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Ong P, McChord J, Pereyra VM, Sechtem U, Bekeredjian R, Seitz A. New avenues for the assessment of stable ischemic heart disease. Clin Res Cardiol 2024:10.1007/s00392-024-02483-6. [PMID: 38913172 DOI: 10.1007/s00392-024-02483-6] [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: 02/21/2024] [Accepted: 06/17/2024] [Indexed: 06/25/2024]
Abstract
Myocardial ischemia is a complex condition which may result from epicardial and/or microvascular causes involving functional and structural mechanisms. These mechanisms may overlap in a given patient illustrating the difficulties for appropriate management. Assessment of myocardial ischemia can be performed using noninvasive and invasive tools. However, despite living in the era of individualized precision medicine, these tools are not yet used in a broader fashion. Emerging noninvasive techniques such as quantitative perfusion cardiac magnetic resonance imaging (CMR) and stress perfusion computed tomography (CT) or photon-counting CT techniques may contribute to new standards in the assessment of stable angina patients. Invasive evaluation of myocardial ischemia should not only focus on hemodynamically relevant epicardial disease but also involve coronary vasomotor function testing (coronary spasm, coronary flow reserve, and microvascular resistance) where appropriate. Optimal patient management will depend on accurate and comprehensive diagnostic evaluation of myocardial ischemia and development of new treatment options in the future.
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Affiliation(s)
- Peter Ong
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany.
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Valeria Martínez Pereyra
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Andreas Seitz
- Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
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Ashokprabhu ND, Quesada O, Alvarez YR, Henry TD. INOCA/ANOCA: Mechanisms and novel treatments. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 30:100302. [PMID: 37377840 PMCID: PMC10299803 DOI: 10.1016/j.ahjo.2023.100302] [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] [Indexed: 06/29/2023]
Abstract
Angina or ischemia with no obstructive coronary disease (ANOCA/INOCA) is a common but under-treated condition due to poorly understood pathophysiologic mechanisms, limited diagnostic tools, and lack of proven targeted therapy. Coronary microvascular dysfunction (CMD) occurs when the microvasculature inadequately perfuses the myocardium under stress, or at rest in the case of microvascular spasm resulting in ANOCA/INOCA. Coronary functional angiography (CFA) measures endothelial independent microvascular dysfunction (coronary flow reduction <2.5) in response to adenosine and endothelial dependent microvascular dysfunction (lack of dilation and/or constriction) to acetylcholine testing as well as epicardial and microvascular spasm. Current treatment for coronary microvascular dysfunction is limited to renin-angiotensin system (RAS) inhibitors and statins as well as antianginal medications. Novel therapies targeting the underlying pathology are under development and include the coronary sinus reducer, CD34+ stem cell therapy, and novel pharmacologic agents such as sGC stimulators or endothelin-receptor blockers. We review the current understanding of pathophysiology, diagnostic tools, and novel therapies for coronary microvascular dysfunction in ANOCA/INOCA.
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Affiliation(s)
| | | | | | - Timothy D. Henry
- Corresponding author at: The Christ Hospital Health Network, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA. (T.D. Henry)
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Hwang D, Park SH, Koo BK. Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management. JACC. ASIA 2023; 3:169-184. [PMID: 37181394 PMCID: PMC10167523 DOI: 10.1016/j.jacasi.2023.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 05/16/2023]
Abstract
In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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4
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Epicardial atherosclerosis and coronary tortuosity in patients with acetylcholine-induced coronary spasm. Coron Artery Dis 2023; 34:34-41. [PMID: 36484218 DOI: 10.1097/mca.0000000000001196] [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: 12/13/2022]
Abstract
BACKGROUND Angina pectoris in the absence of relevant epicardial stenoses is frequently caused by coronary spasm. This mechanism of angina is common yet underdiagnosed in daily clinical practice. The pathophysiology of coronary spasm is complex, multifactorial, and not completely understood. The purpose of this study was to analyze the relationship between macroscopic coronary morphologies and coronary spasm. METHODS Epicardial atherosclerosis, coronary vessel tortuosity, coronary aneurysms, and myocardial bridges were analyzed angiographically in 610 patients and a potential association with the result of an intracoronary acetylcholine (ACh) provocation test was investigated. RESULTS The comparison showed that angiographic morphologic variations in the coronary arteries are related to the occurrence of coronary spasm. We observed a strong association between the presence of epicardial atherosclerosis and epicardial spasm [87 patients of 179 with epicardial spasm had epicardial atherosclerosis (49%) vs. 45 patients of 172 with microvascular spasm (26%) vs. 89 patients of 259 with negative/inconclusive ACh test (36%); P < 0.005]. Moreover, we found a higher frequency of coronary tortuosity in patients with microvascular spasm [99 patients of 172 with microvascular spasm had at least moderate coronary tortuosity (58%) vs. 76 patients of 179 with epicardial spasm (43%) vs. 126 patients of 259 with negative/inconclusive ACh test (49%); P = 0.017]. Multivariable analysis revealed epicardial atherosclerosis (<50% stenosis) on coronary angiography as a predictor for epicardial spasm (OR, 2.096; 95% CI, 1.467-2.995; P < 0.0005). Female sex (OR, 5.469; 95% CI, 3.433-8.713; P < 0.0005), and exertional angina (OR, 2.411; 95% CI, 1.597-3.639; P < 0.0005) were predictors of microvascular spasm in multivariable analysis. CONCLUSION In angina patients with no obstructive coronary artery disease, epicardial atherosclerosis is associated with ACh-induced epicardial coronary spasm. Moreover, coronary microvascular spasm is more prevalent in female patients and those with exertional angina. Our results provide insights into the relationship between coronary morphology and coronary vasomotor function.
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5
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Management des chronischen Koronarsyndroms. Herz 2022; 47:472-482. [DOI: 10.1007/s00059-022-05137-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/27/2022]
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6
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Seitz A, Pereyra VM, Sechtem U, Ong P. Update on coronary artery spasm 2022 – A narrative review. Int J Cardiol 2022; 359:1-6. [DOI: 10.1016/j.ijcard.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/07/2022] [Accepted: 04/04/2022] [Indexed: 12/31/2022]
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Seitz A, McChord J, Bekeredjian R, Sechtem U, Ong P. Definitions and Epidemiology of Coronary Functional Abnormalities. Eur Cardiol 2021; 16:e51. [PMID: 34950247 PMCID: PMC8674628 DOI: 10.15420/ecr.2021.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Coronary functional abnormalities are frequent causes of angina pectoris, particularly in patients with unobstructed coronary arteries. There is a spectrum of endotypes of functional coronary abnormalities with different mechanisms of pathology including enhanced vasoconstriction (i.e. coronary artery spasm) or impaired vasodilatation, such as impaired coronary flow reserve or increased microvascular resistance. These vasomotor abnormalities can affect various compartments of the coronary circulation such as the epicardial conduit arteries and/or the coronary microcirculation. Unequivocal categorisation and nomenclature of the broad spectrum of disease endotypes is crucial both in clinical practice as well as in clinical trials. This article describes the definitions of coronary functional abnormalities with currently accepted cut-off values, as well as diagnostic methods to identify and distinguish endotypes. The authors also provide a summary of contemporary data on the prevalence of the different endotypes of coronary functional abnormalities and their coexistence.
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Affiliation(s)
- Andreas Seitz
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Johanna McChord
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Raffi Bekeredjian
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Udo Sechtem
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Peter Ong
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
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8
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Gomez-Lara J, Oyarzabal L, Ortega-Paz L, Brugaletta S, Romaguera R, Salvatella N, Roura G, Rivero F, Fuentes L, Alfonso F, Otaegui I, Vandeloo B, Vaquerizo B, Sabate M, Comin-Colet J, Gomez-Hospital JA. Coronary Endothelium-Dependent Vasomotor Function After Drug-Eluting Stent and Bioresorbable Scaffold Implantation. J Am Heart Assoc 2021; 10:e022123. [PMID: 34729992 PMCID: PMC8751934 DOI: 10.1161/jaha.121.022123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early generation drug-eluting stents (DESs) showed a high grade of coronary endothelial dysfunction that was attributed to lack of stent reendothelialization. Endothelium-dependent vasomotor response of current DESs and bioresorbable scaffolds (BRSs) remains unknown. This study sought to assess the device-related endothelial function of current devices and to correlate neointima healing with endothelial function. Methods and Results A total of 206 patients from 4 randomized trials treated with the durable-polymer everolimus-eluting Xience (n=44), bioresorbable-polymer sirolimus-eluting Orsiro (n=35), polymer-free biolimus-eluting Biofreedom (n=24), bioactive endothelial-progenitor cell-capturing sirolimus-eluting Combo DES (n=25), polymer-based everolimus-eluting Absorb (n=44), and Mg-based sirolimus-eluting Magmaris BRS (n=34) underwent endothelium-dependent vasomotor tests and optical coherence tomography imaging, as per protocol, at follow-up. Crude vasomotor responses of distal segments to low-dose acetylcholine (10-6 mol/L) were different between groups: bioresorbablepolymer DEShad the worst (-8.4%±12.6%) and durable-polymer DES had the most physiologic (-0.4%±11.8%; P=0.014). High-dose acetylcholine (10-4 mol/L) showed similar responses between groups (ranging from -10.8%±11.6% to -18.1%±15.4%; P=0.229). Device healing was different between devices. Uncovered struts ranged from 6.3%±7.1% (bioresorbable-polymer DES) to 2.5%±4.5% (bioactive DES; P=0.056). In multivariate models, endothelium-dependent vasomotor response was associated with age, bioresorbable-polymer DES, and angiographic lumen loss, but not with strut coverage nor plaque type. Endothelial dysfunction (defined as ≥4% vasoconstriction) was observed in 46.6% of patients with low-dose and 68.9% with high-dose acetylcholine, without differences between groups. Conclusions At follow-up, endothelial dysfunction was frequently observed in distal segments treated with current stents without remarkable differences between devices. Although neointima healing was different between devices, poor healing was not associated with endothelial dysfunction.
