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Boerhout CKM, de Waard GA, Lee JM, Mejia-Renteria H, Lee SH, Jung JH, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Appelman Y, Doh JH, Christiansen EH, Banerjee R, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Beijk MAM, Knaapen P, Escaned J, Kakuta T, Koo BK, Piek JJ, van de Hoef TP. Prognostic value of structural and functional coronary microvascular dysfunction in patients with non-obstructive coronary artery disease; from the multicentre international ILIAS registry. EUROINTERVENTION 2022; 18:719-728. [PMID: 35694826 PMCID: PMC10241297 DOI: 10.4244/eij-d-22-00043] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/02/2022] [Indexed: 07/21/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is an important contributor to angina syndromes. Recently, two distinct endotypes were identified using combined assessment of coronary flow reserve (CFR) and minimal microvascular resistance (MR), termed structural and functional CMD. AIMS We aimed to assess the relevance of the combined assessment of CFR and MR in patients with angina and no obstructive coronary arteries. METHODS Patients with chronic coronary syndromes (CCS) and non-obstructive coronary artery disease (fractional flow reserve [FFR] ≥0.80) were selected (N=1,102). Functional CMD was defined as abnormal CFR in combination with normal MR and structural CMD as abnormal CFR with abnormal MR. Clinical endpoints were the incidence of major adverse cardiac events (MACE) and target vessel failure (TVF) at 5-year follow-up. RESULTS Abnormal CFR was associated with an increased risk of MACE and TVF at 5-year follow-up. Microvascular resistance parameters were not associated with MACE or TVF at 5-year follow-up. The risk of MACE and TVF at 5-year follow-up was similarly increased for patients with structural or functional CMD compared with patients with normal microvascular function. There were no differences between both endotypes (p=0.88 for MACE, and p=0.55 for TVF). CONCLUSIONS Coronary microvascular dysfunction, identified by an impaired CFR, was unequivocally associated with increased MACE and TVF rates over a 5-year follow-up period. In contrast, impaired MR was not associated with 5-year adverse clinical events. Moreover, there was no significant difference in the risk of MACE and TVF between a low CFR accompanied by pathologically increased MR (structural CMD) or not (functional CMD). CLINICALTRIALS gov: NCT04485234.
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Affiliation(s)
- Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC - location AMC, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea
| | - Masahiro Hoshino
- Gifu Heart Center, Department of Cardiovascular Medicine, Gifu, Japan
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, Mexico
| | | | - Hitoshi Matsuo
- Gifu Heart Center, Department of Cardiovascular Medicine, Gifu, Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tadashi Murai
- Tsuchiura Kyodo General Hospital, Department of Cardiology, Tsuchiura City, Japan
| | - Koen Marques
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | | | - Rupak Banerjee
- Mechanical and Materials Engineering Department, University of Cincinnati, Cincinnati, OH, USA; and Research Services, Veteran Affairs Medical Center, Cincinnati, OH, USA
| | - Chang-Wook Nam
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Institute of Cardiology, Rome, Italy
| | - Masafumi Nakayama
- Gifu Heart Center, Department of Cardiovascular Medicine, Gifu, Japan
- Cardiovascular Center, Toda Central General Hospital, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC - location AMC, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Tsunekazu Kakuta
- Tsuchiura Kyodo General Hospital, Department of Cardiology, Tsuchiura City, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University Hospital, Cardiovascular Center, Seoul, Republic of Korea
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC - location AMC, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC - location AMC, Amsterdam, the Netherlands
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
- Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands
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Maas AHEM, Damman P. Some endotypes of microvascular dysfunction may be more worrisome than others. EUROINTERVENTION 2022; 18:703-704. [PMID: 36269210 PMCID: PMC10241298 DOI: 10.4244/eij-e-22-00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Morris PD, Al-Lamee RK, Berry C. Coronary physiological assessment in the catheter laboratory: haemodynamics, clinical assessment and future perspectives. Heart 2022; 108:1737-1746. [PMID: 35768192 PMCID: PMC9606498 DOI: 10.1136/heartjnl-2020-318743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Paul D Morris
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | | | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Golden Jubilee National Hospital, Clydebank, UK
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Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment. J Clin Med 2022; 11:jcm11195497. [PMID: 36233366 PMCID: PMC9571924 DOI: 10.3390/jcm11195497] [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: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.
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55
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Sinha A, Rahman H, Perera D. Vasospastic Angina: A Contemporary Review of its Pathophysiology, Diagnosis and Management. Heart Int 2022; 16:99-104. [PMID: 36741101 PMCID: PMC9872780 DOI: 10.17925/hi.2022.16.2.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 12/25/2022] Open
Abstract
Nearly 40% of patients presenting to the catheter laboratory with angina have non-obstructed coronary arteries (ANOCA), an umbrella term that encompasses distinct pathophysiological entities, such as coronary artery spasm. Coronary artery spasm leads to sudden reversible coronary flow attenuation, which clinically manifests as vasospastic angina (VSA). VSA is associated with poor quality of life and an increased risk of major adverse cardiac events. However, the pathophysiological mechanisms underlying this phenomenon are incompletely understood, which has resulted in limited therapeutic options for patients afflicted with this condition. The past decade has seen a surge in new research being conducted in the field of ANOCA and VSA. This review article provides a comprehensive summary of the underlying pathophysiological mechanisms of VSA and the current therapeutic options. We also appraise the current diagnostic approach in patients with suspected VSA.
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Affiliation(s)
- Aish Sinha
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Haseeb Rahman
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Divaka Perera
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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56
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Pop-Busui R, Januzzi JL, Bruemmer D, Butalia S, Green JB, Horton WB, Knight C, Levi M, Rasouli N, Richardson CR. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care 2022; 45:1670-1690. [PMID: 35796765 PMCID: PMC9726978 DOI: 10.2337/dci22-0014] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/03/2023]
Abstract
Heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates. Data also suggest that HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease and, as such, represents a major cardiovascular complication in this vulnerable population; HF may also be the first presentation of cardiovascular disease in many individuals with diabetes. Given that during the past decade, the prevalence of diabetes (particularly type 2 diabetes) has risen by 30% globally (with prevalence expected to increase further), the burden of HF on the health care system will continue to rise. The scope of this American Diabetes Association consensus report with designated representation from the American College of Cardiology is to provide clear guidance to practitioners on the best approaches for screening and diagnosing HF in individuals with diabetes or prediabetes, with the goal to ensure access to optimal, evidence-based management for all and to mitigate the risks of serious complications, leveraging prior policy statements by the American College of Cardiology and American Heart Association.
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - James L. Januzzi
- Cardiology Division, Massachusetts General Hospital, and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, MA
| | - Dennis Bruemmer
- Center for Cardiometabolic Health, Section of Preventive Cardiology and Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Sonia Butalia
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jennifer B. Green
- Division of Endocrinology and Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC
| | - William B. Horton
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Colette Knight
- Inserra Family Diabetes Institute, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Moshe Levi
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Neda Rasouli
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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57
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Hamaya R, van de Hoef TP, Lee JM, Hoshino M, Kanaji Y, Murai T, Boerhout CKM, de Waard GA, Jung JH, Lee SH, Mejia Renteria H, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Marques K, Doh JH, Christiansen EH, Banerjee R, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Sasano T, Chamuleau SAJ, Knaapen P, Escaned J, Koo BK, Piek JJ, Kakuta T. Differential Impact of Coronary Revascularization on Long-Term Clinical Outcome According to Coronary Flow Characteristics: Analysis of the International ILIAS Registry. Circ Cardiovasc Interv 2022; 15:e011948. [PMID: 35603622 DOI: 10.1161/circinterventions.121.011948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary pressure indices such as fractional flow reserve are the standard for guiding elective revascularization. However, considering additional coronary flow parameters could further individualize and optimize the decision on revascularization. We aimed to investigate the potentially differential prognostic associations of elective percutaneous coronary intervention (PCI) according to coronary flow properties represented by coronary flow reserve (CFR), coronary flow capacity (CFC), and baseline CFC (bCFC). METHODS From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes) composed of 16 hospitals globally from 7 countries, patients with obstructive coronary artery disease who underwent invasive coronary physiological assessment were included (N=2370 vessels). We assessed effect measure modifications of the association of PCI and 5-year target vessel failure according to CFR, CFC, and bCFC either assessed by Doppler-technique or thermodilution-method. RESULTS The mean age of the population was 63.3 years, and there were 1322 (73.6%) males. Median fractional flow reserve was 0.85, and PCI was performed in 600 (25.3%) vessels. Reduced CFR, CFC, and abnormal bCFC were defined in 988 (41.7%), 542 (22.9%), and 600 (25.3%) vessels, respectively. Significant effect measure modifications were observed by CFC either in odds ratio (P=0.0018), additive (P=0.029), and hazard ratio scale (P=0.0002). The absolute risk of 5-year target-vessel failure was higher if treated by PCI in vessels with normal CFC by 1.8 (-1.7 to 5.3) percent, while that was lower by -5.9 (-12 to -0.1) percent in those with reduced CFC. CFR and bCFC were not significant effect modifiers in any scales. Similar associations were observed in per-patient analyses, whereas the findings were less robust. CONCLUSIONS We observed qualitative effect measure modification of PCI and 5-year clinical outcomes according to CFC status in additive scale. CFR and bCFC were not robust effect modifiers. Therefore, CFC could be potentially used to optimize the patient selection for elective PCI treatment combined with fractional flow reserve.
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Affiliation(s)
- Rikuta Hamaya
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.H.).,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (R.H.)
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC - location AMC, the Netherlands (T.P.v.d.H., C.K.M.B., S.A.J.C., J.J.P.).,Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands (T.P.v.d.H., K.M., S.A.J.C., P.K.).,Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands (T.P.v.d.H., G.A.d.W.)
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Seoul, Republic of Korea (J.M.L.)
| | - Masahiro Hoshino
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Japan (M.H., Y.K., T.K.)
| | - Yoshihisa Kanaji
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Japan (M.H., Y.K., T.K.)
| | - Tadashi Murai
- Cardiovascular Center, Yokosuka Kyosai Hospital, Japan (T.M.)
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC - location AMC, the Netherlands (T.P.v.d.H., C.K.M.B., S.A.J.C., J.J.P.)
| | - Guus A de Waard
- Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands (T.P.v.d.H., G.A.d.W.)
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea (J.-H.J.)
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea (S.H.L.)
| | - Hernan Mejia Renteria
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Spain (H.M.R., J.E.)
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de Medicina, Universidad Autónoma de Querétaro, México (M.E.-P.)
| | - Martijn Meuwissen
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.H.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (H.M., M.N.)
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Denmark (A.E., E.H.C.)
| | - Mohamed A Effat
- Division of Cardiovascular Health and Diseases, Department of Internal Medicine (M.A.E.), University of Cincinnati, OH
| | - Koen Marques
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands (T.P.v.d.H., K.M., S.A.J.C., P.K.)
| | - Joon-Hyung Doh
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea (J.-H.D.)
| | | | - Rupak Banerjee
- Mechanical and Materials Engineering Department (R.B.), University of Cincinnati, OH.,Research Services, Veteran Affairs Medical Center, Cincinnati, OH (R.B.)
| | - Chang-Wook Nam
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea (C.-W.N.)
| | - Giampaolo Niccoli
- Catholic University of the Sacred Heart, Department of Cardiovascular Medicine, Institute of Cardiology, Rome, Italy (G.N.)
