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Keeley EC, Handberg EM, Wei J, Merz CNB, Pepine CJ. Coronary microvascular dysfunction as a chronic inflammatory state: Is there a role for omega-3 fatty acid treatment? AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100098. [PMID: 38560085 PMCID: PMC10978178 DOI: 10.1016/j.ahjo.2022.100098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/08/2022] [Indexed: 04/04/2024]
Abstract
Coronary microvascular dysfunction is a ubiquitous pathologic process that is operational in ischemia with no obstructive coronary artery disease and other cardiovascular disorders including heart failure with preserved ejection fraction. It may, in fact, be a manifestation of a multi-systemic condition of small vessel dysfunction that also affects the brain and kidneys. While the pathophysiology driving coronary microvascular dysfunction is multifactorial, chronic inflammation plays an important role. Resolution of inflammation is an active process mediated, in part, by a family of locally active mediators biosynthesized from omega-3 fatty acids, collectively referred to as specialized pro-resolving mediators. Omega-3 fatty acid treatment modulates inflammation and is associated with improved cardiovascular outcomes and attenuation of plaque progression on cardiovascular imaging. Whether omega-3 fatty acid treatment attenuates coronary microvascular dysfunction is unknown.
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Affiliation(s)
- Ellen C. Keeley
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Eileen M. Handberg
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Janet Wei
- Barbra Streisand Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
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53
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Aldiwani H, Mahdai S, Alhatemi G, Bairey Merz CN. Microvascular Angina: Diagnosis and Management. Eur Cardiol 2021; 16:e46. [PMID: 34950242 PMCID: PMC8674627 DOI: 10.15420/ecr.2021.15] [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: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 01/18/2023] Open
Abstract
Recognition of suspected ischaemia with no obstructive coronary artery disease – termed INOCA – has increased over the past decades, with a key contributor being microvascular angina. Patients with microvascular angina are at higher risk for major adverse cardiac events including MI, stroke, heart failure with preserved ejection fraction and death but to date there are no clear evidence-based guidelines for diagnosis and treatment. Recently, the Coronary Vasomotion Disorders International Study Group proposed standardised criteria for diagnosis of microvascular angina using invasive and non-invasive approaches. The management strategy for remains empirical, largely due to the lack of high-levelevidence- based guidelines and clinical trials. In this review, the authors will illustrate the updated approach to diagnosis of microvascular angina and address evidence-based pharmacological and non-pharmacological treatments for patients with the condition.
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Affiliation(s)
- Haider Aldiwani
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center Los Angeles, California, US.,Scripps Health Institution Chula Vista Hospital, Department of Internal Medicine San Diego, US
| | - Suzan Mahdai
- Scripps Health Institution Chula Vista Hospital, Department of Internal Medicine San Diego, US
| | - Ghaith Alhatemi
- St Mary Mercy Hospital, Department of Internal Medicine Livonia, Michigan, US
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center Los Angeles, California, US
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54
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Corban MT, Toya T, Albers DP, Sebaali F, Lewis B, Bois JPP, Gulati R, Prasad A, Best PJ, Bell M, Rihal C, Prasad M, Ahmad A, Lerman LO, Solseth ML, Winters JL, Dietz AB, Lerman A. IMPROvE-CED Trial: Intracoronary Autologous CD34+ Cell Therapy for Treatment of Coronary Endothelial Dysfunction in Patients With Angina and Non-Obstructive Coronary Arteries. Circ Res 2021; 130:326-338. [DOI: 10.1161/circresaha.121.319644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Coronary endothelial dysfunction (CED) causes angina/ischemia in patients with no-obstructive CAD (NOCAD). Patients with CED have decreased number and function of CD34+ cells involved in normal vascular repair with microcirculatory regenerative potential and paracrine anti-inflammatory effects. We evaluated safety and potential efficacy of intracoronary (IC) autologous CD34+ cell therapy for CED.
Methods:
Twenty NOCAD patients with invasively-diagnosed CED and persistent angina despite maximally-tolerated medical therapy (MTMT) underwent baseline exercise stress test (EST), GCSF-mediated CD34+ cell-mobilization, leukapheresis, and selective 1x105 CD34+ cells/kg infusion into LAD. Invasive CED evaluation and EST were repeated 6-months after cell infusion. Primary endpoints were safety and effect of IC autologous CD34+ cell therapy on CED at 6-months follow-up. Secondary endpoints were change in CCS angina class, as-needed sublingual nitroglycerin use/day, Seattle Angina Questionnaire (SAQ) scores, and exercise time at 6-months. Change in CED was compared to that of 51 historic-control NOCAD patients treated with MTMT alone.