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Affiliation(s)
- Josep Gomez-Lara
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Loreto Oyarzabal
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Luis Ortega-Paz
- Clinic Hospital of Barcelona August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona Spain
| | - Salvatore Brugaletta
- Clinic Hospital of Barcelona August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona Spain
| | - Rafael Romaguera
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Neus Salvatella
- Heart Disease Research Group Mar Hospital, Biomedical Research Institute of Mar Hospital (IMIM) Barcelona Spain
| | - Gerard Roura
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Fernando Rivero
- University Hospital of La Princesa Health Resaerch Institute of La Princesa; CIBER-CV Madrid Spain
| | - Lara Fuentes
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Fernando Alfonso
- University Hospital of La Princesa Health Resaerch Institute of La Princesa; CIBER-CV Madrid Spain
| | - Imanol Otaegui
- Interventional Cardiology Department University Hospital of Vall Hebron Barcelona Spain
| | - Bert Vandeloo
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain.,Department of Cardiology Heart and Vascular Disease Center, Universty Hospital of Brussels Brussels Belgium
| | - Beatriz Vaquerizo
- Heart Disease Research Group Mar Hospital, Biomedical Research Institute of Mar Hospital (IMIM) Barcelona Spain
| | - Manel Sabate
- Clinic Hospital of Barcelona August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona Spain
| | - Josep Comin-Colet
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
| | - Joan-Antoni Gomez-Hospital
- University Hospital of Bellvitge, Biomedical Research Institute of Bellvitge (IDIBELL) University of Barcelona, L' Hospitalet de Llobregat Spain
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Brown DL. Optimal Medical Therapy as First-Line Therapy for Chronic Coronary Syndromes: Lessons from COURAGE, BARI 2D, FAME 2, and ISCHEMIA. Cardiovasc Drugs Ther 2021; 36:1039-1045. [PMID: 34767134 DOI: 10.1007/s10557-021-07289-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 02/04/2023]
Abstract
The chronic coronary syndromes (CCS) include patients with a classic history of angina pectoris in the presence of either risk factors for or known atherosclerotic coronary artery disease. Randomized, controlled trials conducted in the optimal medical therapy (OMT) era have convincingly demonstrated that adherence to the outdated paradigm focused on treatment of obstructive coronary disease with initial revascularization fails to reduce death or myocardial infarction and inconsistently reduces angina symptoms. Rather, OMT reduces events and improves symptoms and should be considered first-line treatment for patients with CCS.
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Affiliation(s)
- David L Brown
- Department of Medicine (Cardiovascular Medicine), Washington University St. Louis School of Medicine, Campus Box 8086, 660 S. Euclid Avenue, St. Louis, MO, USA.
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10
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Jansen TPJ, Elias-Smale SE, van den Oord S, Gehlmann H, Dimitiriu-Leen A, Maas AHEM, Konst RE, van Royen N, Damman P. Sex Differences in Coronary Function Test Results in Patient With Angina and Nonobstructive Disease. Front Cardiovasc Med 2021; 8:750071. [PMID: 34722680 PMCID: PMC8551605 DOI: 10.3389/fcvm.2021.750071] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/22/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction: Invasive coronary function testing (CFT) has become the recommended diagnostic tool to assess the various endotypes of coronary vasomotor dysfunction in patients with angina and no obstructive coronary artery disease (ANOCA), which has implications for therapy and prognosis. Although the expanding performance of CFT is leading to increased knowledge of coronary vasomotor dysfunction, little is known about sex-related differences in the results of comprehensive CFT. Methods: We conducted a prospective study of all consecutive patients with ANOCA that underwent clinically indicated CFT in a tertiary interventional from February 2019 to February 2021. CFT consisted of acetylcholine testing to diagnose epicardial or microvascular spasm, and adenosine testing to diagnose CMD. CMD was defined as an index of microvascular resistance (IMR) ≥ 25 and/or coronary flow reserve (CFR) < 2.0. Results: In total, 228 women and 38 men underwent CFT. No differences in traditional risk factors were seen, but women had a higher prevalence of migraine (45 vs. 14%, p = 0.001). Men more often had a history of percutaneous coronary intervention (12 vs. 49%, p = 0.001). We found no difference in clinical presentation. Coronary vasomotor dysfunction was present in 95% of men and 88% of women (p = 0.25), but males show more often epicardial spasm and less microvascular spasm than women (63 vs. 42% and 29 vs. 40% respectively, p = 0.039). Impaired CFR was more prevalent among females (6 vs 20%, p = 0.033). IMR [median of 23 (15–32) vs. 19 (13–25), p = 0.08] did not differ between the sexes. Conclusion: Men undergoing CFT show a comparable prevalence of coronary vascular dysfunction as women. However, men have a higher prevalence of epicardial spasm and a lower prevalence of microvascular spasm compared with women. An impaired CFR was more often present in women, with an equally impairment of IMR.
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Affiliation(s)
| | | | | | | | | | | | - Regina E Konst
- Department of Cardiology, Radboudumc, Nijmegen, Netherlands
| | | | - Peter Damman
- Department of Cardiology, Radboudumc, Nijmegen, Netherlands
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11
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Takahashi J, Suda A, Nishimiya K, Godo S, Yasuda S, Shimokawa H. Pathophysiology and Diagnosis of Coronary Functional Abnormalities. Eur Cardiol 2021; 16:e30. [PMID: 34603510 PMCID: PMC8478147 DOI: 10.15420/ecr.2021.23] [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: 05/15/2021] [Accepted: 07/07/2021] [Indexed: 01/17/2023] Open
Abstract
Approximately one-half of patients undergoing diagnostic coronary angiography for angina have no significant coronary atherosclerotic stenosis. This clinical condition has recently been described as ischaemia with non-obstructive coronary arteries (INOCA). Coronary functional abnormalities are central to the pathogenesis of INOCA, including epicardial coronary spasm and coronary microvascular dysfunction composed of a variable combination of increased vasoconstrictive reactivity and/or reduced vasodilator function. During the last decade - in INOCA patients in particular - evidence for the prognostic impact of coronary functional abnormalities has accumulated and various non-invasive and invasive diagnostic techniques have enabled the evaluation of coronary vasomotor function in a comprehensive manner. In this review, the authors briefly summarise the recent advances in the understanding of pathophysiology and diagnosis of epicardial coronary artery spasm and coronary microvascular dysfunction.