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (H.M., M.N.).,Toda Central General Hospital, Cardiovascular Center, Japan (M.N.)
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan (N.T.)
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, South Korea (E.-S.S.)
| | - Tetsuo Sasano
- Department of Cardiology, Tokyo Medical and Dental University, Japan (T.S.)
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC - location AMC, the Netherlands (T.P.v.d.H., C.K.M.B., S.A.J.C., J.J.P.).,Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands (T.P.v.d.H., K.M., S.A.J.C., P.K.)
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands (T.P.v.d.H., K.M., S.A.J.C., P.K.)
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Spain (H.M.R., J.E.)
| | - Bon Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Republic of Korea (B.K.K.)
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC - location AMC, the Netherlands (T.P.v.d.H., C.K.M.B., S.A.J.C., J.J.P.)
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Japan (M.H., Y.K., T.K.)
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He B, Chen Y, Wang L, Yang Y, Xia C, Zheng J, Gao F. Compact MR-compatible ergometer and its application in cardiac MR under exercise stress: A preliminary study. Magn Reson Med 2022; 88:1927-1936. [PMID: 35649186 PMCID: PMC9545047 DOI: 10.1002/mrm.29311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 02/05/2023]
Abstract
Purpose To develop a compact MR‐compatible ergometer for exercise stress and to initially evaluate the reproducibility of myocardial native T1 and myocardial blood flow (MBF) measurements during exercise stress performed on this ergometer. Methods The compact ergometer consists of exercise, workload, and data processing components. The exercise stress can be achieved by pedaling on a pair of cylinders at a predefined frequency with adjustable resistances. Ten healthy subjects were recruited to perform cardiac MRI scans twice in a 3.0T MR scanner, at different days to assess reproducibility. Myocardial native T1 and MBF were acquired at rest and during a moderate exercise. The reproducibility of the two tests was determined by the intra‐group correlation coefficient (ICC) and coefficient of variation (CoV). Results The mean exercise intensity in this pilot study was 45 Watts (W), with an exercise duration of 5 min. Stress induced a significant increase in systolic blood pressure (from 113 ± 11 mmHg to 141 ± 12, P < 0.05) and maximal increase in heart rate by 74 ± 19%. The rate pressure product increased two‐fold (P < 0.001). Excellent reproducibility was demonstrated in native T1 during the exercise (CoV = 3.0%), whereas the reproducibility of MBF and myocardial perfusion reserve during the exercise was also good (CoV = 10.7% and 8.8%, respectively). Conclusion This pilot study demonstrated that it is possible to acquire reproducible measurements of myocardial native T1 and MBF during the exercise stress in healthy volunteers using our new compact ergometer. Click here for author‐reader discussions
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Affiliation(s)
- Bo He
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Molecular Imaging Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yushu Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Lei Wang
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Molecular Imaging Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yang Yang
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chunchao Xia
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jie Zheng
- Mallinckrodt Institute of Radiology, Washington University in St Louis, St. Louis, Missouri, USA
| | - Fabao Gao
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Molecular Imaging Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Li N, Li B, Liu J, Feng Y, Zhang L, Liu J, Liu Y. The quantitative relationship between coronary microcirculatory resistance and myocardial ischemia in patients with coronary artery disease. J Biomech 2022; 140:111166. [PMID: 35671542 DOI: 10.1016/j.jbiomech.2022.111166] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/17/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
It was hypothesized that the microcirculatory resistance of resting state (Rm-res) might be a good predictor for ischemia. In this study, the quantitative relationship between Rm-res and myocardial ischemia in different stenosed degrees was explored and verified through retrospective analysis, and the diagnostic performance was evaluated. 136 patients were screened and divided into a training set (90 patients) and a validation set (46 patients). In the training set, Rm-res was calculated, and thresholds were determined by exploring the relationship between Rm-res and myocardial ischemia in different stenosed degrees. In the validation set, the diagnostic performance of the thresholds was verified. It was found that the 90 data mean difference (95%CI) of Rm-res between the ischemic group and the non-ischemic group was 63.03 (95 %CI: 25.72-100.34), p < 0.05. In the training set with stenosed degree 41-60%, 61-70%, 71-80%, and >81%, the average of Rm-res in the ischemic and non-ischemic groups were (80.79, 136.87), (96.41, 172.62), (128.99, 198.94) and (175.95, 310.79) mmHg/s/ml. The Rm-res thresholds were 87.18, 118.96, 142.35, and 177.39 mmHg/s/ml. In the validation set, the overall sensitivity, specificity, PPV, NPV, and accuracy were 73.3%, 77.4%, 61.1%, 85.7%, and 76.1%. In conclusion, Rm-res had a significant predictor on myocardial ischemia. As a smaller Rm-res represents greater myocardial mass perfusion, it is more likely that a stenosis will have a functional impact. Threshold analysis showed that Rm-res of different stenosed degrees was a quantitative predictor of myocardial ischemia, which could assist physicians with clinical treatment strategies.
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Affiliation(s)
- Na Li
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Bao Li
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jincheng Liu
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yili Feng
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Liyuan Zhang
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jian Liu
- Peking University People's Hospital, Beijing, China
| | - Youjun Liu
- College of Life Science and Chemistry, Faculty of Environment and Life, Beijing University of Technology, Beijing, China.
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Exercise Enhances Branched-Chain Amino Acid Catabolism and Decreases Cardiac Vulnerability to Myocardial Ischemic Injury. Cells 2022; 11:cells11101706. [PMID: 35626742 PMCID: PMC9139679 DOI: 10.3390/cells11101706] [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: 01/10/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term exercise-induced metabolic adaptations occupy a central position in exercise-afforded cardiac benefits. Emerging evidence suggests that branched-chain amino acid (BCAA) catabolic defect contributes to cardiac dysfunction in multiple cardiometabolic diseases. However, the role of BCAA catabolism in exercise-afforded cardiac benefits remains unknown. Here, we show that exercise improves BCAA catabolism and thus reduce cardiac vulnerability to myocardial ischemic injury. Exercise increased circulating BCAA levels in both humans (male adolescent athletes) and mice (following an 8-week swimming intervention). It increased the expression of mitochondrial localized 2C-type serine-threonine protein phosphatase (PP2Cm), a key enzyme in regulating BCAA catabolism, and decreased BCAA accumulation in mouse hearts, indicating an increase in BCAA catabolism. Pharmacological promotion of BCAA catabolism protected the mouse heart against myocardial infarction (MI) induced by permanent ligation of the left descending coronary artery. Although cardiac-specific PP2Cm knockout showed no significant effects on cardiac structural and functional adaptations to exercise, it blunted the cardioprotective effects of exercise against MI. Mechanistically, exercise alleviated BCAA accumulation and subsequently inactivated the mammalian target of rapamycin in MI hearts. These results showed that exercise elevated BCAA catabolism and protected the heart against myocardial ischemic injury, reinforcing the role of exercise in the promotion of cardiac health.
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Roy TK, Secomb TW. Functional implications of microvascular heterogeneity for oxygen uptake and utilization. Physiol Rep 2022; 10:e15303. [PMID: 35581743 PMCID: PMC9114652 DOI: 10.14814/phy2.15303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023] Open
Abstract
In the vascular system, an extensive network structure provides convective and diffusive transport of oxygen to tissue. In the microcirculation, parameters describing network structure, blood flow, and oxygen transport are highly heterogeneous. This heterogeneity can strongly affect oxygen supply and organ function, including reduced oxygen uptake in the lung and decreased oxygen delivery to tissue. The causes of heterogeneity can be classified as extrinsic or intrinsic. Extrinsic heterogeneity refers to variations in oxygen demand in the systemic circulation or oxygen supply in the lungs. Intrinsic heterogeneity refers to structural heterogeneity due to stochastic growth of blood vessels and variability in flow pathways due to geometric constraints, and resulting variations in blood flow and hematocrit. Mechanisms have evolved to compensate for heterogeneity and thereby improve oxygen uptake in the lung and delivery to tissue. These mechanisms, which involve long-term structural adaptation and short-term flow regulation, depend on upstream responses conducted along vessel walls, and work to redistribute flow and maintain blood and tissue oxygenation. Mathematically, the variance of a functional quantity such as oxygen delivery that depends on two or more heterogeneous variables can be reduced if one of the underlying variables is controlled by an appropriate compensatory mechanism. Ineffective regulatory mechanisms can result in poor oxygen delivery even in the presence of adequate overall tissue perfusion. Restoration of endothelial function, and specifically conducted responses, should be considered when addressing tissue hypoxemia and organ failure in clinical settings.
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Affiliation(s)
- Tuhin K. Roy
- Department of AnesthesiologyMayo ClinicRochesterMinnesotaUSA
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van Herten RLM, Chiribiri A, Breeuwer M, Veta M, Scannell CM. Physics-informed neural networks for myocardial perfusion MRI quantification. Med Image Anal 2022; 78:102399. [PMID: 35299005 PMCID: PMC9051528 DOI: 10.1016/j.media.2022.102399] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/07/2022] [Accepted: 02/18/2022] [Indexed: 11/19/2022]
Abstract
Tracer-kinetic models allow for the quantification of kinetic parameters such as blood flow from dynamic contrast-enhanced magnetic resonance (MR) images. Fitting the observed data with multi-compartment exchange models is desirable, as they are physiologically plausible and resolve directly for blood flow and microvascular function. However, the reliability of model fitting is limited by the low signal-to-noise ratio, temporal resolution, and acquisition length. This may result in inaccurate parameter estimates. This study introduces physics-informed neural networks (PINNs) as a means to perform myocardial perfusion MR quantification, which provides a versatile scheme for the inference of kinetic parameters. These neural networks can be trained to fit the observed perfusion MR data while respecting the underlying physical conservation laws described by a multi-compartment exchange model. Here, we provide a framework for the implementation of PINNs in myocardial perfusion MR. The approach is validated both in silico and in vivo. In the in silico study, an overall decrease in mean-squared error with the ground-truth parameters was observed compared to a standard non-linear least squares fitting approach. The in vivo study demonstrates that the method produces parameter values comparable to those previously found in literature, as well as providing parameter maps which match the clinical diagnosis of patients.
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Affiliation(s)
- Rudolf L M van Herten
- Department of Biomedical Engineering, Medical Image Analysis group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Marcel Breeuwer
- Department of Biomedical Engineering, Medical Image Analysis group, Eindhoven University of Technology, Eindhoven, the Netherlands; Philips Healthcare, Best, the Netherlands
| | - Mitko Veta
- Department of Biomedical Engineering, Medical Image Analysis group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Cian M Scannell
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom.
