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Tada A, Doi S, Harada T, Ibe T, Naser JA, Amdahl M, Reddy YNV, Borlaug BA. Autoimmune Disorders in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2024; 12:1257-1269. [PMID: 38819353 DOI: 10.1016/j.jchf.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Inflammation plays a fundamental role in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). In most patients, inflammation develops secondary to cardiometabolic comorbidities, but in some, HFpEF develops in the setting of an underlying systemic inflammatory disease such as rheumatoid arthritis or systemic lupus erythematosus. OBJECTIVES This study aimed to investigate the prevalence, pathophysiology, and outcome of patients with HFpEF and autoimmune or primary inflammatory disorders. METHODS Of 982 consecutively evaluated patients with HFpEF diagnosed, 79 (8.0%) had autoimmune disorders. HFpEF was defined by invasive cardiopulmonary hemodynamic exercise testing. RESULTS Female sex, higher heart rate, lower hemoglobin, absence of atrial fibrillation, and absence of coronary artery disease were independently associated with autoimmune disorders. Hemodynamics at rest and exercise did not differ between the groups, but peripheral oxygen extraction was lower in those with autoimmune disorders, reflected by lower arterial-venous oxygen content difference at rest (4.2 ± 0.7 mL/dL vs 4.6 ± 1.0 mL/dL; P < 0.001) and during exercise (9.3 ± 2.2 mL/dL vs 10.4 ± 2.2 mL/dL; P < 0.001), suggesting a greater peripheral deficit, and ventilatory efficiency (VE/VCo2 slope, regression slope relating minute ventilation to carbon dioxide output) was also more impaired (38.0 ± 7.9 vs 36.2 ± 7.3; P = 0.043). Patients with autoimmune disorders had a higher risk of death or heart failure (HF) hospitalization compared with those without in adjusted analyses (HR: 1.95 [95% CI: 1.17-3.27]; P = 0.011) over a median follow-up of 3.0 years, which was primarily attributable to higher risk of HF hospitalization (HR: 2.87 [95% CI: 1.09-7.57]; P = 0.033). CONCLUSIONS Patients with HFpEF and autoimmune disorders have similar hemodynamic derangements but greater peripheral deficits in oxygen transport and higher risk for adverse outcome compared with those without.
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Affiliation(s)
- Atsushi Tada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shunichi Doi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tatsuro Ibe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Amdahl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Hagiwara AM, Montano E, Tumurkhuu G, Bose M, Bernardo M, Berman DS, Wiens GC, Nelson MD, Wallace DJ, Wei J, Ishimori M, Bairey Merz CN, Jefferies C. Reduced Left Ventricular Function on Cardiac MRI in SLE Patients Correlates with Measures of SLE Disease Activity and Inflammation. JOURNAL OF RADIOLOGY AND CLINICAL IMAGING 2023; 6:197-207. [PMID: 38505536 PMCID: PMC10949413 DOI: 10.26502/jrci.2809088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Background Women with SLE have an elevated risk of CVD morbidity and mortality and frequently report chest pain in the absence of obstructive CAD. Echocardiographic studies often demonstrate reduced LV function, correlating with higher disease activity. We used cardiac MRI (cMRI) to investigate the relationship between SLE, related inflammatory biomarkers and cardiac function in female SLE patients. Methods Women with SLE reporting chest pain with no obstructive CAD (n=13) and reference controls (n=22) were evaluated using stress-rest cMRI to measure LV structure, function, tissue characteristics, and myocardial perfusion reserve index (MPRI). Coronary microvascular dysfunction (CMD) was defined as MPRI <1.84. Serum samples were analyzed for inflammatory markers. Relationships between clinical and cMRI values of SLE subjects were assessed, and groups were compared. Results 40% of SLE subjects had MPRI < 1.84 on cMRI. Compared to controls, SLE subjects had higher LV volumes and mass and lower LV systolic function. SLICC DI was related to worse cardiac function and higher T1. CRP was related to higher cardiac output and a trend to better systolic function, while ESR and fasting insulin were related to lower LV mass. Lower fasting insulin levels correlated with increased ECV. Conclusions Among our female SLE cohort, 40% had CMD, and SLICC DI correlated with worse cardiac function and diffuse fibrosis. Higher inflammatory markers and low insulin levels may associate with LV dysfunction. Our findings underline the potential of non-invasive cMRI as a tool for monitoring cardiovascular function in SLE patients.