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Affiliation(s)
- Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
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12
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Del Buono MG, Montone RA, Camilli M, Carbone S, Narula J, Lavie CJ, Niccoli G, Crea F. Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1352-1371. [PMID: 34556322 PMCID: PMC8528638 DOI: 10.1016/j.jacc.2021.07.042] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/12/2022]
Abstract
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
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Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy. https://twitter.com/marcodelbuono3
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia, USA; VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, Ochsner Clinical School, New Orleans, Louisiana, USA
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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13
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Kunadian V, Chieffo A, Camici PG, Berry C, Escaned J, Maas AHEM, Prescott E, Karam N, Appelman Y, Fraccaro C, Louise Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott JD, Badimon L, Duncker DJ, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J 2021; 41:3504-3520. [PMID: 32626906 DOI: 10.1093/eurheartj/ehaa503] [Citation(s) in RCA: 411] [Impact Index Per Article: 137.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
| | | | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | | | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk J Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK.,Yale University School of Medicine, New Haven, CT, USA
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14
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Konst RE, Damman P, Pellegrini D, Hartzema-Meijer MJ, van Uden BJC, Jansen TPJ, Brandsma J, Vart P, Gehlmann H, Maas AHEM, van Royen N, Elias-Smale SE. Vasomotor dysfunction in patients with angina and nonobstructive coronary artery disease is dominated by vasospasm. Int J Cardiol 2021; 333:14-20. [PMID: 33711394 DOI: 10.1016/j.ijcard.2021.02.079] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coronary vasomotor dysfunction, comprising endotypes of coronary spasm and/or impaired microvascular dilatation (IMD), is common in patients with angina and no obstructive coronary arteries (ANOCA). However, there are discrepant reports regarding the prevalence of these endotypes. The objective of this study was to determine the prevalence of coronary vasomotor dysfunction in patients with ANOCA, underlying endotypes, and differences in clinical characteristics. METHODS Prospective registry of patients with ANOCA that underwent clinically indicated invasive coronary function testing (CFT), including acetylcholine spasm testing (2-200 μg) to diagnose coronary spasm, and adenosine testing (140 μg/kg/min) to diagnose IMD, defined as an index of microvascular resistance ≥25 and/or coronary flow reserve <2.0. RESULTS Of the 111 patients that completed CFT (88% female, mean age 54 years), 96 (86%) showed vasomotor dysfunction. The majority 93 (97%) had coronary spasm, 63% isolated and 34% combined with IMD. Isolated IMD was rare, occurring in only 3 patients (3%). Hypertension was more prevalent in patients with vasomotor dysfunction compared to those without (39% vs. 7%, p = 0.02). Obesity and a higher severity of angiographic atherosclerotic disease were more prevalent in patients with coronary spasm compared to those without (61% vs. 28%; 40% vs. 0%, respectively, both p < 0.01). No differences in angina characteristics were observed between patients with and without vasomotor dysfunction or between endotypes. CONCLUSIONS Coronary vasomotor dysfunction is highly prevalent in patients with ANOCA, especially epicardial or microvascular vasospasm, whereas isolated IMD was rare. Performing a CFT without acetylcholine testing should be strongly discouraged.
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Affiliation(s)
- Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Dario Pellegrini
- University of Milano-Bicocca, Milan, Italy; University of Milano-Bicocca, Milan, Italy
| | - Mariëlle J Hartzema-Meijer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Bas J C van Uden
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Judith Brandsma
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Priya Vart
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; University of Milano-Bicocca, Milan, Italy
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15
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Kunadian V, Chieffo A, Camici P, Berry C, Escaned J, Maas A, Prescott E, Karam N, Appelman Y, Fraccaro C, Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott J, Badimon L, Duncker D, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. EUROINTERVENTION 2021; 16:1049-1069. [PMID: 32624456 PMCID: PMC9707543 DOI: 10.4244/eijy20m07_01] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Paolo Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | - Gill Buchanan
- North Cumbria Integrated Care NHS Foundation Trust, Cumbria, United Kingdom
| | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Bart’s Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - J. Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. ‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
- Yale University School of Medicine, New Haven, CT, USA
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16
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Hao K, Takahashi J, Kikuchi Y, Suda A, Sato K, Sugisawa J, Tsuchiya S, Shindo T, Nishimiya K, Ikeda S, Tsuburaya R, Shiroto T, Matsumoto Y, Miyata S, Sakata Y, Yasuda S, Shimokawa H. Prognostic Impacts of Comorbid Significant Coronary Stenosis and Coronary Artery Spasm in Patients With Stable Coronary Artery Disease. J Am Heart Assoc 2021; 10:e017831. [PMID: 33455423 PMCID: PMC7955295 DOI: 10.1161/jaha.120.017831] [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: 06/01/2020] [Accepted: 10/05/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Stable coronary artery disease is caused by a variable combination of organic coronary stenosis and functional coronary abnormalities, such as coronary artery spasm. Thus, we examined the clinical importance of comorbid significant coronary stenosis and coronary spasm. METHODS AND RESULTS We enrolled 236 consecutive patients with suspected angina who underwent acetylcholine provocation testing for coronary spasm and fractional flow reserve (FFR) measurement. Among them, 175 patients were diagnosed as having vasospastic angina (VSA), whereas the remaining 61 had no VSA (non-VSA group). The patients with VSA were further divided into the following 3 groups based on angiography and FFR: no organic stenosis (≤50% luminal stenosis; VSA-alone group, n=110), insignificant stenosis of FFR>0.80 (high-FFR group, n=36), and significant stenosis of FFR≤0.80 (low-FFR group, n=29). The incidence of major adverse cardiovascular events, including cardiovascular death, nonfatal myocardial infarction, urgent percutaneous coronary intervention, and hospitalization attributed to unstable angina was evaluated. All patients with VSA received calcium channel blockers, and 28 patients (95%) in the low-FFR group underwent a planned percutaneous coronary intervention. During a median follow-up period of 656 days, although the incidence of major adverse cardiovascular events was low and comparable among non-VSA, VSA-alone, and high-FFR groups, the low-FFR group had an extremely poor prognosis (non-VSA group, 1.6%; VSA-alone group, 3.6%; high-FFR group, 5.6%; low-FFR group, 27.6%) (P<0.001). Importantly, all 8 patients with major adverse cardiovascular events in the low-FFR group were appropriately treated with percutaneous coronary intervention and calcium channel blockers. CONCLUSIONS These results indicate that patients with VSA with significant coronary stenosis represent a high-risk population despite current guideline-recommended therapies, suggesting the importance of routine coronary functional testing in this population.
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Affiliation(s)
- Kiyotaka Hao
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Jun Takahashi
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Yoku Kikuchi
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Akira Suda
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Koichi Sato
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Jun Sugisawa
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Satoshi Tsuchiya
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Tomohiko Shindo
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Kensuke Nishimiya
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Shohei Ikeda
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Ryuji Tsuburaya
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Takashi Shiroto
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Yasuharu Matsumoto
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Satoshi Miyata
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Yasuhiko Sakata
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Satoshi Yasuda
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
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17
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Sun Y, Wang Z, Wang C, Tang Z, Shi J, Zhao H. Effect and safety of Chinese patent medicine capsules for recurrent angina pectoris after percutaneous coronary intervention: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23287. [PMID: 33285705 PMCID: PMC7717720 DOI: 10.1097/md.0000000000023287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Recurrent angina pectoris after percutaneous coronary intervention (PCI) is a common clinical syndrome, which seriously reduces the quality of life and health of patients, increases medical costs, and causes the risk of cardiogenic death. The efficacy of various western medicine improving angina symptoms has not been fully confirmed at the moment, whereas Chinese patent medicine capsules (CPMC) have been generally used in clinical practice due to the therapeutic efficacy and safety. This study evaluates the efficacy and safety of CPMC for stable angina after PCI, designed to provide more evidence for clinical treatment. METHODS This protocol was based on the previous reporting items. We will search 3 English databases (PubMed, Excerpta Medica Database, and the Cochrane Library) and 3 Chinese databases (China Network Knowledge Infrastructure, Wan Fang Database, and Chinese Biomedicine) until January 2020. RCTs to evaluate the efficacy and safety of CPMC for recurrent stable angina pectoris after PCI will be included. The primary outcome will be assessed by major adverse cardiovascular events and angina attack frequency. We will use the criteria provided by Cochrane risk of bias tool for quality evaluation and risk assessment, and use the Revman 5.3 for meta-analysis. ETHICS AND DISSEMINATION Ethical approval is not required for systematic review and meta-analysis. The results of this review will be disseminated in a peer-review journal. PROSPERO REGISTRATION NUMBER CRD42020164005.
