow regulation to the myocardium and possible transient ischaemia. CMD is a disease entity with several pathophysiologic aspects and diagnostic modalities continue to be developed. However, due to the complexity of the disease, it remains elusive whether CMD is the explanation for the symptoms and the poor prognosis in women with angina and no obstructive coronary artery disease.

Coronary microvascular function and myocardial fibrosis in women with angina pectoris and no obstructive coronary artery disease: the iPOWER study

BACKGROUND

Even in absence of obstructive coronary artery disease women with angina pectoris have a poor prognosis possibly due to coronary microvascular disease. Coronary microvascular disease can be assessed by transthoracic Doppler echocardiography measuring coronary flow velocity reserve (CFVR) and by positron emission tomography measuring myocardial blood flow reserve (MBFR). Diffuse myocardial fibrosis can be assessed by cardiovascular magnetic resonance (CMR) T1 mapping. We hypothesized that coronary microvascular disease is associated with diffuse myocardial fibrosis.

METHODS

Women with angina, a clinically indicated coronary angiogram with <50 % stenosis and no diabetes were included. CFVR was measured using dipyridamole (0.84 mg/kg) and MBFR using adenosine (0.84 mg/kg). Focal fibrosis was assessed by 1.5 T CMR late gadolinium enhancement (0.1 mmol/kg) and diffuse myocardial fibrosis by T1 mapping using a modified Look-Locker pulse sequence measuring T1 and extracellular volume fraction (ECV).

RESULTS

CFVR and CMR were performed in 64 women, mean (SD) age 62.5 (8.3) years. MBFR was performed in a subgroup of 54 (84 %) of these women. Mean native T1 was 1023 (86) and ECV (%) was 33.7 (3.5); none had focal fibrosis. Median (IQR) CFVR was 2.3 (1.9; 2.7), 23 (36 %) had CFVR < 2 indicating coronary microvascular disease, and median MBFR was 2.7 (2.2; 3.0) and 19 (35 %) had a MBFR value below 2.5. No significant correlations were found between CFVR and ECV or native T1 (R 2  = 0.02; p = 0.27 and R 2  = 0.004; p = 0.61, respectively). There were also no correlations between MBFR and ECV or native T1 (R 2  = 0.1; p = 0.13 and R 2  = 0.004, p = 0.64, respectively). CFVR and MBFR were correlated to hypertension and heart rate.

CONCLUSION

In women with angina and no obstructive coronary artery disease we found no association between measures of coronary microvascular disease and myocardial fibrosis, suggesting that myocardial ischemia induced by coronary microvascular disease does not elicit myocardial fibrosis in this population. The examined parameters seem to provide independent information about myocardial and coronary disease.

Determinants of Quality of Life in Ageing Populations: Results from a Cross-Sectional Study in Finland, Poland and Spain

Purpose

To comprehensively identify the determinants of quality of life (QoL) in a population study sample of persons aged 18–50 and 50+.

Methods

In this observational, cross-sectional study, QoL was measured with the WHOQOL-AGE, a brief instrument designed to measure QoL in older adults. Eight hierarchical regression models were performed to identify determinants of QoL. Variables were entered in the following order: Sociodemographic; Health Habits; Chronic Conditions; Health State description; Vision and Hearing; Social Networks; Built Environment. In the final model, significant variables were retained. The final model was re-run using data from the three countries separately.

Results

Complete data were available for 5639 participants, mean age 46.3 (SD 18.4). The final model accounted for 45% of QoL variation and the most relevant contribution was given by sociodemographic data (particularly age, education level and living in Finland: 17.9% explained QoL variation), chronic conditions (particularly depression: 4.6%) and a wide and rich social network (4.6%). Other determinants were presence of disabling pain, learning difficulties and visual problems, and living in usable house that is perceived as non-risky. Some variables were specifically associated to QoL in single countries: age in Poland, alcohol consumption in Spain, angina in Finland, depression in Spain, and self-reported sadness both in Finland and Poland, but not in Spain. Other were commonly associated to QoL: smoking status, bodily aches, being emotionally affected by health problems, good social network and home characteristics.

Conclusions

Our results highlight the importance of modifiable determinants of QoL, and provide public health indications that could support concrete actions at country level. In particular, smoking cessation, increasing the level of physical activity, improving social network ties and applying universal design approach to houses and environmental infrastructures could potentially increase QoL of ageing population.