Results:
Mean age was 52{plus minus}13 years, 75% women. No death, myocardial infarction, or stroke occurred. IC CD34+ cell infusion improved microvascular CED [% acetylcholine-mediated coronary blood flow increased from 7.2 (-18.0-32.4) to 57.6 (16.3-98.3) %, p=0.014], decreased CCS angina class (3.7{plus minus}0.5 to 1.7{plus minus}0.9, Wilcoxon signed-rank test p=0.00018) and sublingual nitroglycerin use/day [1 (0.4-3.5) to 0 (0-1), Wilcoxon signed-rank test p=0.00047], and improved all SAQ scores with no significant change in exercise time at 6-months follow-up. Historic-control patients had no significant change in CED.
Conclusion:
A single IC autologous CD34+ cell infusion was safe and may potentially be an effective disease-modifying therapy for microvascular CED in humans. Clinical Trial Registration: NCT03471611
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Affiliation(s)
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, JAPAN
| | | | | | | | | | - Rajiv Gulati
- Cardiovascular Diseases, Mayo Clinic, UNITED STATES
| | | | | | - Malcolm Bell
- Cardiovascular Medicine, Mayo Clinic, UNITED STATES
| | - Charanjit Rihal
- Division of Cardiovascular Diseases, Mayo Clinic, UNITED STATES
| | - Megha Prasad
- Columbia University Medical Center, UNITED STATES
| | | | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, UNITED STATES
| | | | | | - Allan B Dietz
- Lab Medicine and Patholgy, Mayo Clinic, UNITED STATES
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, UNITED STATES
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55
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Abouelnour A, Gori T. Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies. Biomedicines 2021; 9:biomedicines9121774. [PMID: 34944590 PMCID: PMC8698648 DOI: 10.3390/biomedicines9121774] [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] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.
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Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Cardiovascular Institute, Assiut University, Assiut 71515, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Correspondence:
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56
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Affiliation(s)
- Ranil de Silva
- National Heart and Lung Institute, Imperial College London, Royal Brompton and Harefield NHS Trust, London, UK
| | - Kevin Cheng
- National Heart and Lung Institute, Imperial College London, Royal Brompton and Harefield NHS Trust, London, UK
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57
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Wang M, Shan Y, Sun W, Han J, Tong H, Fan M, Chen J, Yu P, Shen L, Chen X. Effects of Shexiang Baoxin Pill for Coronary Microvascular Function: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:751050. [PMID: 34795585 PMCID: PMC8592925 DOI: 10.3389/fphar.2021.751050] [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: 07/31/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022] Open
Abstract
Background: The coronary microvascular dysfunction has attracted more and more attention in recent years, but there is still a lack of effective treatment. Shexiang Baoxin Pill is one of the commonly used drugs for the treatment of coronary artery disease in China. More recently, some studies found that it has the effect of improving coronary microvascular function. Objective: To evaluate the effects of Shexiang Baoxin Pill for coronary microvascular function. Methods: Databases including MEDLINE, Web of Science, CNKI, Wanfang, The Cochrane Library, EMbase, VIP and CBM were searched from inception to June 2021 to screen out relevant clinical studies. The 2019 version 2 of the Cochrane risk of bias tool (RoB2) were used to assess the methodological quality of the included studies. RevMan 5.3 software was used for meta-analysis. Results: Eleven studies meeting the criteria were included, with a total of 1,075 patients. The results of meta-analysis showed that compared with conventional treatment alone, combination of Shexiang Baoxin Pill and conventional treatment can further increase the coronary flow reserve (CFR) [mean difference (MD) = 0.43, 95%CI (0.28, 0.58), p < 0.000 01], decrease the index of microvascular resistance (IMR) [MD = -4.23, 95%CI (-5.49, -2.97), p < 0.000 01], increase serum nitric oxide (NO) [MD = 11.96, 95%CI (2.74, 21.18), p = 0.001] and decrease serum hypersensitive C-reactive protein (hs-CRP) [MD = -2.49, 95%CI (-3.08, -1.90), p < 0.000 01], but did not increase the time of duration on the exercise testing (TET) [MD = 3.64, 95%CI (-1.17, 8.45), p = 0.14]. In terms of safety, a total of 10 patients developed adverse reactions in the intervention group and 17 patients developed adverse reactions in the control group. Conclusion: Current evidence suggests that Shexiang Baoxin Pill may be effective in the improvement of coronary microvascular function when used in combination with conventional treatment. However, due to the low quality of the included studies, lack of placebo control and high heterogeneity among different studies, we should take a cautious attitude towards this conclusion. Moreover, the safety of Shexiang Baoxin Pill remains uncertain, more high-quality clinical studies are needed to verify the efficacy and safety of this drug in the future. Systematic Review Registration: [website], identifier [registration number: CRD42021265113].