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Affiliation(s)
- Yize Sun
- Beijing University of Chinese Medicine
| | | | - Chao Wang
- Oriental Hospital, Beijing University of Chinese Medicine, Beijing, China
| | | | - Jinyu Shi
- Beijing University of Chinese Medicine
| | - Haibin Zhao
- Oriental Hospital, Beijing University of Chinese Medicine, Beijing, China
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18
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Sechtem U, Brown D, Godo S, Lanza GA, Shimokawa H, Sidik N. Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease). Cardiovasc Res 2020; 116:771-786. [PMID: 31958128 DOI: 10.1093/cvr/cvaa005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus, Auerbachstr. 110, D-70376 Stuttgart, Germany
| | - David Brown
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute, Roma, Italy
| | - Hiro Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Novalia Sidik
- University of Glasgow, Golden Jubilee National Hospital, Glasgow, UK
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19
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Crea F, Bairey Merz CN, Beltrame JF, Berry C, Camici PG, Kaski JC, Ong P, Pepine CJ, Sechtem U, Shimokawa H. Mechanisms and diagnostic evaluation of persistent or recurrent angina following percutaneous coronary revascularization. Eur Heart J 2020; 40:2455-2462. [PMID: 30608528 DOI: 10.1093/eurheartj/ehy857] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/09/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023] Open
Abstract
Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20-40% of patients during short-medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Gemelli - IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Roma, Italy
| | - Cathleen Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd, Los Angeles, CA, USA
| | - John F Beltrame
- Discipline of Medicine, Ward 5B, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, Adelaide, South Australia, Australia
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, University Place, Glasgow, UK
| | - Paolo G Camici
- Department of Cardiology, Vita Salute University and San Raffaele Hospital, Via Olgettina 60, Milano, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Departmant of Medicine, College of Medicine, University of Florida, 1600 SW Archer Rd, Box 100288, Gainesville, FL, USA
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Japan
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20
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Pirozzolo G, Seitz A, Martínez Pereyra V, Athanasiadis A, Albert M, Franke UFW, Bekeredjian R, Sechtem U, Ong P. Different vasoreactivity of arterial bypass grafts versus native coronary arteries in response to acetylcholine. Clin Res Cardiol 2020; 110:172-182. [PMID: 32613293 DOI: 10.1007/s00392-020-01694-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 06/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary angiography is often performed in patients with recurrent angina after successful coronary artery bypass grafting (CABG) in search of the progression of atherosclerosis. However, in many of these patients, no relevant stenosis can be detected. We speculate that coronary spasm may be associated with angina in these patients. METHODS From 2307 patients with unobstructed coronaries who underwent intracoronary acetylcholine spasm provocation testing (ACh-test) between 2012 and 2016, 54 consecutive patients who fulfilled the following inclusion criteria were included in this cohort study: previous left internal thoracic artery (LITA) bypass on the left anterior descending (LAD) coronary artery, ongoing/recurrent angina pectoris, no significant (< 50%) coronary artery or bypass stenosis. In all participants, the ACh-test was performed via the LITA bypass. RESULTS In 14 patients (26%) the ACh-test elicited epicardial spasm of the LAD distal to the anastomosis (≥ 90% diameter reduction with reproduction of the patient's symptoms and ischemic ECG shifts). Microvascular spasm (reproduction of symptoms and ischemic ECG-changes but no epicardial spasm) was seen in 30 patients (55%). The ACh-test was normal in the remaining 10 patients (19%). ACh-testing did not elicit any relevant vasoconstriction in the LITA bypasses in contrast to the LAD on quantitative coronary analyses (4.89 ± 7.36% vs. 52.43 ± 36.07%, p < 0.01). CONCLUSION Epicardial and microvascular coronary artery spasm are frequent findings in patients with ongoing or recurrent angina after CABG but no relevant stenosis. Vasoreactivity to acetylcholine is markedly different between LITA bypasses and native LAD arteries with vasoconstriction almost exclusively occurring in the LAD.
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Affiliation(s)
- Giancarlo Pirozzolo
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany.
| | | | - Anastasios Athanasiadis
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
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21
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Consuegra-Sánchez L, Ong P, Kaski JC. Letter by Consuegra-Sánchez et al Regarding Article, "Magnesium-Based Resorbable Scaffold Versus Permanent Metallic Sirolimus-Eluting Stent in Patients With ST-Segment Elevation Myocardial Infarction: The MAGSTEMI Randomized Clinical Trial". Circulation 2020; 141:e746-e747. [PMID: 32282245 DOI: 10.1161/circulationaha.119.044740] [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: 11/16/2022]
Affiliation(s)
| | - Peter Ong
- Cardiology Department, Robert-Bosch Hospital, Stuttgart, Germany (P.O.)
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Insititute, St George's University of London, United Kingdom (J.C.K.)
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22
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Mangiacapra F, Del Buono MG, Abbate A, Gori T, Barbato E, Montone RA, Crea F, Niccoli G. Role of endothelial dysfunction in determining angina after percutaneous coronary intervention: Learning from pathophysiology to optimize treatment. Prog Cardiovasc Dis 2020; 63:233-242. [PMID: 32061633 DOI: 10.1016/j.pcad.2020.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 02/01/2023]
Abstract
Endothelial dysfunction (EnD) is a hallmark feature of coronary artery disease (CAD), representing the key early step of atherosclerotic plaque development and progression. Percutaneous coronary intervention (PCI) is performed daily worldwide to treat symptomatic CAD, however a consistent proportion of patients remain symptomatic for angina despite otherwise successful revascularization. EnD plays a central role in the mechanisms of post-PCI angina, as it is strictly associated with both structural and functional abnormalities in the coronary arteries that may persist, or even accentuate, following PCI. The assessment of endothelial function in patients undergoing PCI might help to identify those patients at higher risk of future cardiovascular events and recurrent/persistent angina who might therefore benefit more from an intensive treatment. In this review, we address the role of EnD in determining angina after PCI, discussing its pathophysiological mechanisms, diagnostic approaches and therapeutic perspectives.
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Affiliation(s)
- Fabio Mangiacapra
- Unit of Cardiovascular Science, Campus Bio-Medico University, Rome, Italy.
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Tommaso Gori
- Kardiologie I, Zentrum für Kardiologie, University Medical Center Mainz and DZHK Standort Rhein-Main, Mainz, Germany
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
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23
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Abstract
PURPOSE OF REVIEW Our review discusses the management of post percutaneous coronary intervention angina (PPCIA) which negatively impacts 20-40% of patients and imposes a high burden on the healthcare system. RECENT FINDINGS Mechanisms of PPCIA include microvascular dysfunction, distal coronary vasospasm or disease, microembolization, myocardial bridge, coronary artery disease (CAD) progression, and rarely stent thrombosis or in-stent restenosis. Nitrates, beta blockers (BB), calcium channel blockers, and ranolazine are the common medical management options. Only BB showed 1-year mortality benefit following myocardial infarction. Stress echocardiography and cardiac magnetic resonance are the best to detect CAD vs. microvascular dysfunction. Invasively, vasoprovocative testing and fractional flow reserve provide useful prognostic information. If the ischemia burden is ≤10%, conservative management should be considered based upon the individual patient scenario. The optimal management of PPCIA remains unclear and further research is necessary. Multiple treatment options exist, which should be implemented in an individualized fashion.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Subrata Kar
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3929] [Impact Index Per Article: 982.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Li Y, Yuan M, Yu M, Lu Z, Shen C, Wang Y, Lu B, Zhang J. Prevalence of Decreased Myocardial Blood Flow in Symptomatic Patients with Patent Coronary Stents: Insights from Low-Dose Dynamic CT Myocardial Perfusion Imaging. Korean J Radiol 2020; 20:621-630. [PMID: 30887744 PMCID: PMC6424835 DOI: 10.3348/kjr.2018.0399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/11/2018] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To study the prevalence and clinical characteristics of decreased myocardial blood flow (MBF) quantified by dynamic computed tomography (CT) myocardial perfusion imaging (MPI) in symptomatic patients without in-stent restenosis. MATERIALS AND METHODS Thirty-seven (mean age, 71.3 ± 10 years; age range, 48-88 years; 31 males, 6 females) consecutive symptomatic patients with patent coronary stents and without obstructive de novo lesions were prospectively enrolled to undergo dynamic CT-MPI using a third-generation dual-source CT scanner. The shuttle-mode acquisition technique was used to image the complete left ventricle. A bolus of contrast media (50 mL; iopromide, 370 mg iodine/mL) was injected into the antecubital vein at a rate of 6 mL/s, followed by a 40-mL saline flush. The mean MBF value and other quantitative parameters were measured for each segment of both stented-vessel territories and reference territories. The MBFratio was defined as the ratio of the mean MBF value of the whole stent-vessel territory to that of the whole reference territory. An MBFratio of 0.85 was used as the cut-off value to distinguish hypoperfused from non-hypoperfused segments. RESULTS A total of 629 segments of 37 patients were ultimately included for analysis. The mean effective dose of dynamic CT-MPI was 3.1 ± 1.2 mSv (range, 1.7-6.3 mSv). The mean MBF of stent-vessel territories was decreased in 19 lesions and 81 segments. Compared to stent-vessel territories without hypoperfusion, the mean MBF and myocardial blood volume were markedly lower in hypoperfused stent-vessel territories (77.5 ± 16.6 mL/100 mL/min vs. 140.4 ± 24.1 mL/100 mL/min [p < 0.001] and 6.4 ± 3.7 mL/100 mL vs. 11.5 ± 4 mL/100 mL [p < 0.001, respectively]). Myocardial hypoperfusion in stent-vessel territories was present in 48.6% (18/37) of patients. None of clinical parameters differed statistically significantly between hypoperfusion and non-hypoperfusion subgroups. CONCLUSION Decreased MBF is commonly present in patients who are symptomatic after percutaneous coronary intervention, despite patent stents and can be detected by dynamic CT-MPI using a low radiation dose.
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Affiliation(s)
- Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Mingyuan Yuan
- Department of Radiology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Science, Shanghai, China
| | - Mengmeng Yu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zhigang Lu
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chengxing Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yining Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Bin Lu
- Department of Radiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiayin Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Amamizu H, Matsumoto Y, Morosawa S, Ohyama K, Uzuka H, Hirano M, Nishimiya K, Gokon Y, Watanabe-Asaka T, Hayashi M, Miyata S, Kamei T, Kawai Y, Shimokawa H. Cardiac Lymphatic Dysfunction Causes Drug-Eluting Stent–Induced Coronary Hyperconstricting Responses in Pigs In Vivo. Arterioscler Thromb Vasc Biol 2019; 39:741-753. [DOI: 10.1161/atvbaha.119.312396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective—
We have previously demonstrated that coronary adventitial inflammation plays important roles in the pathogenesis of coronary vasomotion abnormalities, including drug-eluting stent (DES)–induced coronary hyperconstricting responses. Importantly, the adventitia also harbors lymphatic vessels, which may prevent inflammation by transporting extravasated fluid and inflammatory cells. We thus aimed to examine the roles of coronary adventitial lymphatic vessels in the pathogenesis of DES-induced coronary hyperconstricting responses in a porcine model in vivo.