Coronary Microvascular Function and Cardiovascular Risk Factors in Women With Angina Pectoris and No Obstructive Coronary Artery Disease: The iPOWER Study

BACKGROUND

The majority of women with angina-like chest pain have no obstructive coronary artery disease when evaluated with coronary angiography. Coronary microvascular dysfunction is a possible explanation and associated with a poor prognosis. This study evaluated the prevalence of coronary microvascular dysfunction and the association with symptoms, cardiovascular risk factors, psychosocial factors, and results from diagnostic stress testing.

METHODS AND RESULTS

After screening 3568 women, 963 women with angina-like chest pain and a diagnostic coronary angiogram without significant coronary artery stenosis (<50%) were consecutively included. Mean age (SD) was 62.1 (9.7). Assessment included demographic and clinical data, blood samples, questionnaires, and transthoracic echocardiography during rest and high-dose dipyridamole (0.84 mg/kg) with measurement of coronary flow velocity reserve (CFVR) by Doppler examination of the left anterior descending coronary artery. CFVR was successfully measured in 919 (95%) women. Median (IQR) CFVR was 2.33 (1.98-2.76), and 241 (26%) had markedly impaired CFVR (<2). In multivariable regression analysis, predictors of impaired CFVR were age (P<0.01), hypertension (P=0.02), current smoking (P<0.01), elevated heart rate (P<0.01), and low high-density lipoprotein cholesterol (P=0.02), but these variables explained only a little of the CFVR variation (r(2)=0.09). CFVR was not associated with chest pain characteristics or results from diagnostic stress testing.

CONCLUSION

Impaired CFVR was detected in a substantial proportion, which suggests that coronary microvascular dysfunction plays a role in the development of angina pectoris. CFVR was associated with few cardiovascular risk factors, suggesting that CFVR is an independent parameter in the risk evaluation of these women. Symptom characteristics and results from stress testing did not identify individuals with impaired CFVR.

Angina in Coronary Artery Disease Patients With and Without Diabetes: US National Health and Nutrition Examination Survey 2001-2010

BACKGROUND

Angina pectoris (AP) is common in coronary artery disease (CAD), but whether those with diabetes mellitus (DM) experience AP as often as those without DM is unclear.

HYPOTHESIS

AP prevalence is similar in those with vs without DM in a community sample with CAD.

METHODS

In adults with CAD in the US NHANES 2001-2010, AP was determined by self-report and Rose questionnaire and compared by DM status. Physical functioning and medication use were also evaluated.

RESULTS

Of 1957 adults with CAD, 619 (28.2%) had DM. Prevalence of AP was similar in those with vs without DM (48.9% vs 46.3%; P = 0.38). There was a trend toward more severe AP in those with glycated hemoglobin ≥7% (50.4%) vs <7% (27.1%; P = 0.09). Adjusted logistic regression showed a similar odds of AP (1.06, 95% CI: 0.84-1.33) in those with vs without DM, although among DM, a 2-fold greater odds of AP in women vs men. Physical functioning was worse in those with vs without AP overall (score of 25.9 vs 24.3; P < 0.001) and further diminished within those with comorbid DM (26.7 vs 24.0; P < 0.001). Among those with AP, those with vs without DM were more likely on β-blockers, statins, angiotensin-converting enzyme inhibitors, and antiplatelet therapy.

CONCLUSIONS

AP in CAD patients is similar among those with vs without DM, despite greater use of evidence-based therapies in DM patients. Greater physical limitations exist in those with vs without AP, and further diminish with comorbid DM.

Ivabradine in Combination with Metoprolol Improves Symptoms and Quality of Life in Patients with Stable Angina Pectoris: A post hoc Analysis from the ADDITIONS Trial

OBJECTIVES

Elevated heart rate can increase myocardial oxygen demand and reduce myocardial perfusion, provoking myocardial ischemia and angina symptoms. We evaluated adding ivabradine to the therapy of patients on metoprolol.