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Tourais J, Scannell CM, Schneider T, Alskaf E, Crawley R, Bosio F, Sanchez-Gonzalez J, Doneva M, Schülke C, Meineke J, Keupp J, Smink J, Breeuwer M, Chiribiri A, Henningsson M, Correia T. High-Resolution Free-Breathing Quantitative First-Pass Perfusion Cardiac MR Using Dual-Echo Dixon With Spatio-Temporal Acceleration. Front Cardiovasc Med 2022; 9:884221. [PMID: 35571164 PMCID: PMC9099052 DOI: 10.3389/fcvm.2022.884221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction To develop and test the feasibility of free-breathing (FB), high-resolution quantitative first-pass perfusion cardiac MR (FPP-CMR) using dual-echo Dixon (FOSTERS; Fat-water separation for mOtion-corrected Spatio-TEmporally accelerated myocardial peRfuSion). Materials and Methods FOSTERS was performed in FB using a dual-saturation single-bolus acquisition with dual-echo Dixon and a dynamically variable Cartesian k-t undersampling (8-fold) approach, with low-rank and sparsity constrained reconstruction, to achieve high-resolution FPP-CMR images. FOSTERS also included automatic in-plane motion estimation and T2* correction to obtain quantitative myocardial blood flow (MBF) maps. High-resolution (1.6 x 1.6 mm2) FB FOSTERS was evaluated in eleven patients, during rest, against standard-resolution (2.6 x 2.6 mm2) 2-fold SENSE-accelerated breath-hold (BH) FPP-CMR. In addition, MBF was computed for FOSTERS and spatial wavelet-based compressed sensing (CS) reconstruction. Two cardiologists scored the image quality (IQ) of FOSTERS, CS, and standard BH FPP-CMR images using a 4-point scale (1–4, non-diagnostic – fully diagnostic). Results FOSTERS produced high-quality images without dark-rim and with reduced motion-related artifacts, using an 8x accelerated FB acquisition. FOSTERS and standard BH FPP-CMR exhibited excellent IQ with an average score of 3.5 ± 0.6 and 3.4 ± 0.6 (no statistical difference, p > 0.05), respectively. CS images exhibited severe artifacts and high levels of noise, resulting in an average IQ score of 2.9 ± 0.5. MBF values obtained with FOSTERS presented a lower variance than those obtained with CS. Discussion FOSTERS enabled high-resolution FB FPP-CMR with MBF quantification. Combining motion correction with a low-rank and sparsity-constrained reconstruction results in excellent image quality.
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Affiliation(s)
- Joao Tourais
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of MR R&D – Clinical Science, Philips Healthcare, Best, Netherlands
- Department of Imaging Physics, Magnetic Resonance Systems Lab, Delft University of Technology, Delft, Netherlands
| | - Cian M. Scannell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | | | - Ebraham Alskaf
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Richard Crawley
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Filippo Bosio
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | | | | | | | | | | | - Jouke Smink
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Marcel Breeuwer
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of MR R&D – Clinical Science, Philips Healthcare, Best, Netherlands
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Markus Henningsson
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linkoping University, Linkoping, Sweden
| | - Teresa Correia
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Centre for Marine Sciences (CCMAR), Faro, Portugal
- *Correspondence: Teresa Correia
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Abraham GR, Morrow AJ, Oliveira J, Weir-McCall JR, Davenport EE, Berry C, Davenport AP, Hoole SP. Mechanistic study of the effect of Endothelin SNPs in microvascular angina – Protocol of the PRIZE Endothelin Sub-Study. IJC HEART & VASCULATURE 2022; 39:100980. [PMID: 35242999 PMCID: PMC8885580 DOI: 10.1016/j.ijcha.2022.100980] [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: 01/08/2022] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 11/17/2022]
Abstract
Microvascular angina is a common cause of ischemia with non-obstructive coronary arteries (INOCA). Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathophysiology of microvascular angina. Zibotentan, an Endothelin Receptor Antagonist is being tested as a treatment for microvascular angina in the ‘PRIZE’ trial using a genetic ‘precision medicine’ approach. The PRIZE ET Sub-study will provide a comprehensive genotype and phenotype bio-resource for microvascular angina patients.
Introduction Microvascular angina is a common cause of ischemia with non-obstructive coronary arteries (INOCA) and limited therapeutic options are available to those affected. Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathophysiology of microvascular angina. A large randomised, double blinded, placebo controlled crossover trial, the PRecIsion medicine with ZibotEntan in microvascular angina (PRIZE) trial is currently underway, investigating an endothelin receptor antagonist – Zibotentan, as a new drug treatment for microvascular angina. The trial uses a 'precision medicine' approach by preferential selection of those with higher ET-1 expression conferred by the PHACTR1 minor G allele single nucleotide polymorphism (SNP). The incidence of this SNP occurs in approximately one third of the population therefore a considerable number of screened patients will be ineligible for randomisation and the treatment phase of the trial. Methods In the PRIZE Endothelin (ET) Sub-Study, patients screened out of the PRIZE trial will be genotyped for other genetic variants in the ET-1 pathway. These will be correlated with phenotypic characteristics including exercise tolerance, angina severity and quantitative measures of microvascular function on cardiovascular MRI as well as mechanistic data on endothelin pathway signalling. Conclusions The study will provide a comprehensive genotype and phenotype bio-resource identifying novel ET-1 genotypes to inform the potential wider use of endothelin receptor antagonists for this indication.
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Spione F, Arevalos V, Gabani R, Sabaté M, Brugaletta S. Coronary Microvascular Angina: A State-of-the-Art Review. Front Cardiovasc Med 2022; 9:800918. [PMID: 35433857 PMCID: PMC9005807 DOI: 10.3389/fcvm.2022.800918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/08/2022] [Indexed: 12/28/2022] Open
Abstract
Up to 60–70% of patients, undergoing invasive coronary angiography due to angina and demonstrable myocardial ischemia with provocative tests, do not have any obstructive coronary disease. Coronary microvascular angina due to a dysfunction of the coronary microcirculation is the underlying cause in almost 50% of these patients, associated with a bad prognosis and poor quality of life. In recent years, progress has been made in the diagnosis and management of this condition. The aim of this review is to provide an insight into current knowledge of this condition, from current diagnostic methods to the latest treatments.
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Affiliation(s)
- Francesco Spione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Victor Arevalos
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rami Gabani
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- *Correspondence: Salvatore Brugaletta,
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66
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Seraphim A, Dowsing B, Rathod KS, Shiwani H, Patel K, Knott KD, Zaman S, Johns I, Razvi Y, Patel R, Xue H, Jones DA, Fontana M, Cole G, Uppal R, Davies R, Moon JC, Kellman P, Manisty C. Quantitative Myocardial Perfusion Predicts Outcomes in Patients With Prior Surgical Revascularization. J Am Coll Cardiol 2022; 79:1141-1151. [PMID: 35331408 PMCID: PMC9034686 DOI: 10.1016/j.jacc.2021.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/23/2021] [Accepted: 12/29/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients with previous coronary artery bypass graft (CABG) surgery typically have complex coronary disease and remain at high risk of adverse events. Quantitative myocardial perfusion indices predict outcomes in native vessel disease, but their prognostic performance in patients with prior CABG is unknown. OBJECTIVES In this study, we sought to evaluate whether global stress myocardial blood flow (MBF) and perfusion reserve (MPR) derived from perfusion mapping cardiac magnetic resonance (CMR) independently predict adverse outcomes in patients with prior CABG. METHODS This was a retrospective analysis of consecutive patients with prior CABG referred for adenosine stress perfusion CMR. Perfusion mapping was performed in-line with automated quantification of MBF. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular events defined as nonfatal myocardial infarction and unplanned revascularization. Associations were evaluated with the use of Cox proportional hazards models after adjusting for comorbidities and CMR parameters. RESULTS A total of 341 patients (median age 67 years, 86% male) were included. Over a median follow-up of 638 days (IQR: 367-976 days), 81 patients (24%) reached the primary outcome. Both stress MBF and MPR independently predicted outcomes after adjusting for known prognostic factors (regional ischemia, infarction). The adjusted hazard ratio (HR) for 1 mL/g/min of decrease in stress MBF was 2.56 (95% CI: 1.45-4.35) and for 1 unit of decrease in MPR was 1.61 (95% CI: 1.08-2.38). CONCLUSIONS Global stress MBF and MPR derived from perfusion CMR independently predict adverse outcomes in patients with previous CABG. This effect is independent from the presence of regional ischemia on visual assessment and the extent of previous infarction.
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Affiliation(s)
- Andreas Seraphim
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom. https://twitter.com/andreas_sera
| | - Benjamin Dowsing
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Krishnaraj S Rathod
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Hunain Shiwani
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Kush Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Kristopher D Knott
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sameer Zaman
- Imperial College London, Imperial College, Healthcare NHS Trust, South Kensington, London, United Kingdom
| | - Ieuan Johns
- Imperial College London, Imperial College, Healthcare NHS Trust, South Kensington, London, United Kingdom
| | | | | | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniel A Jones
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Royal Free Hospital, London, United Kingdom
| | | | - Rakesh Uppal
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rhodri Davies
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, United Kingdom.
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Michallek F, Nakamura S, Ota H, Ogawa R, Shizuka T, Nakashima H, Wang YN, Ito T, Sakuma H, Dewey M, Kitagawa K. Fractal analysis of 4D dynamic myocardial stress-CT perfusion imaging differentiates micro- and macrovascular ischemia in a multi-center proof-of-concept study. Sci Rep 2022; 12:5085. [PMID: 35332236 PMCID: PMC8948301 DOI: 10.1038/s41598-022-09144-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/17/2022] [Indexed: 12/30/2022] Open
Abstract
Fractal analysis of dynamic, four-dimensional computed tomography myocardial perfusion (4D-CTP) imaging might have potential for noninvasive differentiation of microvascular ischemia and macrovascular coronary artery disease (CAD) using fractal dimension (FD) as quantitative parameter for perfusion complexity. This multi-center proof-of-concept study included 30 rigorously characterized patients from the AMPLIFiED trial with nonoverlapping and confirmed microvascular ischemia (nmicro = 10), macrovascular CAD (nmacro = 10), or normal myocardial perfusion (nnormal = 10) with invasive coronary angiography and fractional flow reserve (FFR) measurements as reference standard. Perfusion complexity was comparatively high in normal perfusion (FDnormal = 4.49, interquartile range [IQR]:4.46-4.53), moderately reduced in microvascular ischemia (FDmicro = 4.37, IQR:4.36-4.37), and strongly reduced in macrovascular CAD (FDmacro = 4.26, IQR:4.24-4.27), which allowed to differentiate both ischemia types, p < 0.001. Fractal analysis agreed excellently with perfusion state (κ = 0.96, AUC = 0.98), whereas myocardial blood flow (MBF) showed moderate agreement (κ = 0.77, AUC = 0.78). For detecting CAD patients, fractal analysis outperformed MBF estimation with sensitivity and specificity of 100% and 85% versus 100% and 25%, p = 0.02. In conclusion, fractal analysis of 4D-CTP allows to differentiate microvascular from macrovascular ischemia and improves detection of hemodynamically significant CAD in comparison to MBF estimation.