Approach and Results—
We performed 2 experimental studies. In protocol 1, 15 pigs were divided into 3 groups with or without DES and with bare metal stent. Nonstented sites 20 mm apart from stent implantation also were examined. In the protocol 2, 12 pigs were divided into 2 groups with or without lymphatic vessels ligation followed by DES implantation at 2 weeks later (n=6 each). We performed coronary angiography 4 weeks after DES implantation, followed by immunohistological analysis. In protocol 1, the number and the caliber of lymphatic vessels were greater at only the DES edges after 4 more weeks. In protocol 2, coronary hyperconstricting responses were further enhanced in the lymphatic vessels ligation group associated with adventitial inflammation, Rho-kinase activation, and less adventitial lymphatic vessels formation. Importantly, there were significant correlations among these inflammation-related changes and enhanced coronary vasoconstricting responses.
Conclusions—
These results provide evidence that cardiac lymphatic vessel dysfunction plays important roles in the pathogenesis of coronary vasoconstrictive responses in pigs in vivo.
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Affiliation(s)
- Hirokazu Amamizu
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Susumu Morosawa
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuma Ohyama
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hironori Uzuka
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michinori Hirano
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kensuke Nishimiya
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yusuke Gokon
- Department of Gastroenterological Surgery (Y.G., T.K.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomomi Watanabe-Asaka
- Division of Physiology, Tohoku Medical and Pharmaceutical University (T.W.-A., M. Hayashi, Y.K.), Sendai, Japan
| | - Moyuru Hayashi
- Division of Physiology, Tohoku Medical and Pharmaceutical University (T.W.-A., M. Hayashi, Y.K.), Sendai, Japan
| | - Satoshi Miyata
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Gastroenterological Surgery (Y.G., T.K.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiko Kawai
- Division of Physiology, Tohoku Medical and Pharmaceutical University (T.W.-A., M. Hayashi, Y.K.), Sendai, Japan
| | - Hiroaki Shimokawa
- From the Department of Cardiovascular Medicine (H.A., Y.M., S. Morosawa, K.O., H.U., M. Hirano, K.N., S. Miyata, H.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
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Montone RA, Niccoli G, Vergni F, Vetrugno V, Russo M, Mangiacapra F, Fracassi F, Porto I, Leone AM, Burzotta F, D'Amario D, Aurigemma C, Trani C, Lanza GA, Crea F. Endothelial dysfunction as predictor of angina recurrence after successful percutaneous coronary intervention using second generation drug eluting stents. Eur J Prev Cardiol 2018; 25:1360-1370. [PMID: 29785885 DOI: 10.1177/2047487318777435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The role of endothelial dysfunction in predicting angina recurrence after percutaneous coronary intervention is unknown. Design We assessed the role of peripheral endothelial dysfunction measured by reactive-hyperaemia peripheral-artery tonometry (RH-PAT) in predicting recurrence of angina after percutaneous coronary intervention. Methods We enrolled consecutive patients undergoing percutaneous coronary intervention with second-generation drug-eluting stents. RH-PAT was measured at discharge. The endpoint was repeated coronary angiography for angina recurrence and/or evidence of myocardial ischaemia at follow-up. Patients with in-stent restenosis and/or significant de novo stenosis were defined as having angina with obstructed coronary arteries (AOCA); all other patients as having angina with non-obstructed coronary arteries (ANOCA). Results Among 100 patients (mean age 66.7 ± 10.4 years, 80 (80.0%) male, median follow-up 16 (3-20) months), AOCA occurred in 14 patients (14%), ANOCA in nine patients (9%). Repeated coronary angiography occurred more frequently among patients in the lower RH-PAT index tertile compared with middle and upper tertiles (14 (41.2%) vs. 6 (18.2%) vs. 3 (9.1%), p = 0.006, respectively). ANOCA was more frequent in the lower RH-PAT index tertile compared with middle and upper tertiles. In the multivariate regression analysis, the RH-PAT index only predicted angina recurrence. The receiver operating characteristic curve of the RH-PAT index to predict the angina recurrence demonstrated an area under the curve of 0.79 (95% confidence interval: 0.69-0.89; p < 0.001), with a cut-off value of 1.705, having sensitivity 74% and specificity 70%. Conclusions Non-invasive assessment of peripheral endothelial dysfunction using RH-PAT might help in the prediction of recurrent angina after percutaneous coronary intervention, thus identifying patients who may need more intense pharmacological treatment and risk factor control.
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Affiliation(s)
- Rocco A Montone
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giampaolo Niccoli
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Federico Vergni
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Vincenzo Vetrugno
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Michele Russo
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Fabio Mangiacapra
- 2 Unit of Cardiovascular Science, Campus Bio-Medico University, Rome, Italy
| | - Francesco Fracassi
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Italo Porto
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio M Leone
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Burzotta
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Domenico D'Amario
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Cristina Aurigemma
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Trani
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano A Lanza
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- 1 Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Coronary microvascular dysfunction in patients with stable coronary artery disease: The CE-MARC 2 coronary physiology sub-study. Int J Cardiol 2018; 266:7-14. [PMID: 29716756 PMCID: PMC6008494 DOI: 10.1016/j.ijcard.2018.04.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/17/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with angina undergoing invasive management, no obstructive coronary artery disease (NOCAD) is a common finding, and angina may persist following percutaneous coronary intervention (PCI). Coronary microvascular dysfunction may be relevant. We aimed to assess the proportion of patients presenting with suspected CAD who had coronary microvascular dysfunction. METHODS Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 (CE-MARC 2) was a prospective multicenter randomised controlled trial of functional imaging versus guideline-based management in patients with suspected CAD. Invasive coronary angiography was protocol-directed. Fractional flow reserve (FFR) and parameters of microvascular function (coronary flow reserve (CFR), index of microcirculatory resistance (IMR), resistance reserve ratio (RRR)) were measured in major epicardial coronary arteries with ≥40-≤90% diameter stenosis. An FFR value ≤0.80 indicated the presence of obstructive CAD. RESULTS 267/1202 (22.2%) patients underwent angiography and 81 (30%) patients had FFR measured. 63 (78%) of these patients had microvascular function assessed in 85 arteries (mean age 58.5 ± 8.2 years; 47 (75%) male). 25/63 (40%) patients had NOCAD, and of these, 17 (68%) had an abnormality ≥1 parameter of microvascular function (abnormal IMR (≥25), abnormal CFR (<2.0), and abnormal RRR (<2.0) occurred in 10 (40%), 12 (48%), and 11 (44%), respectively). 38/63 (60%) patients had obstructive epicardial CAD. Of these patients, 15/38 (39%), 20/38 (53%), and 12/38 (32%) had an abnormal IMR, CFR and RRR, respectively. CONCLUSIONS Coronary microvascular dysfunction is common in patients with angina. Invasive assessment of microvascular function may be informative and relevant for decision-making in patients with both NOCAD and obstructive epicardial CAD. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01664858.
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Mahmoud AN, Barakat AF, Elgendy AY, Schneibel E, Mentias A, Abuzaid A, Elgendy IY. Long-Term Efficacy and Safety of Everolimus-Eluting Bioresorbable Vascular Scaffolds Versus Everolimus-Eluting Metallic Stents: A Meta-Analysis of Randomized Trials. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005286. [PMID: 28468954 DOI: 10.1161/circinterventions.117.005286] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/11/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Data regarding the long-term efficacy and safety of everolimus-eluting bioresorbable vascular scaffolds (BVS) compared with everolimus-eluting stents are limited. This meta-analysis aimed to compare the long-term outcomes with both devices. METHODS AND RESULTS Randomized trials reporting clinical outcomes beyond 1 year and comparing BVS with everolimus-eluting stents were included. Summary estimates risk ratios (RRs) were constructed. The primary efficacy outcome was target lesion failure, defined as cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization, and the primary safety outcome was definite or probable stent/scaffold thrombosis. Six trials with 5392 patients were included (mean follow-up, 25 months). BVS had a higher rate of target lesion failure (RR, 1.33; 95% confidence interval [CI], 1.11-1.58) driven by the higher rates of target vessel myocardial infarction (RR, 1.65; 95% CI, 1.26-2.17) and target lesion revascularization (RR, 1.39; 95% CI, 1.08-1.78). The risk of definite or probable stent/scaffold thrombosis (RR, 3.22; 95% CI, 1.89-5.49) and very late stent/scaffold thrombosis (>1 year; RR, 4.78; 95% CI, 1.66-13.8) was higher with BVS. The risk of cardiac and all-cause mortality was similar in both groups. CONCLUSIONS Compared with everolimus-eluting stents, BVS is associated with increased risk of target lesion failure driven by the increased rates of target vessel myocardial infarction and ischemia-driven target lesion revascularization in these studies (mean follow-up, 25 months). The risk of definite or probable stent/scaffold thrombosis and very late stent/scaffold thrombosis seems to be higher with BVS. Further information from randomized trials is critical to evaluate clinical outcomes with BVS on complete resolution of the scaffold.