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Affiliation(s)
- Mengxi Wang
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yiwen Shan
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Weixin Sun
- Department of Cardiology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Jie Han
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Huaqin Tong
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Manlu Fan
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jiandong Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Peng Yu
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Le Shen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Xiaohu Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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58
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Srinivasa S, Thomas TS, Feldpausch MN, Adler GK, Grinspoon SK. Coronary Vasculature and Myocardial Structure in HIV: Physiologic Insights From the Renin-Angiotensin-Aldosterone System. J Clin Endocrinol Metab 2021; 106:3398-3412. [PMID: 33624807 PMCID: PMC8864747 DOI: 10.1210/clinem/dgab112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Indexed: 11/19/2022]
Abstract
The landscape of HIV medicine dramatically changed with the advent of contemporary antiretroviral therapies, which has allowed persons with HIV (PWH) to achieve good virologic control, essentially eliminating HIV-related complications and increasing life expectancy. As PWH are living longer, noncommunicable diseases, such as cardiovascular disease (CVD), have become a leading cause of morbidity and mortality in PWH with rates that are 50% to 100% higher than in well-matched persons without HIV. In this review, we focus on disease of the coronary microvasculature and myocardium in HIV. We highlight a key hormonal system important to cardiovascular endocrinology, the renin-angiotensin-aldosterone system (RAAS), as a potential mediator of inflammatory driven-vascular and myocardial injury and consider RAAS blockade as a physiologically targeted strategy to reduce CVD in HIV.
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Affiliation(s)
- Suman Srinivasa
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Teressa S Thomas
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Meghan N Feldpausch
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gail K Adler
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Steven K Grinspoon
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Steven K. Grinspoon, MD, Metabolism Unit, Massachusetts General Hospital, 55 Fruit Street, 5LON207, Boston, MA 02114, USA. E-mail:
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59
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Gutiérrez E, Gómez-Lara J, Moreno R. Importancia de la ateromatosis no obstructiva en pacientes con infarto agudo. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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60
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Gutiérrez E, Gómez-Lara J, Moreno R. Importance of nonobstructive atheromatosis in patients with acute myocardial infarction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:901-904. [PMID: 34289948 DOI: 10.1016/j.rec.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/06/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Enrique Gutiérrez
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Josep Gómez-Lara
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raúl Moreno
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
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61
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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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62
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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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63
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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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64
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Xie J, Yang Y, Wang L, Pan Y, Zhang R, Qu Y, Li R, Wen W, Wu Y, Li J, Ma X. Prognostic value of coronary flow velocity reserve in patients with homozygous familial hypercholesterolemia. Echocardiography 2021; 38:1489-1495. [PMID: 34448504 DOI: 10.1111/echo.15147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 06/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Coronary flow velocity reserve (CFVR) can provide useful quantitative information on the functional status of coronary artery circulation, and an impaired CFVR (< 2.0) was associated with a significant increase in the occurrence of cardiac events. Coronary artery disease (CAD) is the leading cause of death in homozygous familial hypercholesterolemia (HoFH), but the relationship between impaired CFVR and outcome in HoFH has never been discussed before METHODS: To explore the long-term prognostic value of CFVR in patients with HoFH, 39 HoFH patients with CFVR data (mean age with 16.7 years) were enrolled from the Genetic and Imaging of Familial Hypercholesterolemia in Han Nationality Study. All patients were divided into impaired CFVR (CFVR < 2.0, n = 17) and preserved CFVR (CFVR≥2.0, n = 22) group. Follow-up was performed until a major adverse cardiac event (MACE) occurred or up to June 30, 2020 RESULTS: During a median follow-up of 89 months, 16 events were registered, 12 of which were occurred in the impaired CFVR group and four occurred in the preserved CFVR group. The event-free survival rate of impaired CFVR group was significantly lower than that in the preserved CFVR group (29.4% vs 81.8%, P < .001), and CFVR < 2.0 was independently associated with prognosis before and after adjustment for related risk factors (HR 5.197, 95% CI 1.669 to 16.178, P = .004 and HR 5.488, 95% CI 1.470 to 20.496, P = .011, respectively) CONCLUSIONS: an impaired CFVR predicts a worse outcome in HoFH. CFVR shows an independent value in the prediction of long-term outcome in HoFH.