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Affiliation(s)
- Audrey M Hagiwara
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Erica Montano
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gantseg Tumurkhuu
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Moumita Bose
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marianne Bernardo
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center
- Department of Cardiology, Cedars-Sinai Medical Center
| | - Galen Cook Wiens
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Michael D Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Texas, USA
| | - Daniel J Wallace
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - Janet Wei
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Mariko Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - C Noel Bairey Merz
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Caroline Jefferies
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Tobin R, Patel N, Tobb K, Weber B, Mehta PK, Isiadinso I. Atherosclerosis in Systemic Lupus Erythematosus. Curr Atheroscler Rep 2023; 25:819-827. [PMID: 37768411 DOI: 10.1007/s11883-023-01149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE OF THE REVIEW Systemic lupus erythematosus (SLE) patients are at increased risk of cardiovascular disease (CVD) compared to the general population, despite most patients being young females, who are not classically considered to be at high risk for cardiovascular disease using traditional risk assessment tools. The purpose of this review is to discuss the pathophysiology of atherosclerosis in SLE and raise awareness of the relationship between SLE and CVD. RECENT FINDINGS The increased risk of CVD in SLE patients is multifactorial, due to proatherogenic lipid profiles, immune dysregulation and inflammation, side effects of lupus treatment, and microvascular dysfunction. Conventional CV risk models often underperform in the identification of SLE patients at high risk of atherosclerosis. The use of non-invasive imaging serves as a strategy to identify patients with evidence of subclinical CVD and in the evaluation of symptomatic patients. Identification of subclinical atherosclerosis allows for aggressive management of CV risk factors. SLE patients experience an increased risk of atherosclerotic CVD, which is not solely explained by traditional CV risk factors. It is imperative that clinicians are aware of this association to implement prompt detection and treatment of atherosclerotic CVD in SLE patients.
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Affiliation(s)
- Rachel Tobin
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Nidhi Patel
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kardie Tobb
- Cone Health Medical Group, Greensboro, NC, USA
| | - Brittany Weber
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Puja K Mehta
- Division of Cardiology, Department of Medicine, Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, USA
| | - Ijeoma Isiadinso
- Division of Cardiology, Department of Medicine, Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, USA
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Hagiwara AM, Montano E, Tumurkhuu G, Bose M, Bernardo M, Berman DS, Wiens GC, Nelson MD, Wallace D, Wei J, Ishimori M, Merz CNB, Jefferies C. Reduced left ventricular function on cardiac MRI of SLE patients correlates with measures of disease activity and inflammation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.24.23294127. [PMID: 37662185 PMCID: PMC10473799 DOI: 10.1101/2023.08.24.23294127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background Women with SLE have an elevated risk of cardiovascular disease. Many women with SLE frequently report chest pain in the absence of obstructive coronary artery disease (CAD) due to coronary microvascular dysfunction (CMD), a form of ischemia with no obstructive CAD. Echocardiographic studies have shown that SLE patients have reduced left ventricular (LV) function, which may also correlate with higher SLE disease activity scores. As such, we used cardiac magnetic resonance imaging (cMRI) to investigate the relationship between SLE, related inflammatory biomarkers, and cardiac function in female SLE patients. Methods We performed stress cMRI in women with SLE and chest pain with no obstructive CAD (n=13, all met ACR 1997 criteria,) and reference controls (n=22) using our published protocol. We evaluated LV function, tissue characterization (T1 mapping, ECV), and delayed enhancement, using CV142 software (Circle Cardiovascular Imaging Inc, Calgary, AB, Canada). Myocardial perfusion reserve index (MPRI) was calculated using our published protocol. SLEDAI and SLICC Damage Index (DI) were calculated per validated criteria. Serum samples were analyzed for inflammatory markers and autoantibodies. Wilcoxon rank-sum test was performed on clinical values with CMD and no CMD SLE subjects, and on cMRI values with all SLE subjects and controls. Correlation