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Affiliation(s)
- Ahmed N Mahmoud
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Amr F Barakat
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Akram Y Elgendy
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Erik Schneibel
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Amgad Mentias
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Ahmed Abuzaid
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
| | - Islam Y Elgendy
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville (A.N.M., A.Y.E., E.S., I.Y.E.); Department of Medicine, Cleveland Clinic Foundation, OH (A.F.B.); Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine (A.M.); and Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, DE (A.A.)
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Uzuka H, Matsumoto Y, Nishimiya K, Ohyama K, Suzuki H, Amamizu H, Morosawa S, Hirano M, Shindo T, Kikuchi Y, Hao K, Shiroto T, Ito K, Takahashi J, Fukuda K, Miyata S, Funaki Y, Ishibashi-Ueda H, Yasuda S, Shimokawa H. Renal Denervation Suppresses Coronary Hyperconstricting Responses After Drug-Eluting Stent Implantation in Pigs In Vivo Through the Kidney-Brain-Heart Axis. Arterioscler Thromb Vasc Biol 2017; 37:1869-1880. [PMID: 28818859 DOI: 10.1161/atvbaha.117.309777] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/02/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Drug-eluting stent-induced coronary hyperconstricting responses remain an important issue. The adventitia harbors a variety of components that potently modulate vascular tone, including sympathetic nerve fibers (SNF) and vasa vasorum. Catheter-based renal denervation (RDN) inhibits sympathetic nerve activity. We, thus, examined whether RDN suppresses drug-eluting stent-induced coronary hyperconstricting responses, and if so, what mechanisms are involved. APPROACH AND RESULTS Protocol 1: pigs implanted with everolimus-eluting stents into the left coronary arteries underwent coronary angiography at 1 month after implantation for assessment of coronary vasomotion and adventitial SNF formation. Drug-eluting stent-induced coronary hyperconstricting responses were significantly enhanced associated with enhanced coronary adventitial SNF and vasa vasorum formation. Protocol 2: pigs implanted with everolimus-eluting stents were randomly assigned to the RDN or sham group. The RDN group underwent renal ablation. At 1 month, RDN significantly caused marked damage of the SNF at the renal arteries without any stenosis, thrombus, or dissections. Notably, RDN significantly upregulated the expression of α2-adrenergic receptor-binding sites in the nucleus tractus solitarius, attenuated muscle sympathetic nerve activity, and decreased systolic blood pressure and plasma renin activity. In addition, RDN attenuated coronary hyperconstricting responses to intracoronary serotonin at the proximal and distal stent edges associated with decreases in SNF and vasa vasorum formation, inflammatory cell infiltration, and Rho-kinase expression/activation. Furthermore, there were significant positive correlations between SNF and vasa vasorum and between SNF and coronary vasoconstricting responses. CONCLUSIONS These results provide the first evidence that RDN ameliorates drug-eluting stent-induced coronary hyperconstricting responses in pigs in vivo through the kidney-brain-heart axis.
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Affiliation(s)
- Hironori Uzuka
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasuharu Matsumoto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kensuke Nishimiya
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuma Ohyama
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Suzuki
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hirokazu Amamizu
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Susumu Morosawa
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michinori Hirano
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomohiko Shindo
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoku Kikuchi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kiyotaka Hao
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Shiroto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenta Ito
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Takahashi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Fukuda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Miyata
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihito Funaki
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hatsue Ishibashi-Ueda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Shimokawa
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (H.U., Y.M., K.N., K.O., H. Suzuki, H.A., S.M., M.H., T.S., Y.K., K.H., T.S., K.I., J.T., K.F., S.M., H. Shimokawa); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (K.N.); Division of Brain Sciences, Department of Medicine, Imperial College London, United Kingdom (H. Suzuki); Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan (Y.F.); and Department of Pathology (H.I.-U.) and Department of Cardiovascular Medicine (S.Y.), National Cerebral and Cardiovascular Center, Suita, Japan.
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Niccoli G, Montone RA, Lanza GA, Crea F. Angina after percutaneous coronary intervention: The need for precision medicine. Int J Cardiol 2017; 248:14-19. [PMID: 28807510 DOI: 10.1016/j.ijcard.2017.07.105] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/13/2017] [Accepted: 07/27/2017] [Indexed: 01/23/2023]
Abstract
Persistence or recurrence of angina after successful percutaneous coronary intervention (PCI) represent an important clinical issue involving from one fifth to one third of patients undergoing myocardial revascularization at one-year follow-up. A systematic approach to this syndrome is strongly needed. Precision medicine is particularly important in addressing angina after successful PCI because of the multiple underlying causes. Restenosis or coronary atherosclerosis progression explain symptom recurrence after successful PCI in some patients, while functional causes, including vasomotor abnormalities of epicardial coronary arteries and/or coronary microvascular dysfunction, explain symptoms in the remaining patients. In this review, we summarize the mechanisms of persistent or recurrent angina after PCI, proposing a diagnostic algorithm and a systematic therapeutic approach.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy; Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Pirozzolo G, Athanasiadis A, Sechtem U, Ong P. Occlusive Spasm of the Left Anterior Descending Artery and First Diagonal Branch After Implantation of Everolimus Eluting Stents Without Re-stenosis in a Female Patient with Resting Angina. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2017. [DOI: 10.15212/cvia.2017.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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33
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Nishimiya K, Matsumoto Y, Uzuka H, Ogata T, Hirano M, Shindo T, Hasebe Y, Tsuburaya R, Shiroto T, Takahashi J, Ito K, Shimokawa H. Beneficial Effects of a Novel Bioabsorbable Polymer Coating on Enhanced Coronary Vasoconstricting Responses After Drug-Eluting Stent Implantation in Pigs in Vivo. JACC Cardiovasc Interv 2016; 9:281-291. [PMID: 26847120 DOI: 10.1016/j.jcin.2015.09.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/24/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to examine which component of drug-eluting stents (DES) plays a major role in enhanced coronary vasoconstricting responses after DES implantation in pigs. BACKGROUND Recent studies have reported unremitting angina due to vasomotion abnormalities even after successful DES implantation. However, it remains to be elucidated which component of DES (metal stent, polymer coating, or antiproliferative drug) is responsible for DES-induced coronary hyperconstricting responses. METHODS We developed poly-dl-lactic acid and polycaprolactone (PDLLA-PCL) copolymer technology with higher biocompatibility that is resorbed within 3 months. Four types of coronary stents were made: 1) a stent with polylactic acid (PLA) polymer coating containing antiproliferative drug (P1+D+); 2) a stent with PLA polymer coating alone without any drug (P1+D-); 3) a stent with novel PDLLA-PCL polymer coating alone (P2+D-); and 4) a bare metal stent (P-D-). The 4 stents were randomly deployed in the left anterior descending and left circumflex coronary arteries in 12 pigs. RESULTS After 1 month, coronary vasoconstriction by intracoronary serotonin was enhanced at P1+D+ and P1+D- stent edges compared with P2+D- and P-D- stent edges and was prevented by a specific Rho-kinase (a central molecule of coronary spasm) inhibitor, hydroxyfasudil. Immunostainings showed that inflammatory changes and Rho-kinase activation were significantly enhanced at P1+D+ and P1+D- sites compared with P2+D- and P-D- sites. There were significant positive correlations between the extent of inflammation or Rho-kinase expression/activation and that of coronary vasoconstriction. CONCLUSIONS These results indicate the important roles of PLA polymer coating in DES-induced coronary vasoconstricting responses through inflammatory changes and Rho-kinase activation in pigs in vivo, which are ameliorated by PDLLA-PCL copolymers.
