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Park SJ, Park H, Kang D, Park TK, Park J, Cho J, Chung CR, Jeon K, Guallar E, Cho J, Suh GY, Yang JH. Association of statin therapy with clinical outcomes in patients with vasospastic angina: Data from Korean health insurance review and assessment service. PLoS One 2019; 14:e0210498. [PMID: 30699150 PMCID: PMC6353127 DOI: 10.1371/journal.pone.0210498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/22/2018] [Indexed: 11/18/2022] Open
Abstract
There is conflicting evidence for the clinical benefit of statin therapy in patients with vasospastic angina (VSA). We investigated the association of statin therapy with clinical outcomes in relatively large populations with clinically suspected VSA from a nationwide population-based database. Data were collected from the Health Insurance Review and Assessment database records of 4,099 patients that were in an intensive care unit with VSA between January 1, 2008 and May 31, 2015. We divided the patients into a statin group (n = 1,795) and a non-statin group (n = 2,304). The primary outcome was a composite of cardiac arrest and acute myocardial infarction (AMI). The median follow-up duration was 3.8 years (interquartile range: 2.2 to 5.8 years). Cardiac arrest or AMI occurred in 120 patients (5.2%) in the statin group, and 97 patients (5.4%) in the non-statin group (P = 0.976). With inverse probability of treatment weighting, there was no significant difference in the rate of cardiac arrest or AMI between the two groups (adjusted hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.76–1.30; P = 0.937), or even between the non-statin group and high-intensity statin group (adjusted HR, 1.08; 95% CI, 0.69–1.70; P = 0.75). The beneficial association of statin use with the primary outcome was consistently lacking across the various comorbidity types. Statin therapy was not associated with reduced cardiac arrest or AMI in patients with VSA, regardless of statin intensity. Prospective, randomized trials will be needed to confirm our findings.
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Affiliation(s)
- So Jin Park
- Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinkyeong Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eliseo Guallar
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gee Young Suh
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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Ford TJ, Rocchiccioli P, Good R, McEntegart M, Eteiba H, Watkins S, Shaukat A, Lindsay M, Robertson K, Hood S, Yii E, Sidik N, Harvey A, Montezano AC, Beattie E, Haddow L, Oldroyd KG, Touyz RM, Berry C. Systemic microvascular dysfunction in microvascular and vasospastic angina. Eur Heart J 2018; 39:4086-4097. [PMID: 30165438 PMCID: PMC6284165 DOI: 10.1093/eurheartj/ehy529] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/17/2018] [Accepted: 08/23/2018] [Indexed: 12/20/2022] Open
Abstract
Aims Coronary microvascular dysfunction and/or vasospasm are potential causes of ischaemia in patients with no obstructive coronary artery disease (INOCA). We tested the hypothesis that these patients also have functional abnormalities in peripheral small arteries. Methods and results Patients were prospectively enrolled and categorised as having microvascular angina (MVA), vasospastic angina (VSA) or normal control based on invasive coronary artery function tests incorporating probes of endothelial and endothelial-independent function (acetylcholine and adenosine). Gluteal biopsies of subcutaneous fat were performed in 81 subjects (62 years, 69% female, 59 MVA, 11 VSA, and 11 controls). Resistance arteries were dissected enabling study using wire myography. Maximum relaxation to ACh (endothelial function) was reduced in MVA vs. controls [median 77.6 vs. 98.7%; 95% confidence interval (CI) of difference 2.3-38%; P = 0.0047]. Endothelium-independent relaxation [sodium nitroprusside (SNP)] was similar between all groups. The maximum contractile response to endothelin-1 (ET-1) was greater in MVA (median 121%) vs. controls (100%; 95% CI of median difference 4.7-45%, P = 0.015). Response to the thromboxane agonist, U46619, was also greater in MVA (143%) vs. controls (109%; 95% CI of difference 13-57%, P = 0.003). Patients with VSA had similar abnormal patterns of peripheral vascular reactivity including reduced maximum relaxation to ACh (median 79.0% vs. 98.7%; P = 0.03) and increased response to constrictor agonists including ET-1 (median 125% vs. 100%; P = 0.02). In all groups, resistance arteries were ≈50-fold more sensitive to the constrictor effects of ET-1 compared with U46619. Conclusions Systemic microvascular abnormalities are common in patients with MVA and VSA. These mechanisms may involve ET-1 and were characterized by endothelial dysfunction and enhanced vasoconstriction. Clinical trial registration ClinicalTrials.gov registration is NCT03193294.
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Affiliation(s)
- Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Richard Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Aadil Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Keith Robertson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Stuart Hood
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Eric Yii
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Novalia Sidik
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Adam Harvey
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Augusto C Montezano
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Elisabeth Beattie
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Laura Haddow
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Rhian M Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
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53
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Corcoran D, Young R, Cialdella P, McCartney P, Bajrangee A, Hennigan B, Collison D, Carrick D, Shaukat A, Good R, Watkins S, McEntegart M, Watt J, Welsh P, Sattar N, McConnachie A, Oldroyd KG, Berry C. The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease. Int J Cardiol 2018; 252:24-30. [PMID: 29249435 PMCID: PMC5761717 DOI: 10.1016/j.ijcard.2017.10.082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 01/06/2023]
Abstract
Background Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism. Methods We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10− 6, 10− 5, 10− 4 mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235). Results 75 patients were enrolled. Following angiography, 60 patients (mean ± SD age 57.5 ± 8.5 years; 80% male) were eligible and completed the protocol (n = 30 RIPC, n = 30 sham). The mean percentage change in coronary luminal diameter was − 13.3 ± 22.3% and − 2.0 ± 17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2– 21.4, p = 0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01– 21.0, p = 0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function. Conclusions RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIPC.
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Affiliation(s)
- D Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - R Young
- Robertson Centre for Biostatistics, University of Glasgow, Scotland, UK
| | - P Cialdella
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - P McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - A Bajrangee
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - B Hennigan
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - D Collison
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - D Carrick
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - A Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - R Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - S Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - M McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - J Watt
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - P Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - N Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - A McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Scotland, UK
| | - K G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - C Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK.