METHODS

ADDITIONS (prActical Daily efficacy anD safety of Procoralan® In combinaTION with betablockerS) was a multicenter, 4-month, noninterventional, prospective, open-label trial that involved stable-angina patients. Along with metoprolol, patients received ivabradine (5 or 7.5 mg, b.i.d.). We investigated the effect of ivabradine on heart rate, angina attacks, nitrate consumption, quality of life (QoL) and tolerability as well as the influence of baseline heart rate.

RESULTS

Heart rate fell by 19.7 ± 11.2 bpm, with an 8-fold decrease in weekly angina attacks (1.7 ± 2.2 to 0.2 ± 0.7) and nitrate consumption (2.4 ± 3.4 to 0.3 ± 0.9). Patient numbers in Canadian Cardiovascular Society class I more than doubled (i.e. from 29 to 65%) and QoL improved (the EQ-5D index and visual analog scale scores rose from 0.68 ± 0.27 to 0.84 ± 0.20 and 58.1 ± 18.4 to 72.2 ± 15.5 mm, respectively). The effect of ivabradine was greater in patients with a baseline heart rate ≥70 bpm (mean reduction in heart rate -21.2 ± 10.4 bpm, with a relative reduction in angina attacks and short-acting nitrate consumption of 87.1 and 87.2%, respectively).

CONCLUSIONS

Ivabradine combined with metoprolol safely and effectively reduces heart rate, angina attacks and nitrate use, and improves QoL in stable-angina patients.

Frequency and covariates of fear of death during myocardial infarction and its impact on prehospital delay: findings from the multicentre MEDEA Study

BACKGROUND

Fear of death (FoD) is an exceptionally stressful symptom of ST-elevation myocardial infarction (STEMI), which received little scientific attention in recent years. We aimed to describe the prevalence and factors contributing to FoD among STEMI patients and assess the impact of FoD on prehospital delay.

METHODS

This investigation was based on 592 STEMI patients who participated in the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. Multivariate logistic regression models were used to identify factors associated with FoD.

RESULTS

A total of 15% of STEMI patients reported FoD (n = 88), no significant gender difference was found. STEMI pain strength [OR = 2.3 (1.4-3.9)], STEMI symptom severity [OR = 3.7 (2-6.8)], risk perception pre-STEMI [OR = 1.9 (1.2-3.2)] and negative affectivity [OR = 1.9 (1.2-3.1)] were independently associated with FoD. The median delay for those who experienced FoD was 139 min compared to 218 min for those who did not (p = 0.005). Male patients with FoD were significantly more likely to delay less than 120 min [OR = 2.11(1.25-3.57); p = 0.005], whereas in women, this association was not significant. Additionally, a clear dose-response relationship between fear severity and delay was observed. Male FoD patients significantly more often used emergency services to reach the hospital (p = 0.003).

CONCLUSIONS

FoD is experienced by a clinically meaningful minority of vulnerable STEMI patients and is strongly associated with shorter delay times in men but not in women. Patients' uses of emergency services play an important role in reducing the delay in male FoD patients.

Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study: mediating effect of anxiety and depression

BACKGROUND

Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential mediating effects of negative mood states.

METHODS

Any chest pain in the past month was the primary outcome measure reported by 523 patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators.

RESULTS

Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain.

CONCLUSIONS

Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states.

Cardiac shock wave therapy and myocardial perfusion in severe coronary artery disease

BACKGROUND

Ultrasound guided cardiac shock wave therapy (CSWT) is a noninvasive therapeutic option in the treatment of chronic-refractory angina. Clinical trials have shown that CSWT reduces angina symptoms, improves regional systolic function, LV ejection fraction, myocardial perfusion and quality of life parameters. Absolute measurements of myocardial perfusion before and after CSWT have not been performed so far.

METHODS AND RESULTS

We studied a total of 21 CCS III patients with history of CAD and multiple interventions who suffered from disabling angina despite individually optimized medical therapy. An N-13 NH3 PET perfusion scan under adenosine was performed before and after CSWT treatment. CSWT was well tolerated in all patients. Absolute perfusion under adenosine of the global left-ventricular myocardium did not change under therapy or minimal coronary resistance. The treated segments, however, showed in terms of both perfusion and resistance a mild but significant improvement, by 11 and 15 %, respectively, whereas no change could be observed in the remote segments. Considering a threshold of increased perfusion of 5 %, 10 (77 %) out of 13 patients with a better target perfusion improved in their CCS class, whereas 3 (43 %) out of 7 patients without improved target perfusion improved in their CCS class too.