analysis was done on clinical values, and cMRI values on all SLE subjects. Results Overall, 40% of SLE subjects had MPRI values < 1.84, consistent with CMD. Compared to controls, SLE subjects had significantly lower LVEF, and higher LVESVi and LVMi. Corresponding to this, radial, longitudinal, and circumferential strain were significantly lower in the SLE subjects. In correlation analysis of serum inflammatory biomarkers to cMRI values in the SLE subjects, SLICC DI was related to worse cardiac function (lower radial, circumferential and longitudinal strain) and higher T1 time. Additionally, fasting insulin and ESR were negatively correlated with LVMi. Fasting insulin also negatively correlated with ECV. CRP had a positive association with LVESV index and CI and a negative association with longitudinal strain. Conclusions Among women with SLE with chest pain and no obstructive CAD, 40% have CMD. While evaluations of known inflammatory markers (such as CRP and ESR) predictably correlated with decreased cardiac function, our study found that decreased fasting insulin levels as a novel marker of diminished LV function. In addition, low insulin levels were observed to correlate with increased LVMi and ECV, suggesting a cardioprotective effect of insulin in SLE patients. We also noted that SLICC DI, an assessment of SLE damage, correlates with cardiac dysfunction in SLE. Our findings underline the potential of non-invasive cMRI as a tool for monitoring cardiovascular function in SLE, particularly in patients with high SLICC DI, ESR and CRP and low fasting insulin levels.
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Affiliation(s)
- Audrey M. Hagiwara
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Erica Montano
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gantseg Tumurkhuu
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Moumita Bose
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marianne Bernardo
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S. Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center
- Department of Cardiology, Cedars-Sinai Medical Center
| | - Galen Cook Wiens
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Michael D. Nelson
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Texas, USA
| | - Daniel Wallace
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - Janet Wei
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Mariko Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - C. Noel Bairey Merz
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Caroline Jefferies
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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He W, Li J, Zhang P, Wan M, Xie P, Liang L, Liu D. Non-invasive left ventricular myocardial work identifies subclinical myocardial involvement in patients with systemic lupus erythematosus. Int J Cardiol 2023; 381:145-152. [PMID: 37028712 DOI: 10.1016/j.ijcard.2023.04.004] [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] [Received: 01/31/2023] [Revised: 03/16/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Global myocardial work (MW) is a novel indicator that accounts for deformation and afterload, which may provide additional value for assessment of myocardial function. Non-invasive echocardiographic estimated left ventricular (LV) MW incorporates longitudinal strain curves and blood pressure data. This study sought to assess MW in systemic lupus erythematosus (SLE) patients with normal LV ejection fraction (LVEF) by two-dimensional speckle-tracking imaging (2D-STI) to reflect subclinical myocardial damage. METHODS 98 SLE patients and 98 gender and age-matched healthy subjects were included. The patients with SLE were divided into mild activity (SLE disease activity index (SLEDAI) ≤ 4; n = 45), moderate activity (5 ≤ SLEDAI≤9; n = 23), and high activity (SLEDAI≥10; n = 30) subgroups. Standard transthoracic echocardiography was applied to evaluate the systolic myocardial function of the global LV. The parameters of non-invasive MW including global wasted work (GWW) and global work efficiency (GWE) were calculated from echocardiographic LV pressure-strain loops (PSL) and blood pressure at rest. RESULTS The SLE group had a significantly higher GWW (75.7 ± 39.1 mmHg% vs 37.9 ± 18.0 mmHg%, P < 0.001) and decreased GWE ratio (95.5 ± 2.0% vs 97.4 ± 1.0%, P < 0.001) compared with the controls. Among the subgroups with elevating level of disease activity, SLE patients with preserved LVEF had a significantly higher GWW (61.6 ± 29.9 mmHg% to 96.2 ± 42.2 mmHg%, P for trend = 0.001) and markedly decreased GWE (96.4 ± 1.5% to 94.4 ± 2.0%, P for trend = 0.001). In two separate multiple linear regression analyses, SLEDAI were independently associated with GWW (β = 0.271, P = 0.005) and GWE (β = -0.354, P<0.001). CONCLUSION GWW and GWE are promising novel tools for the early detection of subclinical LV dysfunction. GWW and GWE could distinguish distinct patterns in different grades of SLEDAI.