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Berliner D, Maier LS, Wollenberg U, Limberg R, Schmitto JD, Westermann D, Bauersachs J. Clinical care for patients with recurrent myocardial ischemia in Germany-the VOICES trial. J Thorac Dis 2018; 10:S1777-S1784. [PMID: 30034852 DOI: 10.21037/jtd.2017.10.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars S Maier
- Department of Cardiology, Pneumology, and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | | | | | - Jan D Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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Scalone G, Niccoli G, Crea F. Editor's Choice- Pathophysiology, diagnosis and management of MINOCA: an update. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:54-62. [PMID: 29952633 DOI: 10.1177/2048872618782414] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a syndrome with different causes, characterised by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. Its prevalence ranges between 5% and 25% of all myocardial infarction. The prognosis is extremely variable, depending on the cause of MINOCA. The key principle in the management of this syndrome is to clarify the underlying individual mechanisms to achieve patient-specific treatments. Clinical history, electrocardiogram, cardiac enzymes, echocardiography, coronary angiography and left ventricular angiography represent the first level diagnostic investigations to identify the causes of MINOCA. Regional wall motion abnormalities at left ventricular angiography limited to a single epicardial coronary artery territory identify an 'epicardial pattern'whereas regional wall motion abnormalities extended beyond a single epicardial coronary artery territory identify a 'microvascular pattern'. The most common causes of MINOCA are represented by coronary plaque disease, coronary dissection, coronary artery spasm, coronary microvascular spasm, Takotsubo cardiomyopathy, myocarditis, coronary thromboembolism, other forms of type 2 myocardial infarction and MINOCA of uncertain aetiology. This review aims at summarising the diagnosis and management of MINOCA, according to the underlying physiopathology.
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Affiliation(s)
- Giancarla Scalone
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
| | - Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Italy
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Takahashi H, Yagyu S, Furuya S, Washio T, Kawauchi K, Kobori M, Matsumoto N, Hirayama A. Decreased coronary blood flow velocity in two patients with coronary microvascular spasm: case series†. Eur Heart J Case Rep 2018; 2:yty061. [PMID: 31020139 PMCID: PMC6177068 DOI: 10.1093/ehjcr/yty061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/20/2018] [Indexed: 11/12/2022]
Abstract
Introduction Diagnostic criteria for coronary microvascular spasm (CMS) have not yet been fully established. Case presentation We present two cases of CMS in which decreased coronary blood flow velocities were observed during acetylcholine (ACH) provocation tests. The first patient suffered from chest pain occurring while at rest. The patient underwent coronary angiography (CAG), which revealed a decrease in the average peak velocity (APV) from 29 cm/s to 14 cm/s and a slow flow phenomenon following ACH injection. The second patient suffered from chest pain occurring during the night. The patient underwent CAG, which revealed a decrease in the APV from 17 cm/s to 7 cm/s with no significant epicardial coronary artery spasm following ACH injection. Both patients complained of chest pain, and electrocardiogram changes were observed in leads equivalent to the distal area of the vessel during an ACH provocation test. These findings were consistent with CMS, and their conditions improved under medical treatment. Discussion A transient decrease in coronary blood flow velocity following ACH administration might be a phenomenon specific to CMS. These cases may provide some insight into the underlying pathophysiology of CMS.
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Affiliation(s)
- Hiroshi Takahashi
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Seina Yagyu
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Shingo Furuya
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Takehiko Washio
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Kenji Kawauchi
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Masashi Kobori
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-Kamimachi, Itabashi-ku, Tokyo, Japan
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Bainey KR, Welsh RC, Alemayehu W, Westerhout CM, Traboulsi D, Anderson T, Brass N, Armstrong PW, Kaul P. Population-level incidence and outcomes of myocardial infarction with non-obstructive coronary arteries (MINOCA): Insights from the Alberta contemporary acute coronary syndrome patients invasive treatment strategies (COAPT) study. Int J Cardiol 2018; 264:12-17. [PMID: 29655952 DOI: 10.1016/j.ijcard.2018.04.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/26/2018] [Accepted: 04/02/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a known clinical conundrum with limited investigation. Using a large population-based cohort, we examined the incidence, demographic profile, use of evidence-based medicines (EBM) and clinical outcomes of MINOCA patients. METHODS Patients hospitalized with a primary diagnosis of MI who underwent coronary angiography between 01/04/2002 and 31/03/2014 in Alberta, Canada, were included in the study. Comparisons were made between patients with MINOCA versus obstructive coronary disease (OCD). The primary composite endpoint was 1-year all-cause death or re-MI. RESULTS Of 35,928 patients hospitalized with MI, 2092 (5.8%) had MINOCA. In-hospital mortality rate was 0.8% among MINOCA, and 2.7% among patients with OCD (p < 0.0001). At 6 months, cardiovascular EBM rates were significantly lower among MINOCA patients compared to OCD patients. One-year death/re-MI rate was 5.3% in MINOCA and 8.9% in patients with OCD (adjusted hazard ratio (AHR) 0.75, 95% confidence interval (CI) 0.62-0.92, p < 0.0001). Five-year mortality rates were 10.9% in MINOCA and 16.0% in patients with OCD. Upon further stratification, 770 (36.8%) of MINOCA patients had no angiographic evidence of CAD (i.e. normal angiograms). EBM rates were even lower among these patients. One-year death/re-MI rate among these patients was 3.9% as compared to 6.1% among MINOCA patients with stenosis <50% (AHR 0.68, 95% CI 0.44-1.07, p = 0.028). CONCLUSIONS The population-level incidence of MINOCA is approximately 5%. Despite their apparently benign anatomic findings, efforts must be made to improve secondary prevention strategies to reduce the burden of long-term adverse outcomes in this population.