CONCLUSION

Standard CSWT has the potential to improve myocardial perfusion of the therapy zone and clinical CAD symptomatology without affecting global myocardial perfusion. As a noninvasive and well tolerated therapeutic option, these data suggest the use of CSWT in patients with end-stage CAD.

Characteristics and Outcomes of Women Veterans Undergoing Cardiac Catheterization in the Veterans Affairs Healthcare System

Background—

The number of women veterans is increasing, yet little is known about their cardiovascular risk factors, coronary anatomy, cardiac treatments, and outcomes after cardiac catheterization. Prior studies have shown that nonveteran women have more risk factors, receive less aggressive treatment, and have worse outcomes, despite having less obstructive coronary artery disease than men. Whether these differences exist among women veterans in the veterans affairs healthcare system is unknown.

Methods and Results—

Data on 85 936 veterans (3181 women) undergoing initial cardiac catheterization between October 1, 2007, and September 30, 2012, were examined using the national veterans affairs Clinical Assessment Reporting and Tracking (CART) Program. Sex differences in demographics, indications, coronary anatomy, cardiac treatments, and outcomes were analyzed. Women veterans were younger (56.9 versus 63.0 years, P <0.0001) with fewer traditional cardiovascular risk factors, but with more obesity, depression, and posttraumatic stress disorder than men. Women had lower rates of obstructive coronary artery disease than men (22.6% versus 53.3%). Rates of procedural complications were similar in both genders. Adjusted outcomes at 1 year showed women had lower mortality (hazard ratio, 0.74; confidence interval, 0.60–0.92) and less all-cause rehospitalization (hazard ratio, 0.87; confidence interval, 0.82–0.93), but no difference in rates of unplanned percutaneous coronary intervention.

Conclusions—

Women veterans undergoing catheterization are younger, have more obesity, depression, and posttraumatic stress disorder, less obstructive coronary artery disease, and similar long-term outcomes, compared with men. These findings suggest a significant portion of women veterans may have chest pain not attributable to obstructive coronary artery disease. Further research into possible causes, such as endothelial dysfunction or concurrent psychological comorbidities, is needed.

Investigating the role of acute mental stress on endothelial dysfunction: a systematic review and meta-analysis

Chronic stress is a known risk factor for both endothelial dysfunction and cardiovascular disease (CVD), but less is known of how acute mental stress affects the vasculature. In this systematic review and meta-analysis, we analyzed the impact of acute mental stress on flow-mediated dilation (FMD), an indicator of endothelial function. We searched the Medline, Cochrane, EMBASE, and ISI Web of Knowledge databases through May 2014, to identify publications in English-language journals. The primary outcome was the change in FMD from baseline to the time of measurement. We also assessed the risk of bias and the heterogeneity of included studies. Our search identified eight prospective studies, which displayed significant heterogeneity. Four studies measured FMD while the subject was performing the task; six measured FMD after the task had been completed. The total number of participants was 164. The pooled results indicate that FMD did not change significantly while the task was being performed (pooled difference in means: -0.853; 95 % confidence interval (CI), -3.926/2.220; P = 0.586); however, FMD measured after the task was completed was significantly less than baseline (pooled difference in means: -2.450; 95 %CI, -3.925/-0.975; P = 0.001). In conclusions, our findings provide evidence that an acute stressful experience has a delayed, negative impact on the function of the endothelium. Repeated exposure to short-term stress may lead to permanent injury of the vasculature. Therefore, assessment of patients' exposure to both repeated acute mental stress and chronic stress may be useful in determining their risk of developing CVD.

Detection of coronary artery disease in postmenopausal women: the significance of integrated stress imaging tests in a 4-year prognostic study

BACKGROUND

The present prospective study investigated whether a combined approach integrating two different stress imaging modalities may improve the diagnostic accuracy and prognostic impact of non-invasive coronary artery disease (CAD) tests in postmenopausal women. In women non-invasive tests for detecting CAD are less accurate than in men, leading to a high proportion of unnecessary coronary angiographies (CAs).

