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Cattaneo M, Halasz G, Cattaneo MM, Younes A, Gallino C, Sudano I, Gallino A. The Central Nervous System and Psychosocial Factors in Primary Microvascular Angina. Front Cardiovasc Med 2022; 9:896042. [PMID: 35647077 PMCID: PMC9136057 DOI: 10.3389/fcvm.2022.896042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/14/2022] [Indexed: 01/09/2023] Open
Abstract
Patients diagnosed with ischemia without obstructive coronary artery disease (INOCA) comprise the group of patients with primary microvascular angina (MVA). The pathophysiology underlying ischemia and angina is multifaceted. Differences in vascular tone, collateralization, environmental and psychosocial factors, pain thresholds, and cardiac innervation seem to contribute to clinical manifestations. There is evidence suggesting potential interactions between the clinical manifestations of MVA and non-cardiac conditions such as abnormal function of the central autonomic network (CAN) in the central nervous system (CNS), pain modulation pathways, and psychological, psychiatric, and social conditions. A few unconventional non-pharmacological and pharmacological techniques targeting these psychosocial conditions and modulating the CNS pathways have been proposed to improve symptoms and quality of life. Most of these unconventional approaches have shown encouraging results. However, these results are overall characterized by low levels of evidence both in observational studies and interventional trials. Awareness of the importance of microvascular dysfunction and MVA is gradually growing in the scientific community. Nonetheless, therapeutic success remains frustratingly low in clinical practice so far. This should promote basic and clinical research in this relevant cardiovascular field investigating, both pharmacological and non-pharmacological interventions. Standardization of definitions, clear pathophysiological-directed inclusion criteria, crossover design, adequate sample size, and mid-term follow-up through multicenter randomized trials are mandatory for future study in this field.
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Affiliation(s)
- Mattia Cattaneo
- Cardiology Department, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
- *Correspondence: Mattia Cattaneo ;
| | - Geza Halasz
- Heart Failure Unit, Guglielmo da Saliceto Hospital, Azienda unità sanitaria locale (AUSL) Piacenza, University of Parma, Parma, Italy
| | - Magdalena Maria Cattaneo
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
| | - Adel Younes
- Cardiology Department, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Camilla Gallino
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
| | - Isabella Sudano
- Human Medicine Department, University of Zurich, Zurich, Switzerland
- Cardiology Department, University Hospital, University Heart Center Zurich, Zurich, Switzerland
| | - Augusto Gallino
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
- Human Medicine Department, University of Zurich, Zurich, Switzerland
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NAAR JAN, JAYE DEBORAH, LINDE CECILIA, NEUŽIL PETR, DOŠKÁŘ PETR, MÁLEK FILIP, BRAUNSCHWEIG FRIEDER, LUND LARSH, MORTENSEN LARS, LINDEROTH BENGT, LIND GÖRAN, BONE DIANNA, SCHOLTE ARTHURJ, KUEFFER FRED, KOEHLER JODI, SHAHGALDI KAMBIZ, LANG OTTO, STÅHLBERG MARCUS. Effects of Spinal Cord Stimulation on Cardiac Sympathetic Nerve Activity in Patients with Heart Failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:504-513. [DOI: 10.1111/pace.13050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/31/2017] [Accepted: 02/06/2017] [Indexed: 12/18/2022]
Affiliation(s)
- JAN NAAR
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - DEBORAH JAYE
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - CECILIA LINDE
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - PETR NEUŽIL
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - PETR DOŠKÁŘ
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - FILIP MÁLEK
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - FRIEDER BRAUNSCHWEIG
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - LARS H. LUND
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - LARS MORTENSEN
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - BENGT LINDEROTH
- Department of Clinical Neuroscience, Karolinska Institutet; and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - GÖRAN LIND
- Department of Clinical Neuroscience, Karolinska Institutet; and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - DIANNA BONE
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
| | - ARTHUR J. SCHOLTE
- Department of Cardiology; Leiden University Medical Center; Leiden the Netherlands
| | - FRED KUEFFER
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - JODI KOEHLER
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - KAMBIZ SHAHGALDI
- Department of Clinical Physiology; Sunderby Hospital; Luleå Sweden
| | - OTTO LANG
- Department of Nuclear Medicine; University Hospital Královské Vinohrady; Prague Czech Republic
| | - MARCUS STÅHLBERG
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