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Affiliation(s)
- Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Dean Traboulsi
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Todd Anderson
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neil Brass
- CK Hui Heart Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Ciliberti G, Seshasai SRK, Ambrosio G, Kaski JC. Safety of intracoronary provocative testing for the diagnosis of coronary artery spasm. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.05.109] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ong P, Camici PG, Beltrame JF, Crea F, Shimokawa H, Sechtem U, Kaski JC, Bairey Merz CN. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2017; 250:16-20. [PMID: 29031990 DOI: 10.1016/j.ijcard.2017.08.068] [Citation(s) in RCA: 443] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/13/2017] [Accepted: 08/24/2017] [Indexed: 12/11/2022]
Abstract
Standardization of diagnostic criteria for ischemic symptoms due to coronary microvascular dysfunction (CMD) is needed for further investigation of patients presenting with anginal chest pain consistent with "microvascular angina" (MVA). At the annual Coronary Vasomotion Disorders International Study Group (COVADIS) Summits held in August 2014 and 2015, the following criteria were agreed upon for the investigative diagnosis of microvascular angina: (1) presence of symptoms suggestive of myocardial ischemia; (2) objective documentation of myocardial ischemia, as assessed by currently available techniques; (3) absence of obstructive CAD (<50% coronary diameter reduction and/or fractional flow reserve (FFR) >0.80) (4) confirmation of a reduced coronary blood flow reserve and/or inducible microvascular spasm. These standardized criteria provide an investigative structure for mechanistic, diagnostic, prognostic and clinical trial studies aimed at developing an evidence base needed for guidelines in this growing patient population. Standardized criteria will facilitate microvascular angina registries and recruitment of suitable patients into clinical trials. Mechanistic research will also benefit from the implementation of standardized diagnostic criteria for MVA.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Mejía-Rentería H, van der Hoeven N, van de Hoef TP, Heemelaar J, Ryan N, Lerman A, van Royen N, Escaned J. Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests. Int J Cardiovasc Imaging 2017; 33:1041-1059. [PMID: 28501910 DOI: 10.1007/s10554-017-1136-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/08/2017] [Indexed: 01/10/2023]
Abstract
The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.
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Affiliation(s)
- Hernán Mejía-Rentería
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Tim P van de Hoef
- AMC Heart Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Nicola Ryan
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
| | | | | | - Javier Escaned
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain.
- Universidad Complutense de Madrid (UCM), Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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61
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Impact of vasomotion type on prognosis of coronary artery spasm induced by acetylcholine provocation test of left coronary artery. Atherosclerosis 2017; 257:195-200. [DOI: 10.1016/j.atherosclerosis.2016.09.015] [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: 05/14/2016] [Revised: 07/30/2016] [Accepted: 09/14/2016] [Indexed: 11/18/2022]
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62
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Oh MS, Yang JH, Lee DH, Park TK, Song YB, Hahn JY, Choi JH, Lee SH, Gwon HC, Choi SH. Impact of statin therapy on long-term clinical outcomes of vasospastic angina without significant stenosis: A propensity-score matched analysis. Int J Cardiol 2016; 223:791-796. [PMID: 27573612 DOI: 10.1016/j.ijcard.2016.08.229] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 08/12/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Limited data are available on the efficacy of statin therapy for secondary prevention in patients with vasospastic angina (VSA). We investigated the association of statin therapy with long-term clinical outcomes in VSA patients without significant coronary artery disease. METHODS From January 2003 to June 2014, we enrolled a total of 804 patients with VSA proven by an ergonovine provocation test without significant (≥70% diameter stenosis) coronary artery disease. We classified patients into a statin group (n=330) and a no-statin group (n=474) according to the use of statin. Primary outcome were major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, myocardial infarction, and any revascularization. RESULTS Median follow-up duration was 4.5years (interquartile range: 2.0 to 7.3years). MACE occurred in 14 patients (4.2%) in the statin group, and 21 patients (4.4%) in the no-statin group. There were no differences between the two groups (p=0.97). After 1:1 propensity-score matching (281 pairs), MACE (statin versus [vs.] no-statin; 3.2% vs. 4.3%, hazard ratio [HR]; 0.80, 95% confidence interval [CI]; 0.34-1.89, p=0.60) and readmission due to chest pain (17.1% vs. 17.4%, HR; 1.08, 95% CI; 0.72-1.06, p=0.72) were not statistically different between the two groups. CONCLUSION Our results suggest that statin therapy could not improve long-term clinical outcomes in VSA patients without significant coronary artery disease.
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Affiliation(s)
- Min Seok Oh
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Da Hyun Lee
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Choi
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Lee
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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63
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Ong P, Athanasiadis A, Sechtem U. Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders. J Vis Exp 2016. [PMID: 27583694 DOI: 10.3791/54295] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the catheterization laboratory which was introduced more than 30 years ago. Due to the short half-life of acetylcholine it can only be applied directly into the coronary arteries. Several studies have demonstrated the safety and clinical usefulness of this test. However, acetylcholine testing is only rarely applied in the U.S. or Europe. Nevertheless, it has been shown that 62% of Caucasian patients with stable angina and unobstructed coronary arteries on coronary angiography suffer from coronary vasomotor disorders that can be diagnosed with acetylcholine testing. In recent years it has been appreciated that the ACH-test not only assesses the presence of epicardial spasm but that it can also be useful for the detection of coronary microvascular spam. In such cases no epicardial spasm is seen after injection of acetylcholine but ischemic ECG shifts are present together with a reproduction of the patient's symptoms during the test. This article describes the experience with the ACH-test and its implementation in daily clinical routine.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus;
| | | | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus
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64
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Lanza GA. Angina Pectoris and Myocardial Ischemia in the Absence of Obstructive Coronary Artery Disease: Role of Diagnostic Tests. Curr Cardiol Rep 2016; 18:15. [DOI: 10.1007/s11886-015-0688-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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65
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Barletta G, Del Bene MR. Myocardial perfusion echocardiography and coronary microvascular dysfunction. World J Cardiol 2015; 7:861-874. [PMID: 26730291 PMCID: PMC4691812 DOI: 10.4330/wjc.v7.i12.861] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/04/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023] Open
Abstract
Our understanding of coronary syndromes has evolved in the last two decades out of the obstructive atherosclerosis of epicardial coronary arteries paradigm to include anatomo-functional abnormalities of coronary microcirculation. No current diagnostic technique allows direct visualization of coronary microcirculation, but functional assessments of this circulation are possible. This represents a challenge in cardiology. Myocardial contrast echocardiography (MCE) was a breakthrough in echocardiography several years ago that claimed the capability to detect myocardial perfusion abnormalities and quantify coronary blood flow. Research demonstrated that the integration of quantitative MCE and fractional flow reserve improved the definition of ischemic burden and the relative contribution of collaterals in non-critical coronary stenosis. MCE identified no-reflow and low-flow within and around myocardial infarction, respectively, and predicted the potential functional recovery of stunned myocardium using appropriate interventions. MCE exhibited diagnostic performances that were comparable to positron emission tomography in microvascular reserve and microvascular dysfunction in angina patients. Overall, MCE improved echocardiographic evaluations of ischemic heart disease in daily clinical practice, but the approval of regulatory authorities is lacking.