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Affiliation(s)
- Wei He
- Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Li
- Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pengyuan Zhang
- Department of Endocrinology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Minjie Wan
- Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peihan Xie
- Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liuqin Liang
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Donghong Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Kawano H, Umeda M, Okano S, Kudo T. Chest pain and Raynaud's phenomenon after COVID-19 vaccination in a patient previously diagnosed with systemic lupus erythematosus: a case report. Eur Heart J Case Rep 2023; 7:ytad102. [PMID: 36909840 PMCID: PMC10004643 DOI: 10.1093/ehjcr/ytad102] [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: 05/02/2022] [Revised: 08/02/2022] [Accepted: 02/22/2023] [Indexed: 03/12/2023]
Abstract
Background Cardiovascular events, including pericarditis, myocarditis, and myocardial ischaemia, have been reported as complications following COVID-19 vaccination. Case summary A 28-year-old Japanese woman diagnosed 10 years earlier with systemic lupus erythematosus and antiphospholipid syndrome was admitted to our hospital because of chest pain and Raynaud's phenomenon. She had received a second dose of the COVID-19 BNT162b2 mRNA vaccine 28 days earlier. 123I-β-methyl iodophenyl pentadecanoic acid (BMIPP) and 201thallium dual myocardial single-photon emission computed tomography demonstrated mildly reduced perfusion of BMIPP in the mid-anterior wall of the left ventricle. Coronary angiography revealed normal coronary arteries; additionally, an endomyocardial biopsy was performed. Histopathological evaluation revealed a normal myocardium without cell infiltration. However, immunostaining for the severe acute respiratory coronavirus (SARS-CoV)/severe acute respiratory coronavirus 2 (SARS-CoV-2) spike protein was positive in the small intramural coronary arteries. The administration of azathioprine (50 mg/day) and amlodipine (5 mg/day) and increases in her prednisolone (10 mg/day) and aspirin doses led to improvements in the symptoms of the patient. Discussion Our data lead us to speculate that two events in the timeline of the patient, namely, receiving COVID-19 vaccination and the presence of SARS-CoV/SARS-CoV-2 spike protein in small intramural coronary arteries, may be related to the myocardial microangiopathy observed in this patient.
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Affiliation(s)
- Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masataka Umeda
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shinji Okano
- Department of Pathology, Nagasaki University Hospital, Nagasaki, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takashi Kudo
- Department of Radioisotope Medicine, Atomic Bomb Disease Institute, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
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Yamamoto T, Matsushita S, Endo D, Shimada A, Dohi S, Kajimoto K, Yokoyama Y, Sato Y, Machida Y, Asai T, Amano A. Management of cardiovascular surgery in patients with systemic lupus erythematosus including thromboembolism and multiple organ failure prevention: A retrospective observational study. Medicine (Baltimore) 2023; 102:e32979. [PMID: 36800570 PMCID: PMC9936021 DOI: 10.1097/md.0000000000032979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery.