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Affiliation(s)
- Florian Michallek
- grid.6363.00000 0001 2218 4662Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Satoshi Nakamura
- grid.260026.00000 0004 0372 555XDepartment of Radiology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideki Ota
- grid.69566.3a0000 0001 2248 6943Department of Advanced MRI Collaborative Research, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Ryo Ogawa
- grid.459909.80000 0004 0640 6159Saiseikai Matsuyama Hospital, Matsuyama, Japan
| | | | - Hitoshi Nakashima
- grid.416799.4National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Yi-Ning Wang
- grid.413106.10000 0000 9889 6335Peking Union Medical College Hospital, Beijing, China
| | - Tatsuro Ito
- grid.31432.370000 0001 1092 3077Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hajime Sakuma
- grid.260026.00000 0004 0372 555XDepartment of Radiology, Mie University Graduate School of Medicine, Mie, Japan
| | - Marc Dewey
- grid.6363.00000 0001 2218 4662Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany ,grid.452396.f0000 0004 5937 5237DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Kakuya Kitagawa
- grid.260026.00000 0004 0372 555XDepartment of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Mie, Japan
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Mileva N, Nagumo S, Mizukami T, Sonck J, Berry C, Gallinoro E, Monizzi G, Candreva A, Munhoz D, Vassilev D, Penicka M, Barbato E, De Bruyne B, Collet C. Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e023207. [PMID: 35301851 PMCID: PMC9075440 DOI: 10.1161/jaha.121.023207] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background A relevant proportion of patients with suspected coronary artery disease undergo invasive coronary angiography showing normal or nonobstructive coronary arteries. However, the prevalence of coronary microvascular disease (CMD) and coronary spasm in patients with nonobstructive coronary artery disease remains to be determined. The objective of this study was to determine the prevalence of coronary CMD and coronary vasospastic angina in patients with no obstructive coronary artery disease. Methods and Results A systematic review and meta‐analysis of studies assessing the prevalence of CMD and vasospastic angina in patients with no obstructive coronary artery disease was performed. Random‐effects models were used to determine the prevalence of these 2 disease entities. Fifty‐six studies comprising 14 427 patients were included. The pooled prevalence of CMD was 0.41 (95% CI, 0.36–0.47), epicardial vasospasm 0.40 (95% CI, 0.34–0.46) and microvascular spasm 24% (95% CI, 0.21–0.28). The prevalence of combined CMD and vasospastic angina was 0.23 (95% CI, 0.17–0.31). Female patients had a higher risk of presenting with CMD compared with male patients (risk ratio, 1.45 [95% CI, 1.11–1.90]). CMD prevalence was similar when assessed using noninvasive or invasive diagnostic methods. Conclusions In patients with no obstructive coronary artery disease, approximately half of the cases were reported to have CMD and/or coronary spasm. CMD was more prevalent among female patients. Greater awareness among physicians of ischemia with no obstructive coronary arteries is urgently needed for accurate diagnosis and patient‐tailored management.
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Affiliation(s)
- Niya Mileva
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Cardiology Clinic Alexandrovska University Hospital Sofia Bulgaria
| | - Sakura Nagumo
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Division of Cardiology Department of Internal Medicine Showa UniversityFujigaoka Hospital Kanagawa Japan
| | - Takuya Mizukami
- Division of Cardiology Department of Internal Medicine Showa UniversityFujigaoka Hospital Kanagawa Japan
| | - Jeroen Sonck
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre Institute of Cardiovascular and Medical Sciences University of Glasgow Glasgow United Kingdom
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Translational Medical Sciences University of Campania "Luigi Vanvitelli" Naples Italy
| | | | | | - Daniel Munhoz
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Clinical Medicine Discipline of Cardiology University of Campinas UNICAMP Campinas Brazil.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Dobrin Vassilev
- Cardiology Clinic Alexandrovska University Hospital Sofia Bulgaria
| | | | - Emanuele Barbato
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Cardiology Lausanne University Hospital Lausanne Switzerland
| | - Carlos Collet
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium
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Nardone M, McCarthy M, Ardern CI, Nield LE, Toleva O, Cantor WJ, Miner SES. Concurrently Low Coronary Flow Reserve and Low Index of Microvascular Resistance Are Associated With Elevated Resting Coronary Flow in Patients With Chest Pain and Nonobstructive Coronary Arteries. Circ Cardiovasc Interv 2022; 15:e011323. [PMID: 35135301 DOI: 10.1161/circinterventions.121.011323] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary microvascular function can be distinctly quantified using the coronary flow reserve (CFR) and index of microvascular resistance (IMR). Patients with low CFR can present with low or high IMR, although the prevalence and clinical characteristics of these patient groups remain unclear. METHODS One hundred ninety-nine patients underwent coronary microvascular assessments using coronary thermodilution techniques. A pressure-temperature sensor-tipped guidewire measured proximal and distal coronary pressure, whereas the inverse of the mean transit time to room temperature saline was used to measure coronary blood flow. The CFR and IMR were quantified during adenosine and acetylcholine hyperemia. RESULTS Low adenosine and acetylcholine CFR was observed in 70 and 49 patients, respectively, whereas low CFR/low IMR to adenosine and acetylcholine was observed in 39(56%) and 19(39%) patients, respectively. Despite similar adenosine CFR, patients with low CFR/low IMR had increased resting (2.8±1.2 versus 1.3±0.4s-1) and hyperemic coronary blood flow (4.8±1.5 versus 2.1±0.5s-1) compared with patients with low CFR/high IMR (both P<0.01). The same pattern was observed in response to acetylcholine. Patients with low CFR/low IMR to adenosine were younger (56±12 versus 63±10 years), women (84% versus 66%), had fewer coronary risk factors (1.1±1.0 versus 1.6±1.1), lower hemoglobin A1c (5.8±0.7 versus 6.1±0.9 mmol/L), and thinner septal thickness (8.5±2.5 versus 9.9±1.6 mm) compared with patients with low CFR/high IMR to adenosine (all P<0.05). CONCLUSIONS Low CFR/low IMR to adenosine and acetylcholine are associated with elevated resting coronary blood flow and preserved hyperemic coronary blood flow. These patients present with distinct phenotypic characteristics. Simultaneous CFR and IMR measures appear necessary to differentiate these endotypes.
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Affiliation(s)
- Massimo Nardone
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada (M.M., W.J.C., S.E.S.M.)
| | - Mary McCarthy
- Department of Human Health and Nutritional Sciences, University of Guelph, Ontario, Canada (M.N.)
| | - Chris I Ardern
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada (C.I.A., S.E.S.M.)
| | - Lynne E Nield
- Department of Medicine, University of Toronto, Ontario, Canada (L.E.N., W.J.C., S.E.S.M.)
| | - Olga Toleva
- School of Medicine, Emory University, Atlanta, GA (O.T.)
| | - Warren J Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada (M.M., W.J.C., S.E.S.M.).,Department of Medicine, University of Toronto, Ontario, Canada (L.E.N., W.J.C., S.E.S.M.)
| | - Steven E S Miner
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada (M.M., W.J.C., S.E.S.M.).,School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada (C.I.A., S.E.S.M.).,Department of Medicine, University of Toronto, Ontario, Canada (L.E.N., W.J.C., S.E.S.M.)
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Lopez DM, Divakaran S, Gupta A, Bajaj NS, Osborne MT, Zhou W, Hainer J, Bibbo CF, Skali H, Dorbala S, Taqueti VR, Blankstein R, Di Carli MF. Role of Exercise Treadmill Testing in the Assessment of Coronary Microvascular Disease. JACC Cardiovasc Imaging 2022; 15:312-321. [PMID: 34419395 PMCID: PMC8831663 DOI: 10.1016/j.jcmg.2021.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The authors aimed to study the sensitivity and specificity of exercise treadmill testing (ETT) in the diagnosis of coronary microvascular disease (CMD), as well as the prognostic implications of ETT results in patients with CMD. BACKGROUND ETT is validated to evaluate for flow-limiting coronary artery disease (CAD), however, little is known about its use for evaluating CMD. METHODS We retrospectively studied 249 consecutive patients between 2006 and 2016 who underwent ETT and positron emission tomography within 12 months. Patients with obstructive CAD or left ventricular systolic dysfunction were excluded. CMD was defined as a coronary flow reserve <2. Patients were followed for the occurrence of a first major adverse event (composite of death or hospitalization for myocardial infarction or heart failure). RESULTS The sensitivity and specificity of a positive ETT to detect CMD were 34.7% (95% CI: 25.4%-45.0%) and 64.9% (95% CI: 56.7%-72.5%), respectively. The specificity of a positive ETT to detect CMD increased to 86.8% (95% CI: 80.3%-91.7%) when only classifying studies with ischemic electrocardiogram changes that lasted at least 1 minute into recovery as positive, although at a cost of lower sensitivity (15.3%; 95% CI: 8.8%-24.0%). Over a median follow-up of 6.9 years (IQR: 5.1-8.2 years), 30 (12.1%) patients met the composite endpoint, including 13 (13.3%) with CMD (n = 98). In patients with CMD, ETT result was not associated with the composite endpoint (P = 0.076). CONCLUSIONS Our data suggest limited sensitivity of ETT to detect CMD. However, a positive ETT with ischemic changes that persist at least 1 minute into recovery in the absence of obstructive CAD should raise suspicion for the presence of CMD given a high specificity. Further study is needed with larger patient sample sizes to assess the association between ETT results and outcomes in patients with CMD.
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Affiliation(s)
- Diana M. Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Navkaranbir S. Bajaj
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T. Osborne
- Cardiovascular Imaging Research Center, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney F. Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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71
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Wang Q, Zhang Z, Chai Q, Shan Y, Lu D, Chen Y, Liu M, Wu W. Correlation Between Retinopathy and Coronary Microcirculation Dysfunction in Patients with Type 2 Diabetes Mellitus. Eur J Ophthalmol 2022; 32:2857-2863. [PMID: 35060405 DOI: 10.1177/11206721221074201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The aim of this study is to evaluate the correlation between retinopathy and coronary microcirculation dysfunction (CMD) in type 2 diabetes mellitus (T2DM) patients. Methods 198 T2DM patients with left ventricular ejection fraction (LVEF)>50%, no epicardial coronary artery stenosis diagnosis by coronary angiography (CAG) and successfully completed coronary blood flow reserve (CFR) test and laboratory examination were enrolled, and fundus examination was performed on all participants. Two groups were divided according to CFR value, including 86 patients with CMD (CFR≤2.5) in study group and 112 patients without CMD (CFR>2.5) in control group. The composition of various retinopathy in two groups was observed, and the correlation between retinopathy and CMD was analyzed using ordered logistic regression. Results There were 13 cases with arteriovenous (A/V) nicking, 4 cases with proliferative diabetic retinopathy (PDR), 14 cases with non-proliferative diabetic retinopathy (NPDR), 17 cases with diabetic retinopathy (DR) with A/V nicking, 38 cases without retinopathy in study group, and 18 cases, 7 cases, 20 cases, 4 cases and 63 cases for each in control group. After adjustment for age, gender, hypertension, diabetes duration, dyslipidemia, glycosylated hemoglobin (HbA1c), body mass index (BMI), A/V nicking, PDR and NPDR, the diference of DR with A/V nicking between study and control group remained statistically signifcant (OR 2.0, 95% CI 0.79 to 3.21, p = 0.001). Conclusion DR with A/V nicking could be used as an independent predictor of T2DM patients with CMD. CFR testing should be performed on patients with this kind of eye sign, even if they do not have any symptoms of heart disease. Meanwhile, DR with A/V nicking might be served as a reference indicator of CMD in T2DM patients with chest pain who were unable to be tested for CFR.