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66
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Shaw J, Anderson T. Coronary endothelial dysfunction in non-obstructive coronary artery disease: Risk, pathogenesis, diagnosis and therapy. Vasc Med 2015; 21:146-55. [PMID: 26675331 DOI: 10.1177/1358863x15618268] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Up to half of patients with signs and symptoms of stable ischemic heart disease have non-obstructive coronary artery disease (NoCAD). Recent evidence demonstrates that two-thirds of patients with NoCAD have demonstrable coronary endothelial dysfunction represented by microvascular or diffuse epicardial spasm following acetylcholine challenge. Patients with coronary endothelial dysfunction are recognized to have significant health services use and morbidity as well as increased risk of developing flow-limiting coronary artery disease and myocardial events, including death. Currently, there are few centers that test for this etiology owing to lack of knowledge, limited evidence for treatment options and invasive diagnostic strategies. This article reviews the pathophysiology, epidemiology, diagnosis and treatment of coronary endothelial dysfunction as a subgroup of NoCAD.
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Affiliation(s)
- Jeffrey Shaw
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
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67
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Suzuki H. Different definition of microvascular angina. Eur J Clin Invest 2015; 45:1360-6. [PMID: 26480027 DOI: 10.1111/eci.12552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/15/2015] [Indexed: 12/28/2022]
Abstract
We sometimes encounter patients with microvascular angina (MVA), a disease characterized by anginal pain without abnormal coronary arteriographic findings or coronary spasm. More than 40 years have passed since MVA was first confirmed. The terms 'syndrome X', 'cardiac syndrome X' and 'microvascular dysfunction' have also been used to describe conditions similar to MVA, but all with slightly different definitions. The cause of MVA seems almost certain to be organic and functional abnormalities of the small arteries of the heart. Patients with MVA are likely to suffer from endothelial dysfunction and other microvascular abnormalities of both the coronary and peripheral arteries. The major treatment of MVA has been medication, most often calcium channel blockers. The prognosis of MVA is generally excellent, although symptoms remain in many studies. Some MVA patients with accompanying hypertensive heart disease have gone on to develop progressive left ventricular dysfunction, with poor prognosis. The different definitions applied to the terms used to describe this condition, what we refer to here as MVA, can confound issues involved in diagnosis, prognosis and proper treatment. Therefore, it is extremely important to distinguish primary MVA without underlying heart disease from secondary MVA to explore the disease mechanism and examine the clinical characteristics. It is more than 40 years since Likoff first confirmed this disease; therefore, all researchers know that strict diagnostic criteria for MVA should be immediately established.
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Affiliation(s)
- Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
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68
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4260] [Impact Index Per Article: 473.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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69
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Scalone G, Niccoli G. A focus on the prognosis and management of ischemic heart disease in patients without evidence of obstructive coronary artery disease. Expert Rev Cardiovasc Ther 2015; 13:1031-44. [DOI: 10.1586/14779072.2015.1077114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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70
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Pries AR, Badimon L, Bugiardini R, Camici PG, Dorobantu M, Duncker DJ, Escaned J, Koller A, Piek JJ, de Wit C. Coronary vascular regulation, remodelling, and collateralization: mechanisms and clinical implications on behalf of the working group on coronary pathophysiology and microcirculation. Eur Heart J 2015; 36:3134-46. [DOI: 10.1093/eurheartj/ehv100] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 03/13/2015] [Indexed: 12/31/2022] Open
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71
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Al Mheid I, Hayek S, Quyyumi AA. Provoking Coronary Vasospasm for Diagnosis of Variant Angina. JACC Cardiovasc Interv 2015; 8:924-6. [DOI: 10.1016/j.jcin.2015.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/11/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
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73
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Takahashi H, Tani S, Kikushima K, Furuya S, Iida K, Matsumoto N, Hirayama A. Takotsubo cardiomyopathy in two patients with microvascular angina. J Cardiol Cases 2015; 12:26-29. [PMID: 30534272 DOI: 10.1016/j.jccase.2015.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/28/2015] [Accepted: 04/08/2015] [Indexed: 11/28/2022] Open
Abstract
We present two cases in which takotsubo cardiomyopathy (TC) developed immediately after a diagnosis of microvascular angina had been established. One patient who had been diagnosed as having endothelium-dependent microvascular angina (microvascular spasm) developed TC three weeks after the initial admission. The other patient was diagnosed as having endothelium-independent microvascular angina (decreased coronary flow reserve) and subsequently developed TC after the discontinuation of nicorandil treatment. These cases may provide insight into the possible mechanisms underlying the pathophysiological findings of TC. <Learning objective: Impaired coronary microcirculation has been recently reported in many cases during the acute phase of takotsubo cardiomyopathy. However, the exact mechanism responsible for the coronary microvascular dysfunction associated with this entity remains unclear. This report highlights the importance of microvascular angina, which may play a role in the development of this cardiomyopathy.>.