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Affiliation(s)
- Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
- * Correspondence: Taira Yamamoto, Department of Cardiovascular Surgery, Juntendo University Nerima Hospital, 3-1-10 Koyadai, Nerima-ku, Tokyo 177-8521, Japan (e-mail: )
| | | | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Shizuyuki Dohi
- Department of Cardiovascular Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Kan Kajimoto
- Department of Cardiovascular Surgery, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Yasutaka Yokoyama
- Department of Cardiovascular Surgery, Toda Chuo Hospital, Saitama, Japan
| | - Yuichiro Sato
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Yoichiro Machida
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
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Zhou W, Sin J, Yan AT, Wang H, Lu J, Li Y, Kim P, Patel AR, Ng MY. Qualitative and Quantitative Stress Perfusion Cardiac Magnetic Resonance in Clinical Practice: A Comprehensive Review. Diagnostics (Basel) 2023; 13:diagnostics13030524. [PMID: 36766629 PMCID: PMC9914769 DOI: 10.3390/diagnostics13030524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Stress cardiovascular magnetic resonance (CMR) imaging is a well-validated non-invasive stress test to diagnose significant coronary artery disease (CAD), with higher diagnostic accuracy than other common functional imaging modalities. One-stop assessment of myocardial ischemia, cardiac function, and myocardial viability qualitatively and quantitatively has been proven to be a cost-effective method in clinical practice for CAD evaluation. Beyond diagnosis, stress CMR also provides prognostic information and guides coronary revascularisation. In addition to CAD, there is a large body of literature demonstrating CMR's diagnostic performance and prognostic value in other common cardiovascular diseases (CVDs), especially coronary microvascular dysfunction (CMD). This review focuses on the clinical applications of stress CMR, including stress CMR scanning methods, practical interpretation of stress CMR images, and clinical utility of stress CMR in a setting of CVDs with possible myocardial ischemia.
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Affiliation(s)
- Wenli Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Jason Sin
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong SAR, China
| | - Andrew T. Yan
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| | | | - Jing Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Paul Kim
- Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Amit R. Patel
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ming-Yen Ng
- Department of Medical Imaging, HKU-Shenzhen Hospital, Shenzhen 518009, China
- Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Correspondence:
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Cabling MG, Sandhu VK, Downey CD, Torralba KD. Cardiovascular disease and bone health in aging female rheumatic disease populations: A review. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231155286. [PMID: 36825447 PMCID: PMC9969471 DOI: 10.1177/17455057231155286] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Rheumatic diseases cover a wide spectrum of conditions, including primary and secondary degenerative joint diseases and autoimmune inflammatory rheumatic diseases. The risks of cardiovascular disease and osteoporosis and resultant fractures in aging female rheumatic disease populations, especially those with autoimmune rheumatic diseases, are increased. Changes in the immune system in aging populations need to be considered especially among patients with autoimmune rheumatic diseases. Immunosenescence is closely aligned to reduced adaptive immunity and increased non-specific innate immunity leading to chronic inflammation of inflammaging. The effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis. Rheumatic diseases, which largely manifest as arthritis, predispose patients to premature joint degeneration and poor bone health and therefore have a higher risk of developing end-stage arthritis requiring joint arthroplasties sooner or more often than other patients without rheumatic disease.
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Affiliation(s)
- Marven G Cabling
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Vaneet K Sandhu
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Christina D Downey
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Karina D Torralba
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Prakash RO, Chakrala TS, Feuer DS, Valdes CA, Pepine CJ, Keeley EC. Critical role of the coronary microvasculature in heart disease: From pathologic driving force to "innocent" bystander. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100215. [PMID: 38558907 PMCID: PMC10978433 DOI: 10.1016/j.ahjo.2022.100215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 04/04/2024]
Abstract
The coronary microvasculature is responsible for providing oxygen and nutrients to myocardial tissue. A healthy microvasculature with an intact and properly functioning endothelium accomplishes this by seemless changes in vascular tone to match supply and demand. Perturbations in the normal physiology of the microvasculature, including endothelial and/or vascular smooth muscle dysfunction, result in impaired function (vasoconstriction, antithrombotic, etc.) and structural (hypertrophic, fibrotic) abnormalities that lead to microvascular ischemia and potential organ damage. While coronary microvascular dysfunction (CMD) is the primary pathologic driving force in ischemia with non-obstructive coronary artery disease (INOCA), angina with no obstructive coronary arteries (ANOCA), and myocardial infarction with non-obstructed coronary arteries (MINOCA), it may be a bystander in many cardiac disorders which later become pathologically associated with signs and/or symptoms of myocardial ischemia. Importantly, regardless of the primary or secondary basis of CMD in the heart, it is associated with important increases in morbidity and mortality. In this review we discuss salient features pertaining to known pathophysiologic mechanisms driving CMD, the spectrum of heart diseases where it places a critical role, invasive and non-invasive diagnostic testing, management strategies, and the gaps in knowledge where future research efforts are needed.