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Affiliation(s)
- Qian Wang
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Ziying Zhang
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Qian Chai
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Yongyan Shan
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Dexue Lu
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Yangwen Chen
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Meili Liu
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Weihua Wu
- Department of Endocrinology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
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Ma P, Liu J, Hu Y, Zhou X, Shang Y, Wang J. Histologic validation of stress cardiac magnetic resonance T1-mapping techniques for detection of coronary microvascular dysfunction in rabbits. Int J Cardiol 2022; 347:76-82. [PMID: 34736980 DOI: 10.1016/j.ijcard.2021.10.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND To investigate the diagnostic performance of stress cardiac magnetic resonance (CMR) T1-mapping for the detection of coronary microvascular dysfunction (CMD) by correlating microvascular density (MVD) and collagen volume fraction (CVF) with T1 response to adenosine triphosphate (ATP) stress (stress ΔT1) in rabbits. METHODS Twenty-four New Zealand white rabbits were randomly divided into the CMD group induced by microembolization spheres (n = 10), sham-operated group (n = 5), and control group (n = 9). All rabbits underwent 3.0 T CMR, both rest and ATP stress T1-maps were obtained, and first-pass perfusion imaging was performed. Stress ΔT1 and myocardial perfusion reserve index (MPRI) were calculated. For the histologic study, each rabbit was sacrificed after CMR scanning. Left ventricular myocardial tissue was stained with Hematoxylin-eosin (H&E), Masson, and CD31, from which MVD and CVF were extracted. Pearson correlation analyses were performed to determine the strength of the association between the stress ΔT1 and both MVD and CVF. RESULTS The stress ΔT1 values (CMD, 2.53 ± 0.37% vs. control, 6.00 ± 0.64% vs. Sham, 6.07 ± 0.97%, p < 0.001) and MPRI (CMD, 1.45 ± 0.13 vs. control, 1.94 ± 0.23, vs. sham, 1.89 ± 0.15, p < 0.001) were both lower in CMD rabbits compared with sham-operated and control rabbits. Further, the stress ΔT1 showed a high correlation with CVF (r = -0.806, p < 0.001) and MVD (r = 0.920, p < 0.001). CONCLUSIONS Stress T1 response strongly correlates with pathological MVD and CVF, indicating that stress CMR T1 mapping can accurately detect microvascular dysfunction.
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Affiliation(s)
- Peisong Ma
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Juan Liu
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yurou Hu
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ltd., Shanghai, China
| | - Yongning Shang
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Jian Wang
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
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73
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Bilak JM, Alam U, Miller CA, McCann GP, Arnold JR, Kanagala P. Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction: Pathophysiology, Assessment, Prevalence and Prognosis. Card Fail Rev 2022; 8:e24. [PMID: 35846985 PMCID: PMC9274364 DOI: 10.15420/cfr.2022.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) currently accounts for approximately half of all new heart failure cases in the community. HFpEF is closely associated with chronic lifestyle-related diseases, such as obesity and type 2 diabetes, and clinical outcomes are worse in those with than without comorbidities. HFpEF is pathophysiologically distinct from heart failure with reduced ejection fraction, which may explain, in part, the disparity of treatment options available between the two heart failure phenotypes. The mechanisms underlying HFpEF are complex, with coronary microvascular dysfunction (MVD) being proposed as a potential key driver in its pathophysiology. In this review, the authors highlight the evidence implicating MVD in HFpEF pathophysiology, the diagnostic approaches for identifying MVD (both invasive and non-invasive) and the prevalence and prognostic significance of MVD.
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Affiliation(s)
- Joanna M Bilak
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Uazman Alam
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of ManchesterManchester, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of LiverpoolLiverpool, UK
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science CentreManchester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Prathap Kanagala
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Liverpool Centre for Cardiovascular Sciences, Faculty of Health and Life SciencesLiverpool, UK
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Affiliation(s)
- Paco E Bravo
- Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Thomas P Cappola
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Boerhout CKM, Feenstra RGT, Somsen GA, Appelman Y, Ong P, Beijk MAM, Hofstra L, van de Hoef TP, Piek JJ. Coronary computed tomographic angiography as gatekeeper for new-onset stable angina. Neth Heart J 2021; 29:551-556. [PMID: 34676522 PMCID: PMC8556428 DOI: 10.1007/s12471-021-01639-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 01/16/2023] Open
Abstract
Patients with new-onset stable angina constitute a substantial part of the population seen by cardiologists. Currently, the diagnostic workup of these patients depends on the pre-test probability of having obstructive coronary artery disease. It consists of either functional testing for myocardial ischaemia or anatomical testing by using coronary computed tomographic angiography (CCTA) or invasive coronary angiography. In case the pre-test probability is > 5%, the current guidelines for the management of chronic coronary syndromes do not state a clear preference for one of the noninvasive techniques. However, based on the recently published cost-effectiveness analysis of the PROMISE trial and considering the diagnostic yield in patients with angina and nonobstructive coronary artery disease, we argue a more prominent role for CCTA as a gatekeeper for patients with new-onset stable angina.
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Affiliation(s)
- C K M Boerhout
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - R G T Feenstra
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - G A Somsen
- Cardiology Centres of the Netherlands, Amsterdam, The Netherlands
| | - Y Appelman
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - P Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - M A M Beijk
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - L Hofstra
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - T P van de Hoef
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - J J Piek
- Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, The Netherlands.
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Vink CEM, van de Hoef TP, Götte MJW, Eringa EC, Appelman Y. Reduced Microvascular Blood Volume as a Driver of Coronary Microvascular Disease in Patients With Non-obstructive Coronary Artery Disease: Rationale and Design of the MICORDIS Study. Front Cardiovasc Med 2021; 8:730810. [PMID: 34660730 PMCID: PMC8514690 DOI: 10.3389/fcvm.2021.730810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/02/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Ischemia with non-obstructive coronary arteries (INOCA) is part of the ischemic heart disease spectrum, and is particularly observed in women. INOCA has various mechanisms, such as coronary vasospasm and coronary microvascular dysfunction (CMD). A decreased coronary flow reserve (CFR) and-or increased myocardial resistance (MR) are commonly used to diagnose CMD. However, CFR and MR do not describe all pathophysiological mechanisms underlying CMD. Increased myocardial oxygen consumption (MVO2) normally increases myocardial blood volume (MBV), independently from myocardial blood flow (MBF). In addition insulin enhances MBV in healthy skeletal muscle, and this effect is impaired in INOCA-related conditions such as diabetes and obesity. Therefore, we propose that MBV is reduced in INOCA patients. Aim: To assess whether myocardial blood volume (MBV) is decreased in INOCA patients, at baseline, during hyperinsulinemia and during stress. Design: The MICORDIS-study is a single-center observational cross-sectional cohort study (identifier NTR7515). The primary outcome is MBV, compared between INOCA patients and matched healthy controls. The patient group will undergo coronary function testing using a Doppler guidewire, intracoronary adenosine and acetylcholine to measure CFR and coronary vasospasm. Both the patient- and the control group will undergo myocardial contrast echocardiography (MCE) to determine MBV at baseline, during hyperinsulinemia and during stress. Subsequently, cardiac magnetic resonance (CMR) will be evaluated as a new and noninvasive diagnostic tool for CMD in INOCA patients. Microvascular endothelial function is a determinant of MBV and will be evaluated by non-invasive microvascular function testing using EndoPAT and by measuring NO production in circulating endothelial cells (ECFCs).
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Affiliation(s)
- Caitlin E M Vink
- Departments of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences (ACS), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Tim P van de Hoef
- Departments of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences (ACS), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - M J W Götte
- Departments of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences (ACS), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - E C Eringa
- Departments of Physiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences (ACS), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Yolande Appelman
- Departments of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences (ACS), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Toya T, Corban MT, Park J, Ahmad A, Ӧzcan I, Sebaali F, Sara J, Gulati R, Lerman LO, Lerman A. Prognostic impact and clinical outcomes of coronary flow reserve and hyperaemic microvascular resistance. EUROINTERVENTION 2021; 17:569-575. [PMID: 33342762 PMCID: PMC9724958 DOI: 10.4244/eij-d-20-00853] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Most studies dichotomise indices of coronary microvascular function to assess their prognostic values. AIMS We aimed to investigate whether coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR) as continua predict major adverse cardiovascular events (MACE), comprising all-cause death, myocardial infarction, revascularisation, and stroke in patients with ischaemia and non-obstructive coronary artery disease. METHODS A total of 610 patients were included and followed up over a median of 8.0 years (199 individual MACE in 174 patients). RESULTS Both CFR and HMR as continua predicted MACE with an odds ratio (OR) of 0.70 (per 1-unit increase, 95% confidence interval [CI]: 0.53, 0.92; p=0.01) and 1.63 (per 1 mmHg/cm/s, 95% CI: 1.20, 2.21; p=0.002), respectively. This relationship remained significant after adjustment for age and sex with an adjusted OR of 0.66 (per 1 unit increase, 95% CI: 0.49, 0.89; p=0.01) and 1.42 (per 1 mmHg/cm/s, 95% CI: 1.03, 1.94; p=0.03). HMR added prognostic value to CFR in predicting MACE (net reclassification index 0.17, 95% CI: 0.02, 0.31; p=0.03; integrated discrimination improvement 0.01, 95% CI: 0.0001, 0.02; p=0.046). CONCLUSIONS Both CFR and HMR as continuous variables predict future risk of MACE.
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Affiliation(s)
- Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA,Division of Cardiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Michel T. Corban
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ji Park
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ilke Ӧzcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Faten Sebaali
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jaskanwal Sara
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Mayo Clinic, Division of Cardiovascular Diseases, 200 First Street SW, Rochester, MN 55905, USA
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Bourantas C, Chandrasekharan K. Stratifying cardiovascular risk in patients with microvascular dysfunction: new insights from emerging physiology metrics. EUROINTERVENTION 2021; 17:532-533. [PMID: 34554094 PMCID: PMC9707457 DOI: 10.4244/eijv17i7a95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Christos Bourantas
- Barts Heart Centre, 1 St Martin’s Le Grand, London, EC1A 7BE, United Kingdom
| | - Karthik Chandrasekharan
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Sinha A, Rahman H, Webb A, Shah AM, Perera D. Untangling the pathophysiologic link between coronary microvascular dysfunction and heart failure with preserved ejection fraction. Eur Heart J 2021; 42:4431-4441. [PMID: 34529791 PMCID: PMC8599060 DOI: 10.1093/eurheartj/ehab653] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023] Open
Abstract
Coronary microvascular disease (CMD), characterized by impaired coronary flow reserve (CFR), is a common finding in patients with stable angina. Impaired CFR, in the absence of obstructive coronary artery disease, is also present in up to 75% of patients with heart failure with preserved ejection fraction (HFpEF). Heart failure with preserved ejection fraction is a heterogeneous syndrome comprising distinct endotypes and it has been hypothesized that CMD lies at the centre of the pathogenesis of one such entity: the CMD–HFpEF endotype. This article provides a contemporary review of the pathophysiology underlying CMD, with a focus on the mechanistic link between CMD and HFpEF. We discuss the central role played by subendocardial ischaemia and impaired lusitropy in the development of CMD–HFpEF, as well as the clinical and research implications of the CMD–HFpEF mechanistic link. Future prospective follow-up studies detailing outcomes in patients with CMD and HFpEF are much needed to enhance our understanding of the pathological processes driving these conditions, which may lead to the development of physiology-stratified therapy to improve the quality of life and prognosis in these patients.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Andrew Webb
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Ajay M Shah
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
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80
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Hillier E, Friedrich MG. The Potential of Oxygenation-Sensitive CMR in Heart Failure. Curr Heart Fail Rep 2021; 18:304-314. [PMID: 34378154 DOI: 10.1007/s11897-021-00525-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Cardiac magnetic resonance imaging (CMR) use in the context of heart failure (HF) has increased over the last decade as it is able to provide detailed, quantitative information on function, morphology, and myocardial tissue composition. Furthermore, oxygenation-sensitive CMR (OS-CMR) has emerged as a CMR imaging method capable of monitoring changes of myocardial oxygenation without the use of exogenous contrast agents. RECENT FINDINGS The contributions of OS-CMR to the investigation of patients with HF includes not only a fully quantitative assessment of cardiac morphology, function, and tissue characteristics, but also high-resolution information on both endothelium-dependent and endothelium-independent vascular function as assessed through changes of myocardial oxygenation. In patients with heart failure, OS-CMR can provide deep phenotyping on the status and important associated pathophysiology as a one-stop, needle-free diagnostic imaging test.