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Affiliation(s)
| | - Shigemasa Tani
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Kimio Kikushima
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Shingo Furuya
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Kiyoshi Iida
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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74
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Park JJ, Park SJ, Choi DJ. Microvascular angina: angina that predominantly affects women. Korean J Intern Med 2015; 30:140-7. [PMID: 25750553 PMCID: PMC4351318 DOI: 10.3904/kjim.2015.30.2.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/07/2015] [Indexed: 01/12/2023] Open
Abstract
In women receiving evaluation for suspected ischemic symptoms, a "normal" diagnosis is five times more common than it is in men. These women are often labeled as having cardiac syndrome X, also known as microvascular angina (MVA). MVA is defined as angina pectoris caused by abnormalities of the small coronary arteries, and is characterized by effort chest pain and evidence of myocardial ischemia with a non-invasive stress test, although the coronary arteries can appear normal or near normal by angiography. MVA patients are often neglected due to the assumption of a good prognosis. However, MVA has important prognostic implications and a proper diagnosis is necessary in order to relieve the patients' symptoms and improve clinical outcomes. The coronary microvasculature cannot be directly imaged using coronary angiography, due to the small diameter of the vessels; therefore, the coronary microvascular must be assessed functionally. Treatment of MVA initially includes standard anti-ischemic drugs (β-blockers, calcium antagonists, and nitrates), although control of symptoms is often insufficient. In this review, we discuss the pathophysiology, diagnosis, and treatment of MVA.
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Affiliation(s)
- Jin Joo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ju Choi
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Seoul National University College of Medicine, Seoul, Korea
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75
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Acetylcholine-induced coronary spasm in patients with unobstructed coronary arteries is associated with elevated concentrations of soluble CD40 ligand and high-sensitivity C-reactive protein. Coron Artery Dis 2015; 26:126-32. [DOI: 10.1097/mca.0000000000000181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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76
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Evaluation of adiponectin and lipoprotein(a) levels in cardiac syndrome X. Herz 2015; 40 Suppl 3:291-7. [DOI: 10.1007/s00059-014-4191-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/09/2014] [Accepted: 11/23/2014] [Indexed: 10/24/2022]
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77
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Ong P, Aziz A, Hansen HS, Prescott E, Athanasiadis A, Sechtem U. Structural and Functional Coronary Artery Abnormalities in Patients With Vasospastic Angina Pectoris. Circ J 2015; 79:1431-1438. [DOI: 10.1253/circj.cj-15-0520] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert Bosch Krankenhaus
| | - Ahmed Aziz
- Department of Cardiology, Odense University Hospital
- Department of Cardiology, Robert Bosch Krankenhaus
| | | | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen
| | | | - Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus
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78
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Niccoli G, Scalone G, Crea F. Coronary Functional Tests in the Catheterization Laboratory – Pathophysiological and Clinical Relevance –. Circ J 2015; 79:676-84. [DOI: 10.1253/circj.cj-15-0201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | | | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart
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79
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Niccoli G, Scalone G, Crea F. Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management. Eur Heart J 2014; 36:475-81. [PMID: 25526726 DOI: 10.1093/eurheartj/ehu469] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Myocardial infarction (MI) with no obstructive coronary atherosclerosis (MINOCA) is a syndrome with different causes. Its prevalence ranges between 5 and 25% of all MIs. The prognosis is extremely variable, depending on the causes of MINOCA. Clinical history, echocardiography, coronary angiography, and left ventriculography represent the first-level diagnostic investigations. Nevertheless, additional tests are required in order to establish its specific cause, thus allowing an appropriate risk stratification and treatment. We review pathogenesis, diagnosis, prognosis, and therapy of MINOCA and propose an algorithm for its management.
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Affiliation(s)
- Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo Agostino Gemelli, 8, Rome 00168, Italy
| | - Giancarla Scalone
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo Agostino Gemelli, 8, Rome 00168, Italy Department of Cardiology, Thorax Institute, IDIBAPS: Institut d'Investigacions Biomediques Agust Pi i Sunyer, Hospital Clinic, Barcelona, Spain
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo Agostino Gemelli, 8, Rome 00168, Italy
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80
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Current Diagnostic and Therapeutic Strategies in Microvascular Angina. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014; 3:30-37. [PMID: 25685641 DOI: 10.1007/s40138-014-0059-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Microvascular angina is common among patients with signs and symptoms of acute coronary syndrome and is associated with an increased risk of cardiovascular and cerebrovascular events. Unfortunately, microvascular is often under-recognized in clinical settings. The diagnosis of microvascular angina relies on assessment of the functional status of the coronary microvasculature. Invasive strategies include acetylcholine provocation, intracoronary Doppler ultrasound, and intracoronary thermodilution; noninvasive strategies include cardiac positron emission tomography (PET), cardiac magnetic resonance, and Doppler echocardiography. Once the diagnosis of microvascular angina is established, treatment is focused on improving symptoms and reducing future risk of cardiovascular and cerebrovascular events. Pharmacologic options and lifestyle modifications for patients with microvascular angina are similar to those for patients with coronary artery disease.
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81
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Cheezum MK, Marzilli M. Microvascular ischemia and the stress of impaired relaxation. Atherosclerosis 2014; 237:379-80. [DOI: 10.1016/j.atherosclerosis.2014.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/03/2014] [Indexed: 11/26/2022]
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82
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83
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Safdar B, Nagurney JT, Anise A, DeVon HA, D'Onofrio G, Hess EP, Hollander JE, Legato MJ, McGregor AJ, Scott J, Tewelde S, Diercks DB. Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup. Acad Emerg Med 2014; 21:1350-60. [PMID: 25413468 PMCID: PMC6402042 DOI: 10.1111/acem.12527] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 07/20/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age-matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex- and gender-specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy-makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in-person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex-specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex-specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex-specific variations in biology, as well as patient-provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient-centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT
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Tanabe Y, Yoneyama K, Izumo M, Kongoji K, Harada T, Akashi YJ. A case of coronary microvascular spasm with slow flow induced by the intracoronary acetylcholine provocation test. Cardiovasc Interv Ther 2014; 30:372-6. [PMID: 25403747 DOI: 10.1007/s12928-014-0308-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/06/2014] [Indexed: 02/07/2023]
Abstract
Microvascular angina is a rare condition in which myocardial ischemia is caused by microvascular dysfunction without any abnormalities of the epicardial coronary arteries. In clinical practice, it is difficult to diagnose because the microvascular alterations cannot be detected by conventional angiography. Herein we present a rare case of a 67-year-old woman with unstable angina pectoris in whom considerably slow coronary flow was induced by the acetylcholine provocation test with mild epicardial arterial spasm, suggesting the presence of microvascular spasm. Moreover, we show that β-methyl-p-[(123)I]-iodophenyl-pentadecanoic ((123)I-BMIPP) single-photon emission computed tomography imaging is useful for proving myocardial ischemia.