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Affiliation(s)
- Roshni O. Prakash
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Teja S. Chakrala
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Daniel S. Feuer
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carlos A. Valdes
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carl J. Pepine
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ellen C. Keeley
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
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11
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Wan M, Liu D, Zhang P, Xie P, Liang L, He W. Postsystolic shortening and early systolic lengthening for early detection of myocardial involvement in patients with systemic lupus erythematosus. Echocardiography 2022; 39:1284-1290. [PMID: 36074004 DOI: 10.1111/echo.15442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/29/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiac involvement predicts a poor prognosis in patients with systemic lupus erythematosus (SLE). Two-dimensional speckle-tracking echocardiography (2D-STE) are used to identify subclinical myocardial involvement in various diseases. This study objected to evaluate postsystolic shortening (PSS) and early systolic lengthening (ESL) by 2D-STE for early detection of myocardial involvement in patients with SLE. METHODS A total of 121 patients with preserved left ventricular ejection fraction (LVEF) in SLE and 30 healthy controls underwent standard 2D-STE in our study. According to SLE disease activity index (SLEDAI), we divided SLE patients into two groups: the group of inactive disease (SLEDAI ≤ 4) and active disease (SLEDAI ≥ 5). The maximum of postsystolic strain index (PSImax ) and early systolic strain index (ESImax ) were acquired from 17 segments of left ventricular (LV). We also compared the PSImax and ESImax of basal, medial, and apical segments between SLE patients and controls. RESULTS Compared with healthy controls and the group of SLEDAI ≤ 4, the group of SLEDAI ≥ 5 had higher PSImax and ESImax value of global LV and basal segments. The absolute value of global longitudinal strain (GLS) had no difference between the group of active disease and inactive disease. Multivariate analysis demonstrated that PSS was independently associated with SLEDAI and diabetes mellitus. CONCLUSIONS Detection of PSS and ESL enable to identify LV systolic impairment in SLE patients at an early stage.
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Affiliation(s)
- Minjie Wan
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Donghong Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Pengyuan Zhang
- Department of Endocrinology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Peihan Xie
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Liuqin Liang
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei He
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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12
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [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: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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13
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Manchanda AS, Kwan AC, Ishimori M, Thomson LEJ, Li D, Berman DS, Bairey Merz CN, Jefferies C, Wei J. Coronary Microvascular Dysfunction in Patients With Systemic Lupus Erythematosus and Chest Pain. Front Cardiovasc Med 2022; 9:867155. [PMID: 35498009 PMCID: PMC9053571 DOI: 10.3389/fcvm.2022.867155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/28/2022] [Indexed: 01/19/2023] Open
Abstract
Chest pain is a common symptom in patients with systemic lupus erythematosus, an autoimmune disease that is associated with increased cardiovascular morbidity and mortality. While chest pain mechanisms can be multifactorial and often attributed to non-coronary or non-cardiac cardiac etiologies, emerging evidence suggests that ischemia with no obstructive coronary arteries (INOCA) is a prevalent condition in patients with chest pain and no obstructive coronary artery disease. Coronary microvascular dysfunction is reported in approximately half of SLE patients with suspected INOCA. In this mini review, we highlight the cardiovascular risk assessment, mechanisms of INOCA, and diagnostic approach for patients with SLE and suspected CMD.