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Affiliation(s)
- Elizabeth Hillier
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Matthias G Friedrich
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada. .,Departments of Medicine and Diagnostic Radiology, McGill University, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
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81
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Chen Y, Chai Q, Wang Q, Zhang Z, Shan Y, Lu D, Liu M, Wu W. Neutrophil-to-lymphocyte ratio is associated with coronary microvascular dysfunction in type 2 diabetes mellitus patients. Diabetes Res Clin Pract 2021; 178:108983. [PMID: 34311023 DOI: 10.1016/j.diabres.2021.108983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 11/24/2022]
Abstract
AIMS Our study is aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and coronary microvascular dysfunction (CMD) in type 2 diabetes mellitus (T2DM) patients. METHODS We retrospect the consecutive medical files of 160 T2DM patients and recorded their clinical information and laboratory findings. Patients were divided into CMD group (n = 87) and non-CMD group (n = 73). We compared the NLR values of the two groups. Meanwhile we also observed the prevalence of CMD at different NLR levels. Then, logistic regression and ROC analysis were performed. RESULTS NLR value of CMD group was significantly lower than non-CMD group (2.01 ± 0.74 vs 2.53 ± 0.69, P<0.001). Prevalence of CMD in low (NLR ≤ 1.53, n = 30), medium (1.53 < NLR ≤ 2.20, n = 53) and high (NLR > 2.20, n = 77) group were 90%, 61.1%, and 39.2% respectively. The prevalence of CMD significantly increased as NLR level decreased. After adjusting potential related factors, NLR was still significantly correlated with CMD (OR = 0.295, 95 %CI:0.162-0.539, P < 0.001). The area under ROC curve (AUC) was 0.707 (95 %CI:0.627-0.786, P < 0.001). CONCLUSIONS Our results showed that NLR is associated with CMD in T2DM patients, and the prevalence of CMD may increase as NLR level decrease.
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Affiliation(s)
- Yangwen Chen
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Qian Chai
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Qian Wang
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Ziying Zhang
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Yongyan Shan
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Dexue Lu
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Meili Liu
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China
| | - Weihua Wu
- Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, People's Republic of China.
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82
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Junqueira CLC, Ferreira E, Junqueira ASM, de Almeida Cyrino FZG, Maranhão PA, Kraemer-Aguiar LG, Bottino DA, Coelho de Souza MDG, Bouskela E. Peripheral microvascular dysfunction is also present in patients with ischemia and no obstructive coronary artery disease (INOCA). Clin Hemorheol Microcirc 2021; 79:381-393. [PMID: 34151847 DOI: 10.3233/ch-201065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In patients with ischemia and no obstructive coronary artery disease (INOCA), coronary microvascular dysfunction is associated with higher rate of major adverse cardiovascular events. OBJECTIVE To demonstrate if microvascular dysfunction present in coronary microcirculation of patients with INOCA may be detected noninvasively in their peripheral circulation. METHODS 25 patients with INOCA and 25 apparently healthy individuals (controls) were subjected to nailfold videocapillaroscopy (NVC) and venous occlusion plethysmography (VOP) to evaluate peripheral microvascular function and blood collection for biomarkers analysis, including soluble vascular cell adhesion molecule-1 (sVCAM-1), endothelin-1 (ET-1) and C-reactive protein (CRP). RESULTS Red blood cell velocity (RBCV) before and after ischemia (RBCVmax) were significantly lower in patients with INOCA (p = 0.0001). Time to reach maximal red blood cell velocity (TRBCVmax) was significantly longer in INOCA group (p = 0.0004). Concerning VOP, maximal blood flow (p = 0.004) and its relative increment were significantly lower in patients with INOCA (p = 0.0004). RBCVmax showed significant correlations with sVCAM-1 (r = -0.38, p < 0.05), ET-1 (r = -0.73, p < 0.05) and CRP (r = -0.33, p < 0.05). Relative increment of maximal post-ischemic blood flow was significantly correlated with sVCAM-1 (r = -0.42, p < 0.05) and ET-1 (r = -0.48, p < 0.05). CONCLUSIONS The impairment of microvascular function present in coronary microcirculation of patients with INOCA can be also detected in peripheral microcirculation.
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Affiliation(s)
- Camillo L C Junqueira
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Esmeralci Ferreira
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Departamento de Cardiologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Brazil
| | | | | | - Priscila Alves Maranhão
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Luiz Guilherme Kraemer-Aguiar
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Brazil
| | - Daniel Alexandre Bottino
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Maria das Graças Coelho de Souza
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Eliete Bouskela
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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83
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Bays HE, Khera A, Blaha MJ, Budoff MJ, Toth PP. Ten things to know about ten imaging studies: A preventive cardiology perspective ("ASPC top ten imaging"). Am J Prev Cardiol 2021; 6:100176. [PMID: 34327499 PMCID: PMC8315431 DOI: 10.1016/j.ajpc.2021.100176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
Knowing the patient's current cardiovascular disease (CVD) status, as well as the patient's current and future CVD risk, helps the clinician make more informed patient-centered management recommendations towards the goal of preventing future CVD events. Imaging tests that can assist the clinician with the diagnosis and prognosis of CVD include imaging studies of the heart and vascular system, as well as imaging studies of other body organs applicable to CVD risk. The American Society for Preventive Cardiology (ASPC) has published "Ten Things to Know About Ten Cardiovascular Disease Risk Factors." Similarly, this "ASPC Top Ten Imaging" summarizes ten things to know about ten imaging studies related to assessing CVD and CVD risk, listed in tabular form. The ten imaging studies herein include: (1) coronary artery calcium imaging (CAC), (2) coronary computed tomography angiography (CCTA), (3) cardiac ultrasound (echocardiography), (4) nuclear myocardial perfusion imaging (MPI), (5) cardiac magnetic resonance (CMR), (6) cardiac catheterization [with or without intravascular ultrasound (IVUS) or coronary optical coherence tomography (OCT)], (7) dual x-ray absorptiometry (DXA) body composition, (8) hepatic imaging [ultrasound of liver, vibration-controlled transient elastography (VCTE), CT, MRI proton density fat fraction (PDFF), magnetic resonance spectroscopy (MRS)], (9) peripheral artery / endothelial function imaging (e.g., carotid ultrasound, peripheral doppler imaging, ultrasound flow-mediated dilation, other tests of endothelial function and peripheral vascular imaging) and (10) images of other body organs applicable to preventive cardiology (brain, kidney, ovary). Many cardiologists perform cardiovascular-related imaging. Many non-cardiologists perform applicable non-cardiovascular imaging. Cardiologists and non-cardiologists alike may benefit from a working knowledge of imaging studies applicable to the diagnosis and prognosis of CVD and CVD risk - both important in preventive cardiology.
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Affiliation(s)
- Harold E. Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville KY 40213 USA
| | - Amit Khera
- UT Southwestern Medical Center, Dallas, TX USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore MD USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance CA USA
| | - Peter P. Toth
- CGH Medical Cener, Sterling, IL 61081 USA
- Cicarrone center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD USA
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84
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Toya T, Ahmad A, Corban MT, Ӧzcan I, Sara JD, Sebaali F, Escaned J, Lerman LO, Lerman A. Risk Stratification of Patients With NonObstructive Coronary Artery Disease Using Resistive Reserve Ratio. J Am Heart Assoc 2021; 10:e020464. [PMID: 33998253 PMCID: PMC8483554 DOI: 10.1161/jaha.120.020464] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Resistive reserve ratio (RRR), or the ratio of baseline to hyperemic microvascular resistance, has prognostic implications in predicting clinical outcomes in patients with obstructive coronary artery disease. However, its value in patients with angina or ischemia with nonobstructive coronary artery disease is unknown. Methods and Results We included 1692 patients with nonobstructive coronary artery disease who underwent invasive coronary vasoreactivity testing. Abnormal coronary flow reserve (CFR, the ratio of hyperemic and baseline resting flow velocities) and RRR were defined as <2.5 and <2.62, respectively. The mortality rate was marginally higher in patients with abnormal CFR (428 patients [25%]) than those with normal CFR (38 [9%] versus 81 [6%]; P=0.08), and was significantly higher in patients with abnormal RRR (716 patients [42%]) than those with normal RRR (70 [10%] versus 49 [5%], P=0.0002) over the median follow-up of 11.3 years. Patients with abnormal CFR had marginally lower survival than those with normal CFR (log-rank P=0.08). In contrast, patients with abnormal RRR had significantly lower survival than those with normal RRR (log-rank P=0.001). Abnormal RRR was associated with shorter time to death even after adjustment for other covariates (adjusted hazard ratio, 1.63; 95% CI, 1.11-2.38; P=0.01). Conclusions In patients with no obstructive coronary artery disease, RRR was superior to CFR in predicting long-term survival. An RRR <2.62 was associated with 1.6 times increased risk of death in patients with nonobstructive coronary artery disease. Indices of coronary microcirculatory resistive reserve comprising flow- and pressure-derived values may reflect underlying microvascular pathology more faithfully than flow-alone indices like CFR.
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Affiliation(s)
- Takumi Toya
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Division of Cardiology National Defense Medical College Tokorozawa Saitama Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Michel T Corban
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Ilke Ӧzcan
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Faten Sebaali
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Javier Escaned
- Department of Cardiology Hospital Clínico San Carlos Madrid Spain
| | - Lilach O Lerman
- Division of Nephrology and Hypertension Mayo Clinic Rochester MN
| | - Amir Lerman
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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85
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Halabi A, Nolan M, Potter E, Wright L, Asham A, Marwick TH. Role of microvascular dysfunction in left ventricular dysfunction in type 2 diabetes mellitus. J Diabetes Complications 2021; 35:107907. [PMID: 33752963 DOI: 10.1016/j.jdiacomp.2021.107907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although microvascular disease (mVD) has been linked to poor cardiovascular outcomes in diabetes mellitus, the contribution of mVD to diabetic cardiomyopathy (DC) is unexplored. We investigated whether LV systolic and diastolic dysfunction is associated with mVD in T2DM. METHODS We recruited 32 asymptomatic patients with T2DM (age 71 ± 4 years, 31% females) from a community-based population. All underwent a comprehensive echocardiogram at baseline including assessment of global longitudinal strain (GLS) and diastolic function. Adenosine stress perfusion on cardiac magnetic resonance imaging (CMR) was performed in all patients. Coronary sinus flow (CSF) was measured offline at rest and peak stress with coronary flow reserve (CFR) calculated as the ratio of global stress and rest CSF. RESULTS Resting CSF was reduced in 15 (47%) compared to 4 (13%) with adenosine-stress (p = 0.023). Overall, CFR was observed to be reduced in the cohort (2.38 [IQR 2.20]). Abnormal CFR was not associated with diabetes duration of ≥10 years or poor glycaemic control. CFR was not associated with abnormal GLS (OR 1.04 [95% CI 0.49, 2.20], p = 0.93). However, a modest negative correlation was observed with e' and CFR (r = -0.49, p = 0.004). CONCLUSION This pilot study did not show correlation between subclinical systolic dysfunction and a novel MRI biomarker of microvascular disease. However, there was a weak correlation with myocardial relaxation. Confirmation of these findings in larger studies is indicated.