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Affiliation(s)
- Jinjie Xie
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China.,Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ya Yang
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luya Wang
- Department of Atherosclerosis, The Key Laboratory of Remodeling-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Diseases, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yufan Pan
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China.,Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruiying Zhang
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China.,Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yichen Qu
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China.,Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rongjuan Li
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China
| | - Wenhui Wen
- Department of Atherosclerosis, The Key Laboratory of Remodeling-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Diseases, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yue Wu
- Department of Atherosclerosis, The Key Laboratory of Remodeling-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Diseases, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jialu Li
- Department of Atherosclerosis, The Key Laboratory of Remodeling-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Diseases, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohai Ma
- Department of Imaging Medicine and Nuclear Medicine, Capital Medical University, Beijing, China.,Department of Interventional Diagnosis and Treatment, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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65
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Korsiak J, Perepeluk KL, Peterson NG, Kulka R, Weichenthal S. Air pollution and retinal vessel diameter and blood pressure in school-aged children in a region impacted by residential biomass burning. Sci Rep 2021; 11:12790. [PMID: 34140605 PMCID: PMC8211781 DOI: 10.1038/s41598-021-92269-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/07/2021] [Indexed: 11/08/2022] Open
Abstract
Little is known about the early-life cardiovascular health impacts of fine particulate air pollution (PM2.5) and oxidant gases. A repeated-measures panel study was used to evaluate associations between outdoor PM2.5 and the combined oxidant capacity of O3 and NO2 (using a redox-weighted average, Ox) and retinal vessel diameter and blood pressure in children living in a region impacted by residential biomass burning. A median of 6 retinal vessel and blood pressure measurements were collected from 64 children (ages 4-12 years), for a total of 344 retinal measurements and 432 blood pressure measurements. Linear mixed-effect models were used to estimate associations between PM2.5 or Ox (same-day, 3-day, 7-day, and 21-day means) and retinal vessel diameter and blood pressure. Interactions between PM2.5 and Ox were also examined. Ox was inversely associated with retinal arteriolar diameter; the strongest association was observed for 7-day mean exposures, where each 10 ppb increase in Ox was associated with a 2.63 μm (95% CI - 4.63, - 0.63) decrease in arteriolar diameter. Moreover, Ox modified associations between PM2.5 and arteriolar diameter, with weak inverse associations observed between PM2.5 and arteriolar diameter only at higher concentrations of Ox. Our results suggest that outdoor air pollution impacts the retinal microvasculature of children and interactions between PM2.5 and Ox may play an important role in determining the magnitude and direction of these associations.
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Affiliation(s)
- Jill Korsiak
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1100 Pine Avenue West, Montreal, QC, H3A 1A3, Canada
| | - Kay-Lynne Perepeluk
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1100 Pine Avenue West, Montreal, QC, H3A 1A3, Canada
| | - Nicholas G Peterson
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1100 Pine Avenue West, Montreal, QC, H3A 1A3, Canada
| | - Ryan Kulka
- Air Health Science Division, Health Canada, 269 Laurier Ave West, Ottawa, ON, K1A 0K9, Canada
| | - Scott Weichenthal
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1100 Pine Avenue West, Montreal, QC, H3A 1A3, Canada.
- Air Health Science Division, Health Canada, 269 Laurier Ave West, Ottawa, ON, K1A 0K9, Canada.
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66
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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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67
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Florian A. Diastolic dysfunction in women with ischemia and non-obstructive coronary arteries (INOCA) - Could non-invasive imaging reveal the missing piece of the puzzle? Int J Cardiol 2021; 334:21-23. [PMID: 33872656 DOI: 10.1016/j.ijcard.2021.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Anca Florian
- Department of Cardiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany.