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Affiliation(s)
- Ashley S. Manchanda
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Alan C. Kwan
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Mariko Ishimori
- Division of Rheumatology and Department of Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Louise E. J. Thomson
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Daniel S. Berman
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Caroline Jefferies
- Division of Rheumatology and Department of Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- *Correspondence: Janet Wei
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14
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Konst RE, Guzik TJ, Kaski JC, Maas AHEM, Elias-Smale SE. The pathogenic role of coronary microvascular dysfunction in the setting of other cardiac or systemic conditions. Cardiovasc Res 2020; 116:817-828. [PMID: 31977015 PMCID: PMC7526753 DOI: 10.1093/cvr/cvaa009] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/09/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022] Open
Abstract
Coronary microvascular dysfunction (CMD) plays a pathogenic role in cardiac and systemic conditions other than microvascular angina. In this review, we provide an overview of the pathogenic role of CMD in the setting of diabetes mellitus, obesity, hypertensive pregnancy disorders, chronic inflammatory and autoimmune rheumatic disorders, chronic kidney disease, hypertrophic cardiomyopathy, and aortic valve stenosis. In these various conditions, CMD results from different structural, functional, and/or dynamic alterations in the coronary microcirculation associated with the primary disease process. CMD is often detectable very early in the course of the primary disease, before clinical symptoms or signs of myocardial ischaemia are present, and it portrays an increased risk for cardiovascular events.
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Affiliation(s)
- Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Juan-Carlos Kaski
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Coronary Vasomotion Disorders International Study Group (COVADIS), Adelaide, Australia.,Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Waheed N, Elias-Smale S, Malas W, Maas AH, Sedlak TL, Tremmel J, Mehta PK. Sex differences in non-obstructive coronary artery disease. Cardiovasc Res 2020; 116:829-840. [PMID: 31958135 DOI: 10.1093/cvr/cvaa001] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/03/2019] [Accepted: 01/13/2020] [Indexed: 12/31/2022] Open
Abstract
Ischaemic heart disease is a leading cause of morbidity and mortality in both women and men. Compared with men, symptomatic women who are suspected of having myocardial ischaemia are more likely to have no obstructive coronary artery disease (CAD) on coronary angiography. Coronary vasomotor disorders and coronary microvascular dysfunction (CMD) have been increasingly recognized as important contributors to angina and adverse outcomes in patients with no obstructive CAD. CMD from functional and structural abnormalities in the microvasculature is associated with adverse cardiac events and mortality in both sexes. Women may be particularly susceptible to vasomotor disorders and CMD due to unique factors such as inflammation, mental stress, autonomic, and neuroendocrine dysfunction, which predispose to endothelial dysfunction and CMD. CMD can be detected with coronary reactivity testing and non-invasive imaging modalities; however, it remains underdiagnosed. This review focuses on sex differences in presentation, pathophysiologic risk factors, diagnostic testing, and prognosis of CMD.