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Dobias M, Michalek P, Neuzil P, Stritesky M, Johnston P. Interventional treatment of pain in refractory angina. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:518-27. [PMID: 24993738 DOI: 10.5507/bp.2014.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 05/22/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refractory angina is characterized by repeated attacks of chest pain in patients on maximal anti-anginal pharmacotherapy, with a professional conscensus that further surgical or radiological revascularization would be futile. Refractory angina is a serious but relatively uncommon health problem, with a reported incidence of approximately 30 patients per million people/year. In this condition simply treating the associated pain alone is important as this can improve exercise tolerance and quality of life. METHODS An extensive literature search using five different medical databases was performed and from this, eighty-three papers were considered appropriate to include within this review. RESULTS AND CONCLUSION Available literature highlights several methods of interventional pain treatment, including spinal cord stimulation and video-assisted upper thoracic sympathectomy which can provide good analgesia whilst improving physical activities and quality of life. The positive effect of spinal cord stimulation on the intensity of pain and quality of life has been confirmed in nine randomized controlled trials. Other potential treatment methods include stellate ganglion blocks, insertion of thoracic epidural or spinal catheters and transcutaneous electrical nerve stimulation. These approaches however appear more useful for diagnostic purposes and perhaps as short-term treatment measures.
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Affiliation(s)
- Milos Dobias
- Department of Anaesthesia and Intensive Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
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Bi YF, Mao JY, Wang XL, Wang HH, Ge YB, Zhang ZP. Contemporary treatment of Western and Chinese medicine for cardiac syndrome X. Chin J Integr Med 2011; 17:314-20. [PMID: 21509677 DOI: 10.1007/s11655-011-0714-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Indexed: 11/24/2022]
Abstract
Clinical reports on cardiac syndrome X (CSX) have been increasing in recent years. In general, CSX does not increase the cardiovascular mortality, but it can affect the patient's quality of life (QOL) and increase the incidence rates of cardiovascular and cerebrovascular events. Although a variety of drugs and therapies have been utilized in the clinical treatment, the management of CSX still represents a major challenge due to its unclear pathogenesis. It is necessary to explore more effective treatment programs. Many attempts have been made on trials of the Chinese medicine (CM) treatment for CSX and proved that CM has a certain advantage in efficacy to improve clinical symptoms and QOL. CM may provide a new approach for the effective treatment of CSX.
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Affiliation(s)
- Ying-Fei Bi
- Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China
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Di Monaco A, Lanza GA, Bruno I, Careri G, Pinnacchio G, Tarzia P, Battipaglia I, Giordano A, Crea F. Usefulness of impairment of cardiac adrenergic nerve function to predict outcome in patients with cardiac syndrome X. Am J Cardiol 2010; 106:1813-8. [PMID: 21126626 DOI: 10.1016/j.amjcard.2010.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Revised: 07/28/2010] [Accepted: 07/28/2010] [Indexed: 10/18/2022]
Abstract
Patients with cardiac syndrome X (CSX) have an excellent long-term prognosis, but a significant number show worsening angina over time. Previous studies have found a significant impairment of cardiac uptake of iodine-123-meta-iodobenzylguanidine (MIBG) on myocardial scintigraphy, indicating abnormal function of cardiac adrenergic nerve fibers. The aim of this study was to assess whether cardiac MIBG results can predict symptomatic outcome in patients with CSX. Cardiac MIBG scintigraphy was performed in 40 patients with CSX (mean age 58 ± 5 years, 14 men). Cardiac MIBG uptake was measured by the heart/mediastinum uptake ratio and a single photon-emission computed tomographic regional uptake score (higher values reflected lower uptake). Clinical findings, exercise stress test parameters, sestamibi stress myocardial scintigraphy, and C-reactive protein serum levels were also assessed. At an average follow-up of 79 months (range 36 to 144), no patient had died or developed acute myocardial infarction. Cardiac MIBG defect score was significantly lower in patients with worsening versus those without worsening of angina status (13 ± 7 vs 38 ± 28, p = 0.001), in those with versus those without hospital readmission because of recurrent chest pain (15 ± 9 vs 35 ± 29, p = 0.01), and in those who underwent versus those who did not undergo repeat coronary angiography (11 ± 7 vs 36 ± 27, p = 0.001). Significant correlations were found between quality of life (as assessed by the EuroQoL scale) and heart/mediastinum ratio (r = 0.48, p = 0.002) and cardiac MIBG uptake score (r = -0.69, p <0.001). No other clinical or laboratory variable showed a significant association with clinical end points. In conclusion, in patients with CSX, abnormal function of cardiac adrenergic nerve fibers, as assessed by an impairment of cardiac MIBG uptake, identifies those with worse symptomatic clinical outcomes.