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Affiliation(s)
- Yasuhiro Tanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
| | - Kihei Yoneyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Ken Kongoji
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Tomoo Harada
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
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Arrebola-Moreno AL, Arrebola JP, Moral-Ruiz A, Ramirez-Hernandez JA, Melgares-Moreno R, Kaski JC. Coronary microvascular spasm triggers transient ischemic left ventricular diastolic abnormalities in patients with chest pain and angiographically normal coronary arteries. Atherosclerosis 2014; 236:207-14. [DOI: 10.1016/j.atherosclerosis.2014.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 06/18/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
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87
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Ladwig KH, Waller C. [Gender-specific aspects of coronary heart disease]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 57:1083-91. [PMID: 25112950 DOI: 10.1007/s00103-014-2020-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The total number of deaths from cardiovascular diseases (CVD) is greater for women than for men, although the mean age at manifestation of CVD is about 10 years older. However, the annual number of cases treated for CVD in acute hospital settings in men exceeds that of women by 50 %. Remarkable gender differences exist in terms of morphological and physiological conditions (e.g. mean coronary vessel diameter; ability to adapt to protective exercise-induced myocardial hypertrophy), as well as of the frequency and clinical significance of somatic risk factors (e.g. smoking). Female body weight increases after menopause and the body shape assumes a more android fat distribution. Women report higher levels of unspecific and affective symptoms. They suffer more from anxiety and depression than men; however, the secondary impact on CVD onset may be less pronounced. The post-acute CVD course is more complicated in women, mainly because they are older and suffer more from multi-morbidity. Whilst male CVD patients aim for a rapid recovery, physical fitness and an increased life expectancy, female patients seek relief from everyday challenges, the maintenance of their independence and emotional support.
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Affiliation(s)
- K-H Ladwig
- Institut für Epidemiologie, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt, Institut für Epidemiologie-II, Mental Health Research Unit, Ingolstädter Landstr. 1, 85764, Neuherberg, Deutschland,
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Yoneyama K, Akashi YJ, Ashikaga K, Kida K, Sato Y, Tsukahara M, Yamada M, Takagi Y, Kamijima R, Suzuki K, Musha H, Harada T. Severity of myocardial fatty acid dysmetabolism induced by coronary spasm does not differ with Thrombolysis in Myocardial Infarction (TIMI) grade during intracoronary acetylcholine provocation tests. Int Heart J 2014; 55:416-21. [PMID: 25088582 DOI: 10.1536/ihj.14-102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Whether additional intracoronary acetylcholine (ACH) injections are required for severe coronary spasm without limited coronary flow in the ACH provocation test remains unclear. We used (123)I-β-methyl-iodophenyl pentadecanoic acid ((123)I-BMIPP) to identify myocardial ischemic memory to compare the severity of myocardial fatty acid dysmetabolism among Thrombolysis in Myocardial Infarction (TIMI) grade flow.Thirteen hypertensive volunteers (mean age, 69.5 years) and 37 patients with VSA (mean age, 62.8 years) were enrolled. The patients with VSA were stratified according to TIMI flow grades of 3 (90% luminal narrowing; n = 12) or TIMI 0-2 (≥ 99% or total occlusion; n = 25) during ACH provocation tests. Two weeks after cardiac catheterization, (123)I-BMIPP myocardial scintigraphic images were obtained at 15 minutes (early) and at 4 hours (delayed) after tracer injection. The heart-to-mediastinum (H/M) ratio and washout rates (WR) were calculated from planar images.The TIMI 3 and TIMI 0-2 groups had significantly lower early and delayed H/M ratios than controls but the difference did not reach significance between the two groups (Early: 2.7 ± 0.5 versus 2.3 ± 0.4 and 2.2 ± 0.3, P = 0.024; Delayed: 2.4 ± 0.4 versus 1.8 ± 0.3 and 1.8 ± 0.3, P = 0.001). The washout rate was greater for TIMI 0-2 than the controls.The severity of myocardial fatty acid dysmetabolism did not differ between TIMI 3 and TIMI 0-2 coronary spasms. Additional ACH might not be required considering safety and the severity of coronary spams with TIMI 3 grade flow.
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Affiliation(s)
- Kihei Yoneyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
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Labruijere S, Chan KY, de Vries R, van den Bogaerdt AJ, Dirven CM, Danser AJ, Kori SH, MaassenVanDenBrink A. Dihydroergotamine and sumatriptan in isolated human coronary artery, middle meningeal artery and saphenous vein. Cephalalgia 2014; 35:182-9. [PMID: 25078720 DOI: 10.1177/0333102414544977] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Dihydroergotamine (DHE) and sumatriptan are contraindicated in patients with cardiovascular disease because of their vasoconstricting properties, which have originally been explored in proximal coronary arteries. Our aim was to investigate DHE and sumatriptan in the proximal and distal coronary artery, middle meningeal artery and saphenous vein. METHODS Blood vessel segments were mounted in organ baths and concentration response curves for DHE and sumatriptan were constructed. RESULTS In the proximal coronary artery, meningeal artery and saphenous vein, maximal contractions to DHE (proximal: 8 ± 4%; meningeal: 32 ± 7%; saphenous: 52 ± 11%) and sumatriptan (proximal: 17 ± 7%; meningeal: 61 ± 18%, saphenous: 37 ± 8%) were not significantly different. In the distal coronary artery, contractions to DHE (5 ± 2%) were significantly smaller than those to sumatriptan (17 ± 9%). At clinically relevant concentrations, mean contractions to DHE and sumatriptan were below 3% in proximal coronary arteries and below 6% in distal coronary arteries. Contractions in the meningeal artery and saphenous vein were higher (7%-38%). CONCLUSIONS Contractions to DHE in distal coronary arteries are smaller than those to sumatriptan, while at clinical concentrations they both induce only slight contractions. In meningeal arteries contractions to DHE and sumatriptan are significantly larger, showing their cranioselectivity. Contractions to DHE in the saphenous vein are higher than those in the arteries, confirming its venous contractile properties.