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Affiliation(s)
- Nida Waheed
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Waddah Malas
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
| | - Angela H Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tara L Sedlak
- Leslie Diamond Women's Heart Center, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Puja K Mehta
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
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16
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Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
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17
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Packer M, Lam CS, Lund LH, Maurer MS, Borlaug BA. Characterization of the inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction: a hypothesis to explain influence of sex on the evolution and potential treatment of the disease. Eur J Heart Fail 2020; 22:1551-1567. [PMID: 32441863 PMCID: PMC7687188 DOI: 10.1002/ejhf.1902] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 12/11/2022] Open
Abstract
Accumulating evidence points to the existence of an inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction (HFpEF), which is characterized by biomarkers of inflammation, an expanded epicardial adipose tissue mass, microvascular endothelial dysfunction, normal-to-mildly increased left ventricular volumes and systolic blood pressures, and possibly, altered activity of adipocyte-associated inflammatory mediators. A broad range of adipogenic metabolic and systemic inflammatory disorders - e.g. obesity, diabetes and metabolic syndrome as well as rheumatoid arthritis and psoriasis - can cause this phenotype, independent of the presence of large vessel coronary artery disease. Interestingly, when compared with men, women are both at greater risk of and may suffer greater cardiac consequences from these systemic inflammatory and metabolic disorders. Women show disproportionate increases in left ventricular filling pressures following increases in central blood volume and have greater arterial stiffness than men. Additionally, they are particularly predisposed to epicardial and intramyocardial fat expansion and imbalances in adipocyte-associated proinflammatory mediators. The hormonal interrelationships seen in inflammatory-metabolic phenotype may explain why mineralocorticoid receptor antagonists and neprilysin inhibitors may be more effective in women than in men with HFpEF. Recognition of the inflammatory-metabolic phenotype may improve an understanding of the pathogenesis of HFpEF and enhance the ability to design clinical trials of interventions in this heterogeneous syndrome.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTXUSA
- Imperial College LondonLondonUK
| | - Carolyn S.P. Lam
- National Heart Centre Singapore and Duke‐National University of SingaporeSingapore
- University Medical Centre GroningenGroningenThe Netherlands
- The George Institute for Global HealthSydneyAustralia
| | - Lars H. Lund
- Department of Medicine, Karolinska Institutet and Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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18
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Packer M. Link Between Synovial and Myocardial Inflammation: Conceptual Framework to Explain the Pathogenesis of Heart Failure with Preserved Ejection Fraction in Patients with Systemic Rheumatic Diseases. Card Fail Rev 2020. [DOI: 10.15420/cfr.2019.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with a broad range of systemic rheumatic diseases are at increased risk of heart failure (HF), an event that is not related to traditional cardiovascular risk factors or underlying ischaemic heart disease. The magnitude of risk is linked to the severity of arthritic activity, and HF is typically accompanied by a preserved ejection fraction. Subclinical evidence for myocardial fibrosis, microcirculatory dysfunction and elevated cardiac filling pressures is present in a large proportion of patients with rheumatic diseases, particularly those with meaningful systemic inflammation. Drugs that act to attenuate pro-inflammatory pathways (methotrexate and antagonists of tumour necrosis factor and interleukin-1) may ameliorate myocardial inflammation and cardiac structural abnormalities and reduce the risk of HF events.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, US and Imperial College, London, UK
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19
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Zanatta E, Colombo C, D’Amico G, d’Humières T, Dal Lin C, Tona F. Inflammation and Coronary Microvascular Dysfunction in Autoimmune Rheumatic Diseases. Int J Mol Sci 2019; 20:ijms20225563. [PMID: 31703406 PMCID: PMC6888405 DOI: 10.3390/ijms20225563] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 02/07/2023] Open
Abstract
Autoimmune rheumatic diseases (ARDs) form a heterogeneous group of disorders that include systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), idiopathic inflammatory myopathies (IIMs), and systemic vasculitis. Coronary microvascular dysfunction (CMD) is quite common in patients with ARDs and is linked to increased cardiovascular morbidity and mortality. Inflammation plays a crucial role in the pathogenesis of both accelerated atherosclerosis and CMD in ARDs, especially in patients affected by SLE and RA. In this regard, some studies have highlighted the efficacy of immunosuppressants and/or biologics in restoring CMD in these patients. By contrast, the role of inflammation in the pathogenesis of CMD-SSc appears to be much less relevant compared to endothelial dysfunction and microvascular ischemia, with calcium-channel blockers providing some benefits. Few studies have endeavored to assess the occurrence of CMD in IIMs and systemic vasculitis, thus warranting further investigations. The present review summarizes the current evidence on the occurrence of CMD in ARDs, focusing on the role of inflammation and possible therapeutic approaches.
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Affiliation(s)
| | - Claudia Colombo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Gianpiero D’Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Thomas d’Humières
- Department of Cardiovascular Physiology, AP-HP, Henri-Mondor Teaching Hospital, 94010 Créteil, France;
| | - Carlo Dal Lin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
- Correspondence:
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