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Affiliation(s)
- Amera Halabi
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Nolan
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia
| | - Elizabeth Potter
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Atef Asham
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia.
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86
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Escaned J, Kakuta T. Coronary flow reserve and coronary flow capacity at a time of shifting paradigms of ischaemic heart disease. EUROINTERVENTION 2021; 16:e1463-e1465. [PMID: 33792541 PMCID: PMC9707477 DOI: 10.4244/eijv16i18a264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Javier Escaned
- Hospital Clinico San Carlos/Cardiología, Prof Martin Lagos s/n, 28040 Madrid, Spain
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
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87
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Sinha A, Rahman H, Perera D. Coronary microvascular disease: current concepts of pathophysiology, diagnosis and management. Cardiovasc Endocrinol Metab 2021; 10:22-30. [PMID: 33634252 PMCID: PMC7901821 DOI: 10.1097/xce.0000000000000223] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/23/2020] [Indexed: 12/28/2022]
Abstract
Coronary microvascular disease (CMD) is present in 30% of patients with angina and is associated with increased morbidity and mortality. We now have an improved understanding of the pathophysiology of CMD and the invasive and noninvasive tests that can be used to make the diagnosis. Recent studies have shown that management of CMD guided by physiological testing yields better results than empirical treatment. Despite major advances in diagnosing and stratifying this condition, therapeutic strategies remain limited and poorly defined. This review article discusses recent advances in understanding the pathophysiology of CMD, the modalities that are available to diagnose it clinically, current management options and a look at what is in store for the future.
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Affiliation(s)
- Aish Sinha
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Haseeb Rahman
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Divaka Perera
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
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88
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Modi B, Perera D. How to select patients requiring coronary revascularisation using coronary physiology. JRSM Cardiovasc Dis 2021; 10:2048004020979476. [PMID: 33614020 PMCID: PMC7868490 DOI: 10.1177/2048004020979476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 01/10/2023] Open
Abstract
The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of 'Precision PCI'.
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Affiliation(s)
- Bhavik Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
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89
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Liu QR, Liu HX, Xing WL, Zhou Q, Zhang HL, Zhang HT, Song GY, Wu YJ. Effect of Danhong Injection () on Improving Coronary Microcirculation Injury after Percutaneous Coronary Intervention. Chin J Integr Med 2021; 27:455-460. [PMID: 33433847 DOI: 10.1007/s11655-021-2853-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2018] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To explore the effectiveness of Danhong Injection () on improving microcirculatory injury after percutaneous coronary intervention (PCI) in patients with coronary heart disease (CHD). METHODS A randomized controlled trial was conducted and 90 patients were enrolled. A random sequence was generated using statistical analysis software. Patients with microcirculatory injuries after PCI were randomly divided into 3 groups for treatment (30 subjects in each group): Danhong Injection group: after PCI, Danghong Injections were given with intravenous administration with 40 mL twice a day for a week; statins intensive group: after PCI, atorvastatin calcium tablets were given oral medication with 80 mg once, and then atorvastatin 40 mg daily for 1 week; the control group: after PCI, atorvastatin calcium tablets were given oral medication with 10-20 mg daily for 1 week. The index of microcirculation resistance (IMR) was used to assess microcirculatory injury during PCI. The IMR of the target vessel was reexamined after 1 week of drug treatment. RESULTS After one week's drug treatment, IMR was significantly decreased in both statins intensive group and Danhong Injection group compared with the control group (P<0.01), but no difference was found between statins intensive group and Danhong injection group (14.03 ± 2.54 vs. 16.03 ± 5.72 U, P=0.080). CONCLUSIONS The efficacy of Danhong Injection is non-inferior to statin. Early use of Danhong Injection after PCI can effectively improve coronary microcirculation injury after PCI.
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Affiliation(s)
- Qing-Rong Liu
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Beijing, 100037, China.,Key Laboratory of Cellular Physiology, Ministry of Education (Shanxi Medical University), Taiyuan, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, China
| | - Hong-Xu Liu
- Department of Cardiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, 100010, China
| | - Wen-Long Xing
- Department of Cardiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, 100010, China
| | - Qi Zhou
- Department of Cardiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, 100010, China
| | - Hong-Liang Zhang
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Hai-Tong Zhang
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Guang-Yuan Song
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Yong-Jian Wu
- Department of Cardiology, Fuwai Hospital of Chinese Academy of Medical Sciences, Beijing, 100037, China.
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90
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Groepenhoff F, Klaassen RGM, Valstar GB, Bots SH, Onland-Moret NC, Den Ruijter HM, Leiner T, Eikendal ALM. Evaluation of non-invasive imaging parameters in coronary microvascular disease: a systematic review. BMC Med Imaging 2021; 21:5. [PMID: 33407208 PMCID: PMC7789672 DOI: 10.1186/s12880-020-00535-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/08/2020] [Indexed: 05/08/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is an important underlying cause of angina pectoris. Currently, no diagnostic tool is available to directly visualize the coronary microvasculature. Invasive microvascular reactivity testing is the diagnostic standard for CMD, but several non-invasive imaging techniques are being evaluated. However, evidence on reported non-invasive parameters and cut-off values is limited. Thus, we aimed to provide an overview of reported non-invasive parameters and corresponding cut-off values for CMD. Methods Pubmed and EMBASE databases were systematically searched for studies enrolling patients with angina pectoris without obstructed coronary arteries, investigating at least one non-invasive imaging technique to quantify CMD. Methodological quality assessment of included studies was performed using QUADAS-2. Results Thirty-seven studies were included. Ten cardiac magnetic resonance studies reported MPRI and nine positron emission tomography (PET) and transthoracic echocardiography (TTE) studies reported CFR. Mean MPRI ranged from 1.47 ± 0.36 to 2.01 ± 0.41 in patients and from 1.50 ± 0.47 to 2.68 ± 0.49 in controls without CMD. Reported mean CFR in PET and TTE ranged from 1.39 ± 0.31 to 2.85 ± 1.35 and 1.69 ± 0.40 to 2.40 ± 0.40 for patients, and 2.68 ± 0.83 to 4.32 ± 1.78 and 2.65 ± 0.65 to 3.31 ± 1.10 for controls, respectively. Conclusions This systematic review summarized current evidence on reported parameters and cut-off values to diagnose CMD for various non-invasive imaging modalities. In current clinical practice, CMD is generally diagnosed with a CFR less than 2.0. However, due to heterogeneity in methodology and reporting of outcome measures, outcomes could not be compared and no definite reference values could be provided.
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Affiliation(s)
- F Groepenhoff
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R G M Klaassen
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - G B Valstar
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - S H Bots
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - N C Onland-Moret
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H M Den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - T Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A L M Eikendal
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Rationale and Study Design of Differences in Cardiopulmonary Exercise Capacity According to Coronary Microvascular Dysfunction and Body Composition in Patients with Suspected Heart Failure with Preserved Ejection Fraction. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:237-243. [PMID: 36262558 PMCID: PMC9536684 DOI: 10.36628/ijhf.2021.0029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/20/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022]
Abstract
Coronary microvascular dysfunction (CMD) is one of the mechanisms of myocardial ischemia and left ventricular (LV) diastolic dysfunction, which is closely related to heart failure with preserved ejection fraction (HFpEF). Frailty, associated with sarcopenia, is often accompanied by HFpEF. In the present study, we aim to evaluate the relationship between CMD, body composition, and cardiopulmonary exercise capacity in patients with suspected HFpEF. We will enroll patients experiencing chest symptoms (chest pain or dyspnea) with an indication of non-obstructive coronary artery disease (<50% stenosis) on coronary angiography and preserved LV ejection fraction (≥50%) on echocardiography. All patients will undergo body composition analysis and adenosine stress echocardiography with the evaluation of coronary artery blood flow and maximal oxygen consumption by cardiopulmonary exercise test. LV end-diastolic pressure will be assessed using coronary angiography. Coronary flow reserve (CFR) is defined as the ratio of the peak to the baseline mean diastolic velocity of coronary blood flow. A CFR <2.3 is defined as coronary microvascular dysfunction. The correlation of CFR and body composition with LV diastolic function and cardiopulmonary exercise capacity will be assessed. This trial will suggest the specific phenotypes of HFpEF according to body composition and CMD and the specific management of the different phenotypes of HFpEF.
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92
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Roy TK, Secomb TW. Effects of impaired microvascular flow regulation on metabolism-perfusion matching and organ function. Microcirculation 2020; 28:e12673. [PMID: 33236393 DOI: 10.1111/micc.12673] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Impaired tissue oxygen delivery is a major cause of organ damage and failure in critically ill patients, which can occur even when systemic parameters, including cardiac output and arterial hemoglobin saturation, are close to normal. This review addresses oxygen transport mechanisms at the microcirculatory scale, and how hypoxia may occur in spite of adequate convective oxygen supply. The structure of the microcirculation is intrinsically heterogeneous, with wide variations in vessel diameters and flow pathway lengths, and consequently also in blood flow rates and oxygen levels. The dynamic processes of structural adaptation and flow regulation continually adjust microvessel diameters to compensate for heterogeneity, redistributing flow according to metabolic needs to ensure adequate tissue oxygenation. A key role in flow regulation is played by conducted responses, which are generated and propagated by endothelial cells and signal upstream arterioles to dilate in response to local hypoxia. Several pathophysiological conditions can impair local flow regulation, causing hypoxia and tissue damage leading to organ failure. Therapeutic measures targeted to systemic parameters may not address or may even worsen tissue oxygenation at the microvascular level. Restoration of tissue oxygenation in critically ill patients may depend on restoration of endothelial cell function, including conducted responses.
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Affiliation(s)
- Tuhin K Roy
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy W Secomb
- Department of Physiology, University of Arizona, Tucson, AZ, 85724, USA
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93
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Ma H, Guo L, Fei H, Yin H, Wang H, Bai B, Liu Y, Wang S, Geng Q, Jiang W. Assessing mental stress on myocardial perfusion and myocardial blood flow in women without obstructive coronary disease: protocol for a mechanistic clinical trial. BMJ Open 2020; 10:e038362. [PMID: 33293388 PMCID: PMC7725072 DOI: 10.1136/bmjopen-2020-038362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Two-thirds of women with symptoms of angina have 'angina with no obstructive coronary artery disease' (ANOCA). Growing evidence supports the use of coronary artery function testing for the diagnosis of ANOCA. Research into the prevalence of mental stress-induced myocardial ischaemia (MSIMI) among women with ANOCA is lacking. MSIMI is common in clinically stable patients with coronary artery disease. It is not associated coronary stenosis but is a prognostic risk factor. Here, we describe the rationale and protocol for a mechanistic clinical trial to test the following hypotheses: (1) that MSIMI is more common in women with ANOCA women than in age-matched and sex-matched controls, and (2) MSIMI is associated with mental stress-induced myocardial blood flow (MBF) change but not with adenosine vasodilator stress-induced MBF change. METHODS AND ANALYSIS This is a mechanistic clinical trial. 84 women with confirmed ANOCA and 42 aged-matched healthy women (neither angina symptoms nor coronary stenosis) are to be recruited for mental and adenosine vasodilator stress tests. Positron emission tomography CT with ammonia N-13 will be used to evaluate the myocardial perfusion and MBF changes between stress and rest. MSIMI is defined as a summed difference score (SDS) of ≥3 and adenosine stress-induced myocardial ischaemia is defined as an SDS of ≥4. Other assessments include Reactive Hyperemia Index for microvascular endothelial function, peripheral arterial tonometry or digital vasomotor response, and a series of blood and psychometric tests. ETHICS AND DISSEMINATION This mechanistic clinical trial was approved by the Ethics Committee of Guangdong Provincial People's Hospital. Findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03982901; Pre-results.