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Affiliation(s)
- Sieneke Labruijere
- Department of Internal Medicine, Division of Pharmacology, Erasmus Medical Center, The Netherlands
| | - Kayi Y Chan
- Department of Internal Medicine, Division of Pharmacology, Erasmus Medical Center, The Netherlands
| | - René de Vries
- Department of Internal Medicine, Division of Pharmacology, Erasmus Medical Center, The Netherlands
| | | | - Clemens M Dirven
- Department of Neurosurgery, Erasmus Medical Center, The Netherlands
| | - Ah Jan Danser
- Department of Internal Medicine, Division of Pharmacology, Erasmus Medical Center, The Netherlands
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Kuruvilla S, Kramer CM. Coronary microvascular dysfunction in women: an overview of diagnostic strategies. Expert Rev Cardiovasc Ther 2014; 11:1515-25. [PMID: 24160578 DOI: 10.1586/14779072.2013.833854] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Coronary microvascular dysfunction (CMD) also known as syndrome X, is characterized by typical anginal symptoms, evidence of myocardial ischemia on non-invasive testing and normal to minimal coronary disease on coronary angiography. It has a female preponderance and has been detected in up to 50% of women presenting with chest pain symptoms. Definitive diagnosis of CMD is critical as recent evidence suggests that women with this condition are at increased risk of cardiovascular events in the future. Invasive coronary reactivity testing on coronary angiography is considered to be the 'gold standard' for diagnosis of CMD. Non-invasive imaging techniques such as PET and cardiac magnetic resonance hold promise for detection of CMD in the future.
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Affiliation(s)
- Sujith Kuruvilla
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA and
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Chan KY, Labruijere S, Ramírez Rosas MB, de Vries R, Garrelds IM, Danser AHJ, Villalón CM, van den Bogaerdt A, Dirven C, MaassenVanDenBrink A. Cranioselectivity of sumatriptan revisited: pronounced contractions to sumatriptan in small human isolated coronary artery. CNS Drugs 2014; 28:273-8. [PMID: 24430784 DOI: 10.1007/s40263-013-0136-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Initial concerns about the coronary side-effect potential of the anti-migraine drug sumatriptan and second-generation triptans initiated cranioselectivity studies using proximal human coronary arteries. However, myocardial ischaemia may originate from both large and small human coronary arteries. METHODS We investigated the contractions to sumatriptan in proximal (internal diameter 2-3 mm), distal (internal diameter 1,000-1,500 μm) and small (internal diameter 500-1,000 μm) human epicardial coronary arteries and compared these with contractions in the human middle meningeal artery. Concentration response curves to sumatriptan in human coronary arteries were constructed in the absence or presence of the 5-hydroxytryptamine1B (5-HT1B) receptor antagonist SB224289 and the 5-HT1D receptor antagonist BRL15572. The effect of sumatriptan on increased cyclic adenosine monophosphate (cAMP) levels induced by forskolin in proximal and distal coronary artery segments was investigated using a biochemical assay. Western blotting was used to analyse the 5-HT1B receptor density in the human arteries. RESULTS Contractions in the proximal human coronary artery were significantly smaller than those in the human meningeal artery, as we showed previously. In contrast, contractions to sumatriptan in distal and small human coronary arteries were not different from those in the human meningeal artery. The 5-HT1B receptor antagonist SB224289, but not the 5-HT1D receptor antagonist BRL15572, inhibited the contraction induced by sumatriptan in the coronary arteries. Moreover, in distal, but not in proximal, coronary arteries, sumatriptan inhibited the increase in cAMP levels induced by forskolin. Contrary to our expectations, the 5-HT1B receptor expression was more pronounced in the proximal human coronary artery than in the distal and small human coronary artery. CONCLUSIONS Based on functional experiments in distal and small human coronary arteries, contractions to sumatriptan are not as cranioselective as previously assumed. However, the vast clinical experience with sumatriptan and other triptans has proven that these drugs are cardiovascularly safe when contraindications are taken into account.
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Affiliation(s)
- Kayi Y Chan
- Department of Internal Medicine, Division of Pharmacology, Erasmus Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Ong P, Athanasiadis A, Borgulya G, Vokshi I, Bastiaenen R, Kubik S, Hill S, Schäufele T, Mahrholdt H, Kaski JC, Sechtem U. Clinical usefulness, angiographic characteristics, and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive white patients with unobstructed coronary arteries. Circulation 2014; 129:1723-30. [PMID: 24573349 DOI: 10.1161/circulationaha.113.004096] [Citation(s) in RCA: 238] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Coronary spasm can cause myocardial ischemia and angina in patients with and those without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine administration are rarely performed in clinical routine in the United States and Europe. Thus, we assessed the clinical usefulness, angiographic characteristics, and safety of intracoronary acetylcholine provocation testing in white patients with unobstructed coronary arteries. METHODS AND RESULTS From September 2007 to June 2010, a total of 921 consecutive patients (362 men, mean age 62±12years) who underwent diagnostic angiography for suspected myocardial ischemia and were found to have unobstructed coronary arteries (no stenosis ≥50%) were enrolled. The intracoronary acetylcholine provocation testing was performed directly after angiography according to a standardized protocol. Three hundred forty-six patients (35%) reported chest pain at rest, 222 (22%) reported chest pain on exertion, 238 (24%) reported a combination of effort and resting chest pain, and 41 (4%) presented with troponin-positive acute coronary syndrome. The overall frequency of epicardial spasm (>75% diameter reduction with angina and ischemic ECG shifts) was 33.4%, and the overall frequency of microvascular spasm (angina and ischemic ECG shifts without epicardial spasm) was 24.2%. Epicardial spasm was most often diffuse and located in the distal coronary segments (P<0.01). No fatal or irreversible nonfatal complications occurred. However, 9 patients (1%) had minor complications (nonsustained ventricular tachycardia [n=1], fast paroxysmal atrial fibrillation [n=1], symptomatic bradycardia [n=6], and catheter-induced spasm [n=1]). CONCLUSIONS Epicardial and microvascular spasm are frequently found in white patients with unobstructed coronary arteries. Epicardial spasm is most often diffuse and located in the distal coronary segments. The intracoronary acetylcholine provocation test is a safe technique to assess coronary vasomotor function.