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Mathematical methods to determine quantitative parameters of myocardial 123I-MIBG studies: a review of the literature. Nucl Med Commun 2010; 31:617-28. [PMID: 20220545 DOI: 10.1097/mnm.0b013e328337a99b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
(123)I-meta-iodobenzyl-guanidine ((123)I-MIBG) scintigraphy is used to visualize and quantify the sympathetic nerve activity. Although it has been used since 1980 to identify myocardial innervation, it is not yet regarded a routine sympathetic imaging agent in this respect. The lack of large multicentre studies and the presence of variations in the protocols that are used for planar MIBG acquisition confines the comparability of study results and application of normal values. Therefore, the aim of this study was to assess the variations in mathematical methods that are currently used to quantify the heart-to-mediastinum ratio and washout rate (WOR). In addition, normal values were evaluated in concordance with these methods. A systematic literature search yielded 169 unique manuscripts, of which 30 contained a complete description of the acquisition protocol for planar MIBG acquisition, image analysis and quantification of the parameters. The results indicate not only large variations in mathematical methods, but also in various aspects of the protocols that are used during acquisition. In many manuscripts method-specific normal values were used; however, these values were generally generated from small, single-centre studies. This study stresses the need to produce guidelines to achieve a standardized method for MIBG acquisition, image analysis and methods to quantify parameters.
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Di Monaco A, Bruno I, Calcagni ML, Nerla R, Lamendola P, Barone L, Scalone G, Mollo R, Coviello I, Bagnato A, Sestito A, Giordano A, Lanza GA, Crea F. Cardiac adrenergic nerve function in patients with cardiac syndrome X. J Cardiovasc Med (Hagerstown) 2010; 11:151-6. [PMID: 20010111 DOI: 10.2459/jcm.0b013e328330321d] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We previously found a severe impairment of cardiac uptake of I-metaiodobenzylguanidine (MIBG), an analogue of norepinephrine, on myocardial scintigraphy in a small group of patients with cardiac syndrome X (CSX), suggesting a dysfunction of cardiac adrenergic nerve fibres. In this study, we assessed the consistency of these previous findings in a larger group of these patients. METHODS Planar and single-photon emission computed tomography MIBG myocardial scintigraphy was performed in 40 CSX patients (58 +/- 7 years, 17 men). Cardiac MIBG uptake was measured by the heart/mediastinum ratio and by a single-photon emission computed tomography regional cardiac MIBG uptake defect score (higher values = lower uptake). As a control group, we studied 20 healthy individuals (56 +/- 6 years, nine men). An exercise stress Tc-SestaMIBI myocardial scintigraphy was performed in 34 CSX patients (85%). RESULTS Cardiac MIBG defects were observed in 30 patients (75%), with nine (22.5%) showing no cardiac MIBG uptake at all. Compared with controls, CSX patients showed a significantly lower heart/mediastinum ratio (1.70 +/- 0.35 vs. 2.1 +/- 0.22, P < 0.001) and a higher cardiac MIBG defect score (27 +/- 25 vs. 4.4 +/- 2.5, P < 0.001). No differences were found in lung MIBG uptake between the two groups. Reversible perfusion defects on stress myocardial scintigraphy were found in 17 out of 34 CSX patients (50%), all of whom also had abnormal cardiac MIBG uptake; cardiac MIBG uptake abnormalities were also present in nine of 17 patients with normal perfusion scintigraphic images. Cardiac MIBG uptake findings were similar in our first 12 patients and in the 28 patients studied subsequently. CONCLUSION Our data show a relevant impairment of cardiac MIBG uptake in patients with CSX, suggesting that functional abnormalities in cardiac adrenergic nerve function may play a significant role in the mechanisms responsible for the syndrome.
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Affiliation(s)
- Antonio Di Monaco
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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