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68
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Olesen KKW, Madsen M, Gyldenkerne C, Thrane PG, Thim T, Jensen LO, Bøtker HE, Sørensen HT, Maeng M. Ten-year cardiovascular risk in diabetes patients without obstructive coronary artery disease: a retrospective Western Denmark cohort study. Cardiovasc Diabetol 2021; 20:23. [PMID: 33478504 PMCID: PMC7819163 DOI: 10.1186/s12933-021-01212-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Diabetes patients without obstructive coronary artery disease as assessed by coronary angiography have a low risk of myocardial infarction, but their myocardial infarction risk may still be higher than the general population. We examined the 10-year risks of myocardial infarction, ischemic stroke, and death in diabetes patients without obstructive coronary artery disease according to coronary angiography, compared to risks in a matched general population cohort. METHODS We included all diabetes patients without obstructive coronary artery disease examined by coronary angiography from 2003 to 2016 in Western Denmark. Patients were matched by age and sex with a cohort from the Western Denmark general population without a previous myocardial infarction or coronary revascularization. Outcomes were myocardial infarction, ischemic stroke, and death. Ten-year cumulative incidences were computed. Adjusted hazard ratios (HR) then were computed using stratified Cox regression with the general population as reference. RESULTS We identified 5734 diabetes patients without obstructive coronary artery disease and 28,670 matched individuals from the general population. Median follow-up was 7 years. Diabetes patients without obstructive coronary artery disease had an almost similar 10-year risk of myocardial infarction (3.2% vs 2.9%, adjusted HR 0.93, 95% CI 0.72-1.20) compared to the general population, but had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.87, 95% CI 1.47-2.38) and death (29.6% vs 17.8%, adjusted HR 1.24, 95% CI 1.13-1.36). CONCLUSIONS Patients with diabetes and no obstructive coronary artery disease have a 10-year risk of myocardial infarction that is similar to that found in the general population. However, they still remain at increased risk of ischemic stroke and death.
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Affiliation(s)
- Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N, 8200, Denmark. .,Department of Cardiology, Viborg Regional Hospital, Heibergs Allé 4A, Viborg, 8800, Denmark.
| | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N, 8200, Denmark
| | - Christine Gyldenkerne
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Pernille Gro Thrane
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lisette Okkels Jensen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, Odense, 5000, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N, 8200, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Mosarla RC, Wood M. The Impact of Depression and Anxiety on Cardiovascular Disease Risk and Outcomes in Women. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00889-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Gdowski MA, Murthy VL, Doering M, Monroy-Gonzalez AG, Slart R, Brown DL. Association of Isolated Coronary Microvascular Dysfunction With Mortality and Major Adverse Cardiac Events: A Systematic Review and Meta-Analysis of Aggregate Data. J Am Heart Assoc 2020; 9:e014954. [PMID: 32345133 PMCID: PMC7428565 DOI: 10.1161/jaha.119.014954] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The impact of coronary microvascular dysfunction (CMD), as diagnosed by reduced coronary flow reserve, on the outcomes of patients with symptoms of myocardial ischemia and nonobstructive coronary artery disease is poorly understood. We performed a systematic review and meta-analysis of observational studies to determine the association of CMD with outcomes. Methods and Results We searched online databases for studies where coronary flow reserve was measured invasively or noninvasively, clinical events were recorded after determination of coronary flow reserve, and the frequency of those events was reported for patients with and without CMD. The primary outcome was all-cause mortality. The secondary outcome was major adverse cardiac events, including cardiac or cardiovascular death, nonfatal myocardial infarction, cardiac hospitalization, or coronary revascularization. Estimates of effect were calculated from crude event rates with a random-effects model. There were 122 deaths in the 4661 patients without CMD (2.6%) and 183 deaths in the 1970 patients with CMD (9.3%). The odds ratio for mortality in patients with CMD compared with those without CMD was 3.93 (95% CI, 2.91-5.30; P<0.001). There were 167 major adverse cardiac events in the 3742 patients without CMD (4.5%) and 245 events in the 1447 patients with CMD (16.9%). The odds ratio for major adverse cardiac events in patients with CMD compared with those without CMD was 5.16 (95% CI, 2.81-9.47; P<0.001). Conclusions CMD is associated with a nearly 4-fold increase in mortality and a 5-fold increase in major adverse cardiac events. Future studies are needed to identify effective strategies to diagnose and treat CMD.
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Affiliation(s)
- Mark A Gdowski
- Cardiovascular Division Washington University School of Medicine St. Louis MO.,Washington University School of Medicine St. Louis MO
| | | | | | - Andrea G Monroy-Gonzalez
- Medical Imaging Center Departments of Nuclear Medicine and Molecular Imaging and Radiology University of Groningen University Medical Center Groningen the Netherlands
| | - Riemer Slart
- Medical Imaging Center Departments of Nuclear Medicine and Molecular Imaging and Radiology University of Groningen University Medical Center Groningen the Netherlands.,TechMed Centre Department of Biomedical Photonic Imaging University of Twente Enschede the Netherlands
| | - David L Brown
- Cardiovascular Division Washington University School of Medicine St. Louis MO.,Washington University School of Medicine St. Louis MO
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