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Affiliation(s)
- Huan Ma
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Lan Guo
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Hongwen Fei
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Han Yin
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Haochen Wang
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Bingqing Bai
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yuting Liu
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Shuxia Wang
- Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guanghzou, Guangdong, China
| | - Qingshan Geng
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Wei Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
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94
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Rahman H, Scannell CM, Demir OM, Ryan M, McConkey H, Ellis H, Masci PG, Perera D, Chiribiri A. High-Resolution Cardiac Magnetic Resonance Imaging Techniques for the Identification of Coronary Microvascular Dysfunction. JACC Cardiovasc Imaging 2020; 14:978-986. [PMID: 33248969 DOI: 10.1016/j.jcmg.2020.10.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/01/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study assessed the ability to identify coronary microvascular dysfunction (CMD) in patients with angina and nonobstructive coronary artery disease (NOCAD) using high-resolution cardiac magnetic resonance (CMR) and hypothesized that quantitative perfusion techniques would have greater accuracy than visual analysis. BACKGROUND Half of all patients with angina are found to have NOCAD, while the presence of CMD portends greater morbidity and mortality, it now represents a modifiable therapeutic target. Diagnosis currently requires invasive assessment of coronary blood flow during angiography. With greater reliance on computed tomography coronary angiography as a first-line tool to investigate angina, noninvasive tests for diagnosing CMD warrant validation. METHODS Consecutive patients with angina and NOCAD were enrolled. Intracoronary pressure and flow measurements were acquired during rest and vasodilator-mediated hyperemia. CMR (3-T) was performed and analyzed by visual and quantitative techniques, including calculation of myocardial blood flow (MBF) during hyperemia (stress MBF), transmural myocardial perfusion reserve (MPR: MBFHYPEREMIA / MBFREST), and subendocardial MPR (MPRENDO). CMD was defined dichotomously as an invasive coronary flow reserve <2.5, with CMR readers blinded to this classification. RESULTS A total of 75 patients were enrolled (57 ± 10 years of age, 81% women). Among the quantitative perfusion indices, MPRENDO and MPR had the highest accuracy (area under the curve [AUC]: 0.90 and 0.88) with high sensitivity and specificity, respectively, both superior to visual assessment (both p < 0.001). Visual assessment identified CMD with 58% accuracy (41% sensitivity and 83% specificity). Quantitative stress MBF performed similarly to visual analysis (AUC: 0.64 vs. 0.60; p = 0.69). CONCLUSIONS High-resolution CMR has good accuracy at detecting CMD but only when analyzed quantitatively. Although omission of rest imaging and stress-only protocols make for quicker scans, this is at the cost of accuracy compared with integrating rest and stress perfusion. Quantitative perfusion CMR has an increasingly important role in the management of patients frequently encountered with angina and NOCAD.
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Affiliation(s)
- Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Cian M Scannell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Ozan M Demir
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Matthew Ryan
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Hannah McConkey
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Howard Ellis
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom.
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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95
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Sinha A, Rahman H, Perera D. Ischaemia without obstructive coronary artery disease: the pathophysiology of microvascular dysfunction. Curr Opin Cardiol 2020; 35:720-725. [PMID: 32852345 DOI: 10.1097/hco.0000000000000788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Nearly one-third of patients presenting with angina have unobstructed epicardial coronary arteries and evidence of coronary microvascular disease. Up until recently, the pathophysiology of coronary microvascular disease has been poorly understood, resulting in limited effective therapeutic options in these patients. As a result, patients with coronary microvascular disease continue to suffer from a poor quality of life and adverse cardiovascular outcomes. RECENT FINDINGS Recent mechanistic studies have improved our understanding of the pathophysiology underlying coronary microvascular dysfunction; these studies have implicated the nitric oxide and endothelin pathways as the main drivers. The aim of this article is to review our current understanding of the pathophysiology of ischaemia in patients with coronary microvascular disease. SUMMARY Patients with angina who have coronary microvascular disease, but no obstructive coronary artery disease, are unable to augment their coronary blood flow in response to physiological stress, thereby predisposing them to myocardial ischaemia as a result of supply:demand mismatch in the myocardium. In addition to abnormalities of vascular resistance, perturbations in cardiac-coronary coupling also contribute to ischaemia in these patients. Although impaired flow reserve is the diagnostic hallmark, mechanistic studies have demonstrated that the underlying pathophysiology is heterogeneous. At present, two main endotypes have been identified, which can be readily differentiated on the basis of minimal microvascular resistance. A better understanding of the pathophysiology and mechanisms driving ischaemia in coronary microvascular dysfunction may stimulate the development of individualised therapies that may lead to an improvement in patients' quality of life and prognosis.
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Affiliation(s)
- Aish Sinha
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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96
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Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease. Cardiovasc Interv Ther 2020; 36:39-51. [PMID: 33108592 PMCID: PMC7829227 DOI: 10.1007/s12928-020-00720-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022]
Abstract
Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD.
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97
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Meadows JL, Shah S, Burg MM, Pfau S, Soufer R. The Foundational Role of Cardiovascular Imaging in the Characterization of Mental Stress-Induced Myocardial Ischemia in Patients with Coronary Artery Disease. Curr Cardiol Rep 2020; 22:162. [PMID: 33037938 DOI: 10.1007/s11886-020-01407-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Mental stress-provoked myocardial ischemia (MSIMI) is an ischemic phenomenon provoked by the experience of psychologically stressful circumstances. While MSIMI was initially identified 50 years ago during activities of daily living through the use of wearable Holter monitor, subsequent research utilized the technologies of cardiac imaging-ventriculography and myocardial perfusion-under controlled conditions to pursue an understanding of pathophysiology and prognosis. This work revealed that MSIMI occurs in almost half of patients with stable coronary artery disease (CAD) and is associated with cardiac events and early mortality. We provide a focused review of the instrumental role that cardiac imaging has played in elucidating how stress affects cardiac physiology and how emerging diagnostic techniques will allow for further research on stress-mediated changes in the coronary macro- and microvasculature. RECENT FINDINGS Observations about the cardiac response to mental stress diverge from underlying cornerstones of the traditional CAD paradigm which is based upon myocardial oxygen demand and the degree of epicardial coronary stenosis. Evidence from studies utilizing non-invasive and invasive studies of coronary perfusion indicates perturbations in the microvascular compartment in response to mental stress. Cardiovascular imaging enjoined with mental stress provocation may be a commanding tool to advance our understanding of non-obstructive CAD and the coronary microvasculature. This further understanding will facilitate incorporation of mental stress testing in the clinical care of patients with discrepant diagnostic work-up of CAD and in patients who experience anginal symptoms due to non-exertional and/or emotional triggers. Such algorithms will be crucial to identify treatment targets to modify the risk associated with mental stress-associated ischemia and adverse prognosis.
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Affiliation(s)
- Judith L Meadows
- Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Samit Shah
- Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Matthew M Burg
- Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Steven Pfau
- Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert Soufer
- Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA.
- VA Connecticut Healthcare System, West Haven, CT, USA.
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98
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Ford TJ, Ong P, Sechtem U, Beltrame J, Camici PG, Crea F, Kaski JC, Bairey Merz CN, Pepine CJ, Shimokawa H, Berry C. Assessment of Vascular Dysfunction in Patients Without Obstructive Coronary Artery Disease: Why, How, and When. JACC Cardiovasc Interv 2020; 13:1847-1864. [PMID: 32819476 PMCID: PMC7447977 DOI: 10.1016/j.jcin.2020.05.052] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 02/08/2023]
Abstract
Ischemic heart disease secondary to coronary vascular dysfunction causes angina and impairs quality of life and prognosis. About one-half of patients with symptoms and signs of ischemia turn out not to have obstructive coronary artery disease, and coronary vascular dysfunction may be relevant. Adjunctive tests of coronary vasomotion include guidewire-based techniques with adenosine and reactivity testing, typically by intracoronary infusion of acetylcholine. The CorMicA (Coronary Microvascular Angina) trial provided evidence that routine management guided by an interventional diagnostic procedure and stratified therapy improves angina and quality of life in patients with angina but no obstructive coronary artery disease. In this paper, the COVADIS study group provide a comprehensive review of why, how, and when coronary vascular dysfunction should be assessed invasively. They discuss the rationale through a shared understanding of vascular pathophysiology and clinical evidence. They propose a consensus approach to how an interventional diagnostic procedure is performed with focus on practical aspects. Finally, the authors discuss the clinical scenarios in patients with stable and acute coronary syndromes in which measurement of coronary vascular function may be helpful for patient care.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Faculty of Medicine, University of Newcastle, Callaghan, Australia; Department of Cardiology, Gosford Hospital, Central Coast Local Health District, Gosford, Australia
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - John Beltrame
- Basil Hetzel Institute, Central Adelaide Local Health Network, University of Adelaide, Adelaide, Australia
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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99
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Fearon WF. A link between resting flow, coronary flow reserve and adverse outcomes. Int J Cardiol 2020; 309:25-26. [PMID: 32192749 DOI: 10.1016/j.ijcard.2020.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/06/2020] [Indexed: 11/17/2022]
Affiliation(s)
- William F Fearon
- Stanford University and, the Stanford Cardiovascular Institute, Stanford, CA, USA.
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100
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Rahman H, Demir OM, Ryan M, McConkey H, Scannell C, Ellis H, Webb A, Chiribiri A, Perera D. Optimal Use of Vasodilators for Diagnosis of Microvascular Angina in the Cardiac Catheterization Laboratory. Circ Cardiovasc Interv 2020; 13:e009019. [PMID: 32519879 PMCID: PMC7299228 DOI: 10.1161/circinterventions.120.009019] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Among patients with angina and nonobstructive coronary artery disease, those with coronary microvascular dysfunction have a poor outcome. Coronary microvascular dysfunction is usually diagnosed by assessing flow reserve with an endothelium-independent vasodilator like adenosine, but the optimal diagnostic threshold is unclear. Furthermore, the incremental value of testing endothelial function has never been assessed before. We sought to determine what pharmacological thresholds correspond to exercise pathophysiology and myocardial ischemia in patients with coronary microvascular dysfunction.
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Affiliation(s)
- Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Ozan M Demir
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Matthew Ryan
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Hannah McConkey
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Cian Scannell
- School of Biomedical Engineering and Imaging Sciences (C.S., A.C.), King's College London, United Kingdom
| | - Howard Ellis
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Andrew Webb
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences (C.S., A.C.), King's College London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
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