METHODS

424 consecutive postmenopausal women (mean 61 ± 7 years, mean Reynolds Risk Score 13 ± 3 %) with symptoms suggestive of CAD were prospectively included and followed up for 4 ± 1 years. Each patient underwent CA, stress cardiovascular magnetic resonance (CMR) by adenosine, dobutamine stress echocardiography (DSE) and single-photon emission computed tomography (SPECT) within 7 ± 3 days.

RESULTS

Anatomically obstructive coronary artery disease (≥50 % diameter stenosis) was present in 157 women (37 %). The combination of two stress imaging modalities significantly increased the positive predictive values (PPV) to 90 ± 3, 88 ± 3 and 87 ± 2 % for CMR/DSE, DSE/SPECT and CMR/SPECT, respectively. For patients with negative combined test results, the survival analysis showed a 4-year cumulative event-free survival rate of 96-97 % for all combinations. This new approach is cost effective due to the resulting reduction in unnecessary CAs (with potential side effects and corresponding therapies) as well as reducing hospitalization time.

CONCLUSIONS

In symptomatic postmenopausal women, combination of two negative stress imaging results significantly increases the PPV for detection of CAD and excludes future cardiovascular events with high accuracy. This approach may be applied to improve the prognostic precision of non-invasive CAD tests and to avoid unnecessary CAs.

[Chronic chest pain]

BACKGROUND

Chest pain is a symptom commonly reported by persons in the general population and represents a differential diagnostic challenge.

MATERIAL AND METHODS

The paper is based on a narrative review with a selective search of the literature in Medline for reviews and guidelines on the prevalence and treatment of non-malignant diseases with chronic chest pain in gastroenterology, gynecology and cardiology.

RESULTS

The prevalence and current treatment recommendations for the different forms of gastroesophageal reflux disease (GERD), erosive and non-erosive types and irritable esophagus, non-cardiac chest pain, refractory angina in coronary heart disease and postmastectomy nand poststernotomy syndromes are presented. In cases of failure of the established therapy of a single medical discipline, an interdisciplinary assessment including psychosocial issues is recommended. Evidence-based guidelines are available for the management of GERD and of refractory angina. Treatment of postmastectomy and poststernotomy syndromes is based on case reports and expert opinion.

CONCLUSION

There is a need for controlled studies on the symptomatic treatment of pain in irritable esophagus, non-cardiac chest pain, postmastectomy and poststernotomy syndromes.

Burden of hospital admission and repeat angiography in angina pectoris patients with and without coronary artery disease: a registry-based cohort study

AIMS

To evaluate risk of hospitalization due to cardiovascular disease (CVD) and repeat coronary angiography (CAG) in stable angina pectoris (SAP) with no obstructive coronary artery disease (CAD) versus obstructive CAD, and asymptomatic reference individuals.

METHODS AND RESULTS

We followed 11,223 patients with no prior CVD having a first-time CAG in 1998-2009 due to SAP symptoms and 5,695 asymptomatic reference individuals from the Copenhagen City Heart Study through registry linkage for 7.8 years (median). In recurrent event survival analysis, patients with SAP had 3-4-fold higher risk of hospitalization for CVD irrespective of CAG findings and cardiovascular comorbidity. Multivariable adjusted hazard ratios(95%CI) for patients with angiographically normal coronary arteries was 3.0(2.5-3.5), for angiographically diffuse non-obstructive CAD 3.9(3.3-4.6) and for 1-3-vessel disease 3.6-4.1(range)(all P<0.001). Mean accumulated hospitalization time was 3.5(3.0-4.0)(days/10 years follow-up) in reference individuals and 4.5(3.8-5.2)/7.0(5.4-8.6)/6.7(5.2-8.1)/6.1(5.2-7.4)/8.6(6.6-10.7) in patients with angiographically normal coronary arteries/angiographically diffuse non-obstructive CAD/1-, 2-, and 3-vessel disease, respectively (all P<0.05, age-adjusted). SAP symptoms predicted repeat CAG with multivariable adjusted hazard ratios for patients with angiographically normal coronary arteries being 2.3(1.9-2.9), for angiographically diffuse non-obstructive CAD 5.5(4.4-6.8) and for obstructive CAD 6.6-9.4(range)(all P<0.001).