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Affiliation(s)
- Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Hironori Uzuka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tsuyoshi Ogata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michinori Hirano
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuhi Hasebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuji Tsuburaya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenta Ito
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Hokimoto S, Tabata N, Yamanaga K, Sueta D, Akasaka T, Tsujita K, Sakamoto K, Yamamoto E, Yamamuro M, Izumiya Y, Kaikita K, Kojima S, Matsui K, Ogawa H. Prevalence of coronary macro- and micro-vascular dysfunctions after drug-eluting stent implantation without in-stent restenosis. Int J Cardiol 2016; 222:185-194. [PMID: 27497093 DOI: 10.1016/j.ijcard.2016.07.221] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 07/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim was to examine the prevalence and characteristics of epicardial vasomotor abnormality (EVA) and coronary microvascular dysfunction (CMD) including endothelium-dependent (EDCMD) or -independent (EICMD) in patients following a second-generation drug-eluting stent (second DES) implantation without in-stent restenosis. METHODS AND RESULTS In 105 patients who underwent second DES implantation in the left anterior descending coronary artery (74 men; mean age, 67.9±9.6years), and in 105 suspected angina patients without stenting (65 men; mean age 66.4±9.1years), we evaluated EVA using the acetylcholine provocation test, EDCMD and EICMD by measuring the coronary flow reserve and the relationship between myocardial ischemia (intracoronary lactate production between aorta and coronary sinus and ST-T changes) or recurrent angina and vascular function. There was no difference in the incidence of EVA between DES and control (49.5% versus 55.2%; P=0.41). Given that the prevalence of CMD was higher in DES than in control (59.0% versus 29.5%; P<0.001), CMD may be associated with stent placement. Of the CMD patients, EDCMD alone, EICMD alone, and both CMDs were found in 40.3%, 22.6%, and 37.1%, respectively. Myocardial ischemia was detected in 42.4% of patients, and recurrent angina was more common in the presence of both EDCMD and EICMD in patients with EVA or CMD compared to patients with normal vascular function (EVA, 42.9% versus 7.7%, P=0.015: CMD, 39.1% versus 7.7%, P=0.007). CONCLUSIONS Myocardial ischemia and recurrent angina may be caused by the presence of both EDCMD and EICMD after a second DES implantation without ISR.
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Affiliation(s)
- Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomonori Akasaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Megumi Yamamuro
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kunihiko Matsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Poerner TC, Duderstadt C, Goebel B, Kretzschmar D, Figulla HR, Otto S. Fractional flow reserve-guided coronary angioplasty using paclitaxel-coated balloons without stent implantation: feasibility, safety and 6-month results by angiography and optical coherence tomography. Clin Res Cardiol 2016; 106:18-27. [PMID: 27379610 PMCID: PMC5226992 DOI: 10.1007/s00392-016-1019-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/30/2016] [Indexed: 12/11/2022]
Abstract
Background Percutaneous coronary interventions (PCI) with drug-coated balloons (DCB) might be a promising trade-off between balloon angioplasty and drug-eluting stents, since DCB inhibit neointimal proliferation and limit duration of dual antiplatelet therapy. We investigated the safety, feasibility, and 6-month results of fractional flow reserve (FFR)-guided use of the paclitaxel-coated SeQuent Please® balloon without stenting for elective PCI of de novo lesions. Methods and results In 46 patients (54 lesions) with stable symptomatic coronary artery disease (CAD), a FFR-guided POBA (plain old balloon angioplasty) was performed. In case of a sufficient POBA result with residual stenosis < 40 %, FFR > 0.8 and no severe dissection, the target lesion was finally dilated using the DCB. Quantitative coronary angiography (QCA) was performed before and after the index procedure and at 6-month follow-up (f/u) to calculate late lumen loss (LLL) and net luminal gain (NLG). Optical coherence tomography (OCT) was performed at f/u to assess vascular remodeling. DCB-only treatment was applied to 43 patients (51 lesions), while 3 patients (3 lesions) needed provisional stenting. Invasive f/u was completed in 39 patients (47 lesions). At the stenotic site, the lumen diameter showed a trend toward progressive increase at f/u (LLL: −0.13 ± 0.44 mm, n.s.; NLG: 1.10 ± 0.53 mm, p < 0.001) without aneurysm formation or restenosis after DCB-only treatment. Conclusions FFR-guided DCB-only PCI of de novo lesions appeared feasible and safe in stable CAD with clopidogrel discontinuation after 4 weeks, showing a trend toward positive vessel remodeling without lumen loss at 6 months. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT02120859 Electronic supplementary material The online version of this article (doi:10.1007/s00392-016-1019-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tudor C Poerner
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Corinna Duderstadt
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Björn Goebel
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Daniel Kretzschmar
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Hans R Figulla
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Sylvia Otto
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany.
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Tsuburaya R, Takahashi J, Nakamura A, Nozaki E, Sugi M, Yamamoto Y, Hiramoto T, Horiguchi S, Inoue K, Goto T, Kato A, Shinozaki T, Ishida E, Miyata S, Yasuda S, Shimokawa H. Beneficial effects of long-acting nifedipine on coronary vasomotion abnormalities after drug-eluting stent implantation: The NOVEL study. Eur Heart J 2016; 37:2713-21. [DOI: 10.1093/eurheartj/ehw256] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/31/2016] [Indexed: 12/30/2022] Open
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Outcomes with bioabsorbable vascular scaffolds versus everolimus eluting stents. Int J Cardiol 2016; 212:214-22. [DOI: 10.1016/j.ijcard.2016.03.070] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/13/2016] [Accepted: 03/19/2016] [Indexed: 11/18/2022]
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Rastogi V, Asaithambi G, Patel A, Park K, Bidari S, Hedna VS. Oral verapamil in the prevention of recurrent cerebral ischaemia due to post-stent vasospasm. J Clin Pharm Ther 2016; 41:365-367. [PMID: 27060706 DOI: 10.1111/jcpt.12387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/15/2016] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Endovascular embolization of basilar tip aneurysms (BTA) is performed to prevent rupture, but little is known regarding post-procedural vasospasm and its consequences. We relate management of post-procedural vasospasm found in cardiovascular literature on this rare post-procedural intracranial complication. CASE DESCRIPTION A 52-year-old man develops ischaemic strokes after undergoing posterior cerebral artery (PCA) stent-assisted coil embolization of BTA. Work-up suggested that vasospasm was the cause of his strokes. WHAT IS NEW AND CONCLUSION Vasospasm after intracranial stenting may share similar pathophysiological features to coronary stenting, resulting in ischaemia. Verapamil should be considered an empiric therapy in prevention of stent-related vasospasm.
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Affiliation(s)
- V Rastogi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - G Asaithambi
- John Nasseff Neuroscience Institute and United Hospital, Allina Health, St. Paul, MN, USA
| | - A Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - K Park
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - S Bidari
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - V S Hedna
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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Stone GW, Gao R, Kimura T, Kereiakes DJ, Ellis SG, Onuma Y, Cheong WF, Jones-McMeans J, Su X, Zhang Z, Serruys PW. 1-year outcomes with the Absorb bioresorbable scaffold in patients with coronary artery disease: a patient-level, pooled meta-analysis. Lancet 2016; 387:1277-89. [PMID: 26825231 DOI: 10.1016/s0140-6736(15)01039-9] [Citation(s) in RCA: 231] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Compared with metallic drug-eluting stents, bioresorbable vascular scaffolds (BVS) offer the potential to improve long-term outcomes of percutaneous coronary intervention. Whether or not these devices are as safe and effective as drug-eluting stents within the first year after implantation is unknown. METHODS We did a patient-level, pooled meta-analysis of four randomised trials in which 3389 patients with stable coronary artery disease or a stabilised acute coronary syndrome were enrolled at 301 academic and medical centres in North America, Europe, and the Asia-Pacific region. These patients were randomly assigned to the everolimus-eluting Absorb BVS (n=2164) or the Xience cobalt-chromium everolimus-eluting stent (CoCr-EES; n=1225). The primary endpoints were the 1-year relative rates of the patient-oriented composite endpoint (all-cause mortality, all myocardial infarction, or all revascularisation) and the device-oriented composite endpoint of target lesion failure (cardiac mortality, target vessel-related myocardial infarction, or ischaemia-driven target lesion revascularisation). All analyses were by intention to treat. The four randomised trials included in our meta-analysis are all registered with ClinicalTrials.gov, numbers NCT01751906, NCT01844284, NCT01923740, and NCT01425281. FINDINGS The summary treatment effect for the 1-year relative rates of the patient-oriented composite endpoint did not differ significantly different between BVS and CoCr-EES (relative risk [RR] 1·09 [0·89-1·34], p=0·38). Similarly, the 1-year relative rates of the device-oriented composite endpoint did not differ between the groups (RR 1·22 [95% CI 0·91-1·64], p=0·17). Target vessel-related myocardial infarction was increased with BVS compared with CoCr-EES (RR 1·45 [95% CI 1·02-2·07], p=0·04), due in part to non-significant increases in peri-procedural myocardial infarction and device thrombosis with BVS (RR 2·09 [0·92-4·75], p=0·08). The relative rates of all-cause and cardiac mortality, all myocardial infarction, ischaemia-driven target lesion revascularisation, and all revascularisation did not differ between BVS and CoCr-EES. Results were similar after multivariable adjustment for baseline imbalances, and were consistent across most subgroups and in sensitivity analysis when two additional randomised trials with less than 1 year of follow-up were included. INTERPRETATION In this meta-analysis, BVS did not lead to different rates of composite patient-oriented and device-oriented adverse events at 1-year follow-up compared with CoCr-EES. FUNDING Abbott Vascular.