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Affiliation(s)
- Peter Ong
- Robert-Bosch-Krankenhaus, Department of Cardiology, Stuttgart, Germany (P.O., A.A., S.H. T.S., H.M., U.S.); St George's University of London, Clinical Trials Unit, London, United Kingdom (G.B.); and Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom (I.V., R.B., S.K., J.C.K.)
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Paul Taggart D, van der Wall EE, Vrints CJ, Luis Zamorano J, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Anton Sirnes P, Luis Tamargo J, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, González-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Dalby Kristensen S, Lancellotti P, Pietro Maggioni A, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Anton Sirnes P, Gabriel Steg P, Timmis A, Wijns W, Windecker S, Yildirir A, Luis Zamorano J. Guía de Práctica Clínica de la ESC 2013 sobre diagnóstico y tratamiento de la cardiopatía isquémica estable. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Advances in mechanisms, imaging and management of the unstable plaque. Atherosclerosis 2014; 233:467-477. [PMID: 24530781 DOI: 10.1016/j.atherosclerosis.2014.01.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 01/09/2023]
Abstract
Post-mortem observations demonstrated that plaque fissure was the final event leading to coronary thrombosis and occlusion in about two-thirds of cases of sudden coronary death. Plaques prone to fissure have, therefore, been defined "vulnerable plaques" and are identified by specific anatomic features including thin inflamed fibrous cap, large lipidic core and positive remodeling. Accordingly, elegant imaging modalities have been developed in order to identify this "holy grail". However, the results of prognostic studies based on the identification of vulnerable plaques have not been encouraging because of the low positive predictive value for major cardiovascular events. This observation is not surprising as the pathogenesis of acute coronary syndromes is complex and multifactorial. In this review we propose a pathogenetic classification of acute coronary syndromes in the attempt to identify homogeneous groups of patients with a common mechanism of coronary instability which can be identified by using specific biomarkers and imaging techniques, and become a specific therapeutic target.
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A case of vasospastic angina in which the ergonovine provocation test with intracoronary isosorbide dinitrate and nicorandil was effective in the diagnosis of microvascular spasm. Cardiovasc Interv Ther 2014; 29:344-9. [PMID: 24407773 DOI: 10.1007/s12928-013-0237-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
Abstract
A 60-year-old man was admitted with early morning angina while at rest. Coronary angiogram revealed no organic lesions; therefore, a spasm provocation test with ergonovine was performed. Administration of intracoronary ergonovine induced total occlusion of the right coronary artery. The induced total occlusion improved but coronary flow velocity remained severely reduced and chest discomfort with ST-T changes in ECG remained in spite of repeated administration of isosorbide dinitrate (ISDN). Intracoronary administration of nicorandil following ISDN alleviated the chest discomfort, normalized the ST-T change in ECG, and improved the coronary flow. This suggested that microvascular spasm and the epicardial spasm were not relieved by ISDN but by nicorandil. Intracoronary nicorandil injection following ISDN administration may be useful for the diagnosis of microvascular spasm in the ergonovine provocation test.
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96
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Ong P, Athanasiadis A, Perne A, Mahrholdt H, Schäufele T, Hill S, Sechtem U. Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis. Clin Res Cardiol 2013; 103:11-9. [DOI: 10.1007/s00392-013-0615-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/22/2013] [Indexed: 10/26/2022]
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97
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJM, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013; 34:2949-3003. [PMID: 23996286 DOI: 10.1093/eurheartj/eht296] [Citation(s) in RCA: 2906] [Impact Index Per Article: 264.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
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- The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kim HS, Cho KI. Impact of chronic emotional stress on myocardial function in postmenopausal women and its relationship with endothelial dysfunction. Korean Circ J 2013; 43:295-302. [PMID: 23755075 PMCID: PMC3675303 DOI: 10.4070/kcj.2013.43.5.295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/19/2013] [Accepted: 03/29/2013] [Indexed: 01/22/2023] Open
Abstract
Background and Objectives An association between chronic stress and cardiovascular diseases has been described, but the underlying mechanisms have not been fully elucidated. We investigate the impact of perceived stress on the left ventricular (LV) and endothelial functions in postmenopausal women. Subjects and Methods We investigated 64 consecutive postmenopausal women (mean age 56.7±9.7 years) with atypical chest pain and chronic stress. Patients with coronary heart disease were excluded. Global and segmental longitudinal deformation parameters of LV were used as parameters to assess myocardial function and brachial flow-mediated dilatation (FMD) was used to assess the endothelial function, and patients were analyzed by the Symptom Checklist 90 Revised (SCL-90-R) to determine emotional stress. The study participants were divided into two groups, based on global severity index (GSI): ≥50 (group A, n=27) or <50 (group B, n=37). Results Although there were no significant differences in LV geometry or myocardial performance indices between the groups, global LV strain was significantly reduced in group A compared to group B (-16.6±2.7% vs. -19.1±1.9%, p=0.001). There were also significant differences in the value of reactive FMD (6.6±2.2% vs. 9.5±2.9%, p<0.001), and same result was observed for nitroglycerine-induced dilatation (14.6±4.7% vs. 18.0±5.8%, p=0.016). Multivariate linear regression analysis showed that GSI was the only significant attributor to global LV strain (β=0.149, p=0.008) and reactive FMD (β=-0.200, p=0.041). Conclusion Chronic emotional stress may exert negative effects on the LV and endothelial functions, which may be associated with the severity of stress. This study provides a possible mechanism by which stress is associated with an increased risk of cardiovascular dysfunction.
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Affiliation(s)
- Hyun Soo Kim
- Division of Cardiology, Department of Internal Medicine, Kosin University School of Medicine, Busan, Korea
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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