CONCLUSIONS

Patients with SAP symptoms and angiographically normal coronary arteries or angiographically diffuse non-obstructive CAD suffer from considerably greater CVD burdens in terms of hospitalization for CVD and repeat CAG compared with asymptomatic reference individuals even after adjustment for cardiac risk factors and exclusion of cardiovascular comorbidity as cause. Contrary to common perception, excluding obstructive CAD by CAG in such patients does not ensure a benign cardiovascular prognosis.

Improving diagnosis and treatment of women with angina pectoris and microvascular disease: the iPOWER study design and rationale

BACKGROUND

The iPOWER study aims at determining whether routine assessment of coronary microvascular dysfunction (CMD) in women with angina and no obstructive coronary artery disease is feasible and identifies women at risk.

METHODS

All women with angina referred to invasive angiographic assessment in Eastern Denmark are invited to join the study according to in- and exclusion criteria. Assessment includes demographic, clinical and psychosocial data, symptoms, electrocardiogram, blood- and urine samples and transthoracic echocardiography during rest and dipyridamol stress with measurement of coronary flow reserve (CFR) by Doppler of the left anterior descending artery. In substudies CMD will be assessed by positron emission tomography, peripheral endothelial function, magnetic resonance imaging-and computed tomography derived myocardial perfusion scans, angiographic corrected TIMI frame counts, advanced echocardiographic modalities at rest and during stress, and invasive measures of CFR and coronary vascular reactivity. The study will include 2000 women who will be followed for 5 years for cardiovascular outcomes.

RESULTS

By May 2013, 1685 women have been screened, 759 eligible patients identified, 530 contacted, and 299 (56%) agreed to participate. Among the first 50 patients, Doppler CFR was successfully measured in 49 (98%).

CONCLUSIONS

Among women with suspected ischemic heart disease and no obstructive coronary artery disease, non-invasive Doppler CFR is feasible as a routine assessment. The study will provide information on methods to diagnose CMD and determine the prognostic value of routine non-invasive assessment of microvascular function. Future study will provide women identified with CMD participation in interventional substudies designed to test treatment strategies.

A randomized, double-blind, clinical trial comparing the efficacy and safety of Crocus sativus L. with fluoxetine for improving mild to moderate depression in post percutaneous coronary intervention patients

OBJECTIVE

A significant correlation exists between coronary artery diseases and depression. The aim of this trial was to compare the efficacy and safety of saffron versus fluoxetine in improving depressive symptoms of patients who were suffering from depression after performing percutaneous coronary intervention (PCI).

METHODS

In this randomized double-blind parallel-group study, 40 patients with a diagnosis of mild to moderate depression who had undergone PCI in the last six months were randomized to receive either fluoexetine (40mg/day) or saffron (30mg/day) capsule for six weeks. Participants were evaluated by Hamilton depression rating scale (HDRS) at weeks 3 and 6 and the adverse events were systemically recorded.

RESULTS

By the study endpoint, no significant difference was detected between two groups in reduction of HDRS scores (P=0.62). Remission and response rates were not significantly different as well (P=1.00 and P=0.67; respectively). There was no significant difference between two groups in the frequency of adverse events during this trial.

LIMITATIONS

Relatively small sample size and short observational period were the major limitations of this study.

CONCLUSION

Short-term therapy with saffron capsules showed the same antidepressant efficacy compared with fluoxetine in patients with a prior history of PCI who were suffering from depression.

The effect of placebo adherence on reducing cardiovascular mortality: a meta-analysis

OBJECTIVE

We aim to demonstrate the effect of placebo adherence on reducing CV mortality.

BACKGROUNDS

Good adherence, whether to drug or placebo treatment, is associated with lower CV mortality. However, current evidence for the positive effect of placebo adherence on reducing CV mortality is relatively weak.

METHODS

We conducted a fixed-effect meta-analysis of eight randomized clinical trials to evaluate the effect of placebo adherence on reducing CV mortality. We made a comparison between good placebo adherence and poor drug adherence.

RESULTS

Compared with poor adherence to drug treatment, good adherence to placebo treatment was associated with lower CV mortality (OR = 0.68, 95% CI 0.60-0.77).

CONCLUSION

Good adherence to placebo has a positive effect on reducing CV mortality. The effect of adherence on reducing CV mortality may be independent of the drug effect.