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Affiliation(s)
- Gregg W Stone
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA.
| | - Runlin Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Dean J Kereiakes
- The Christ Hospital, Heart and Vascular Center, Lindner Research Center, Cincinnati, OH, USA
| | | | - Yoshinobu Onuma
- Thoraxcenter, Erasmus Medical Center, Rotterdam, Netherlands
| | | | | | - Xiaolu Su
- Abbott Vascular, Santa Clara, CA, USA
| | | | - Patrick W Serruys
- International Centre for Cardiovascular Health, Imperial College, London, UK
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Huqi A, Guarini G, Morrone D, Marzilli M. Prediction of Post Percutaneous Coronary Intervention Myocardial Ischaemia. Eur Cardiol 2016; 11:85-89. [PMID: 30310453 DOI: 10.15420/ecr.2016:27:2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Following revascularisation the majority of patients obtain symptom relief and improved quality of life. However, myocardial ischaemia may recur or persist in a significant patient subset. Symptom recurrence is usually attributed to inaccurate evaluation of epicardial stenosis, incomplete revascularisation or stent failure and disease progression. However, technological advances with modern imaging and/or physiological evaluation of epicardial plaques have not solved this issue. Conversely, recent clinical studies have shown that abnormal coronary vasomotion and increased myocardial resistance are frequent determinants of post-percutaneous coronary intervention (PCI) myocardial ischaemia. Strategies to enhance prediction of post-PCI angina include proper selection of patients undergoing revascularisation, construction of clinical prediction models, and further invasive evaluation at the time of coronary angiography in those with high likelihood.
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Affiliation(s)
- Alda Huqi
- Cardiac Care Unit, Santa Maria Maddalena Hospital, Pisa, Italy
| | | | | | - Mario Marzilli
- Cardiac Care Unit, Santa Maria Maddalena Hospital, Pisa, Italy
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Ellis SG, Kereiakes DJ, Metzger DC, Caputo RP, Rizik DG, Teirstein PS, Litt MR, Kini A, Kabour A, Marx SO, Popma JJ, McGreevy R, Zhang Z, Simonton C, Stone GW. Everolimus-Eluting Bioresorbable Scaffolds for Coronary Artery Disease. N Engl J Med 2015; 373:1905-15. [PMID: 26457558 DOI: 10.1056/nejmoa1509038] [Citation(s) in RCA: 485] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In patients with coronary artery disease who receive metallic drug-eluting coronary stents, adverse events such as late target-lesion failure may be related in part to the persistent presence of the metallic stent frame in the coronary-vessel wall. Bioresorbable vascular scaffolds have been developed to attempt to improve long-term outcomes. METHODS In this large, multicenter, randomized trial, 2008 patients with stable or unstable angina were randomly assigned in a 2:1 ratio to receive an everolimus-eluting bioresorbable vascular (Absorb) scaffold (1322 patients) or an everolimus-eluting cobalt-chromium (Xience) stent (686 patients). The primary end point, which was tested for both noninferiority (margin, 4.5 percentage points for the risk difference) and superiority, was target-lesion failure (cardiac death, target-vessel myocardial infarction, or ischemia-driven target-lesion revascularization) at 1 year. RESULTS Target-lesion failure at 1 year occurred in 7.8% of patients in the Absorb group and in 6.1% of patients in the Xience group (difference, 1.7 percentage points; 95% confidence interval, -0.5 to 3.9; P=0.007 for noninferiority and P=0.16 for superiority). There was no significant difference between the Absorb group and the Xience group in rates of cardiac death (0.6% and 0.1%, respectively; P=0.29), target-vessel myocardial infarction (6.0% and 4.6%, respectively; P=0.18), or ischemia-driven target-lesion revascularization (3.0% and 2.5%, respectively; P=0.50). Device thrombosis within 1 year occurred in 1.5% of patients in the Absorb group and in 0.7% of patients in the Xience group (P=0.13). CONCLUSIONS In this large-scale, randomized trial, treatment of noncomplex obstructive coronary artery disease with an everolimus-eluting bioresorbable vascular scaffold, as compared with an everolimus-eluting cobalt-chromium stent, was within the prespecified margin for noninferiority with respect to target-lesion failure at 1 year. (Funded by Abbott Vascular; ABSORB III ClinicalTrials.gov number, NCT01751906.).
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Affiliation(s)
- Stephen G Ellis
- From Cleveland Clinic, Cleveland (S.G.E.), the Christ Hospital, Heart and Vascular Center, Lindner Research Center, Cincinnati (D.J.K.), and Mercy St. Vincent's Medical Center, Toledo (A. Kini) - all in Ohio; Wellmont Holston Valley Medical Center, Kingsport, TN (D.C.M.); St. Joseph's Hospital Health Center, Liverpool, NY (R.P.C.); Scottsdale Healthcare, Scottsdale, AZ (D.G.R.); Scripps Clinic, La Jolla (P.S.T.), and Abbott Vascular, Santa Clara (R.M., Z.Z., C.S.) - both in California; Baptist Medical Center, Jacksonville, FL (M.R.L.); Mount Sinai Medical Center (A. Kabour), Columbia University Medical Center (S.O.M., G.W.S.), and the Cardiovascular Research Foundation (G.W.S.) - all in New York; and the Beth Israel Deaconess Medical Center, Boston (J.J.P.)
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Thermodilutional Confirmation of Coronary Microvascular Dysfunction in Patients With Recurrent Angina After Successful Percutaneous Coronary Intervention. Can J Cardiol 2015; 31:989-97. [DOI: 10.1016/j.cjca.2015.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 12/27/2022] Open
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Anderson TJ. Chest Pain After Percutaneous Coronary Intervention: More Than Meets the Eye. Can J Cardiol 2015; 31:960-2. [PMID: 26100215 DOI: 10.1016/j.cjca.2015.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 04/17/2015] [Accepted: 04/17/2015] [Indexed: 12/27/2022] Open
Affiliation(s)
- Todd J Anderson
- Libin Cardiovascular Institute and the Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Lindemann H, Sechtem U, Ong P. Recurrent Angina Due to Epicardial Coronary Artery Spasm After Successful Bioresorbable Vascular Scaffold Implantation. Circ J 2015; 79:1853-1854. [DOI: 10.1253/circj.cj-15-0279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | - Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus
| | - Peter Ong
- Department of Cardiology, Robert Bosch Krankenhaus
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46
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Ong P, Aziz A, Hansen HS, Prescott E, Athanasiadis A, Sechtem U. Structural and Functional Coronary Artery Abnormalities in Patients With Vasospastic Angina Pectoris. Circ J 2015; 79:1431-1438. [DOI: 10.1253/circj.cj-15-0520] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert Bosch Krankenhaus
| | - Ahmed Aziz
- Department of Cardiology, Odense University Hospital
- Department of Cardiology, Robert Bosch Krankenhaus
| | | | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen
| | | | - Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus
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Schmidt F, Kolle K, Kreuder K, Schnorbus B, Wild P, Hechtner M, Binder H, Gori T, Münzel T. Nighttime aircraft noise impairs endothelial function and increases blood pressure in patients with or at high risk for coronary artery disease. Clin Res Cardiol 2014; 104:23-30. [PMID: 25145323 PMCID: PMC4300412 DOI: 10.1007/s00392-014-0751-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/01/2014] [Indexed: 11/10/2022]
Abstract
Aims Epidemiological studies suggest the existence of a relationship between aircraft noise exposure and increased risk for myocardial infarction and stroke. Patients with established coronary artery disease and endothelial dysfunction are known to have more future cardiovascular events. We therefore tested the effects of nocturnal aircraft noise on endothelial function in patients with or at high risk for coronary artery disease. Methods 60 Patients (50p 1–3 vessels disease; 10p with a high Framingham Score of 23 %) were exposed in random and blinded order to aircraft noise and no noise conditions. Noise was simulated in the patients’ bedroom and consisted of 60 events during one night. Polygraphy was recorded during study nights, endothelial function (flow-mediated dilation of the brachial artery), questionnaires and blood sampling were performed on the morning after each study night. Results The mean sound pressure levels Leq(3) measured were 46.9 ± 2.0 dB(A) in the Noise 60 nights and 39.2 ± 3.1 dB(A) in the control nights. Subjective sleep quality was markedly reduced by noise from 5.8 ± 2.0 to 3.7 ± 2.2 (p < 0.001). FMD was significantly reduced (from 9.6 ± 4.3 to 7.9 ± 3.7 %; p < 0.001) and systolic blood pressure was increased (from 129.5 ± 16.5 to 133.6 ± 17.9 mmHg; p = 0.030) by noise. The adverse vascular effects of noise were independent from sleep quality and self-reported noise sensitivity. Conclusions Nighttime aircraft noise markedly impairs endothelial function in patients with or at risk for cardiovascular disease. These vascular effects appear to be independent from annoyance and attitude towards noise and may explain in part the cardiovascular side effects of nighttime aircraft noise.
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Affiliation(s)
- Frank Schmidt
- 2 Medical Clinic, Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
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Successful ablation of a bioresorbable polymeric vascular scaffold by rotational atherectomy. Clin Res Cardiol 2014; 103:501-4. [PMID: 24590003 DOI: 10.1007/s00392-014-0689-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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