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Rehan R, Wong CCY, Weaver J, Chan W, Tremmel JA, Fearon WF, Ng MKC, Yong ASC. Multivessel Coronary Function Testing Increases Diagnostic Yield in Patients With Angina and Nonobstructive Coronary Arteries. JACC Cardiovasc Interv 2024; 17:1091-1102. [PMID: 38749588 DOI: 10.1016/j.jcin.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield. OBJECTIVES The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA). METHODS Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 μg) and right (20 to 80μg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels. RESULTS This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486). CONCLUSIONS Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.
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Affiliation(s)
- Rajan Rehan
- Royal Prince Alfred Hospital, Sydney, Australia
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Coronary artery bypass grafting after acute ST-elevation myocardial infarction. J Thorac Cardiovasc Surg 2023; 165:672-683.e10. [PMID: 33931231 DOI: 10.1016/j.jtcvs.2021.03.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The study objectives were to describe the trends and outcomes of isolated coronary artery bypass grafting after ST-elevation myocardial infarction using a nationwide database. METHODS We queried the 2002-2016 National Inpatient Sample database for hospitalized patients with ST-elevation myocardial infarction who underwent isolated coronary artery bypass grafting. We report temporal trends, predictors, and outcomes of coronary artery bypass grafting in the early (2002-2010) and recent (2011-2016) cohorts. RESULTS Of 3,347,470 patients hospitalized for ST-elevation myocardial infarction, 7.7% underwent isolated coronary artery bypass grafting. The incidence of isolated coronary artery bypass grafting after ST-elevation myocardial infarction decreased over time (9.2% in 2002 vs 5.5% in 2016, Ptrend < .001), whereas perioperative crude in-hospital mortality did not change (5.1% in 2002 vs 4.2% in 2016, Ptrend = .66), coinciding with an increase in the burden of comorbidities. There was an increase in performing isolated coronary artery bypass grafting on hospitalization day 3 or more, as well as an increase in the use of mechanical support devices and precoronary artery bypass grafting percutaneous coronary intervention. In the early cohort, isolated coronary artery bypass grafting on days 1 and 2 was associated with higher in-hospital mortality. In the recent cohort, coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more and lower rates of acute kidney injury, ischemic stroke, ventricular arrhythmia, and length of hospital stay. CONCLUSIONS In this nationwide analysis, there has been a decline in the use of isolated coronary artery bypass grafting after ST-elevation myocardial infarction. Isolated coronary artery bypass grafting on day 1 was performed in sicker patients and was associated with higher in-hospital mortality than coronary artery bypass grafting performed on day 3 or more. In the recent cohort, isolated coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more.
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Ong GJ, Horowitz JD. Ambulance ramping and patients with cardiac‐type symptoms: understanding the unloading queue. Med J Aust 2022; 217:238-239. [DOI: 10.5694/mja2.51677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Gao Jing Ong
- Central Adelaide Local Health Network Adelaide SA
- Basil Hetzel Institute for Translational Health Research Adelaide SA
- The University of Adelaide Adelaide SA
| | - John D Horowitz
- Basil Hetzel Institute for Translational Health Research Adelaide SA
- The University of Adelaide Adelaide SA
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Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081124. [PMID: 36013303 PMCID: PMC9409871 DOI: 10.3390/life12081124] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 12/26/2022]
Abstract
Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.
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Nguyen TH, Ong GJ, Girolamo OC, De Menezes Caceres' V, Muminovic A, Chirkov YY, Horowitz JD. Angina due to coronary artery spasm (variant angina): diagnosis and intervention strategies. Expert Rev Cardiovasc Ther 2021; 19:917-927. [PMID: 34633245 DOI: 10.1080/14779072.2021.1991314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Since Prinzmetal first described a 'variant' form of angina pectoris, with predominantly resting episodes of pain and cyclic severity variations, it has gradually become apparent that this clinical presentation is caused by episodes of coronary artery spasm (CAS) involving focal or diffuse changes in large and/or small coronary arteries in the presence or absence of 'fixed' coronary artery stenoses. However, most clinicians have only limited understanding of this group of disorders. AREAS COVERED We examine the clinical presentation of CAS, associated pathologies outside the coronary vasculature, impediments to making the diagnosis, provocative diagnostic tests, available and emerging treatments, and the current understanding of pathogenesis. EXPERT OPINION CAS is often debilitating and substantially under-diagnosed and occur mainly in women. Many patients presenting with CAS crises have non-diagnostic ECGs and normal serum troponin concentrations, but CAS can be suspected on the basis of history and association with migraine, Raynaud's phenomenon and Kounis syndrome. Definitive diagnosis requires provocative testing at coronary angiography. Treatment still centers around the use of calcium antagonists, but with greater understanding of pathogenesis, new management options are emerging.
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Affiliation(s)
- Thanh Ha Nguyen
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Gao-Jing Ong
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Olivia C Girolamo
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Viviane De Menezes Caceres'
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Armin Muminovic
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Yuliy Y Chirkov
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - John D Horowitz
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
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Imam H, Nguyen TH, Stafford I, Liu S, Heresztyn T, Chirkov YY, Horowitz JD. Impairment of platelet NO signalling in coronary artery spasm: role of hydrogen sulphide. Br J Pharmacol 2021; 178:1639-1650. [PMID: 33486763 DOI: 10.1111/bph.15388] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 12/22/2020] [Accepted: 01/04/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND PURPOSE The pathophysiology of coronary artery spasm (CAS), with its associated ischaemic crises, is currently poorly understood and treatment is frequently ineffective. In view of increasing evidence that platelet-based defects may occur in CAS patients, we investigated platelet reactivity in CAS patients and whether symptomatic crises reflect activation of platelet-endothelial interactions. EXPERIMENTAL APPROACH CAS patients were evaluated during acute and/or chronic symptomatic phases and compared with healthy control subjects. Inhibition of ADP-induced platelet aggregation by the NO donor sodium nitroprusside (SNP) and plasma concentrations of syndecan 1 (glycocalyx shedding marker), tryptase (mast cell activation marker) and platelet microparticles were measured. KEY RESULTS Inhibition of platelet aggregation by SNP was diminished in chronic CAS, with further (non-significant) deterioration during symptomatic crises, whereas plasma concentrations of syndecan 1, tryptase and platelet microparticles increased. Treatment of patients with high-dose N-acetylcysteine (NAC) plus glyceryl trinitrate rapidly increased platelet responsiveness to SNP and decreased plasma syndecan 1 concentrations. The effect of NAC on platelet responsiveness to SNP was confirmed in vitro and mimicked by the H2 S donor NaHS. Conversely, inhibition of enzymatic production of H2 S attenuated NAC effect. CONCLUSION AND IMPLICATIONS CAS is associated with substantial impairment of platelet NO signalling. During acute symptomatic exacerbations, platelet resistance to NO is aggravated, together with mast cell activation and damage to both vasculature and platelets. NAC, via release of H2 S, reverses platelet resistance to NO and terminates glycocalyx shedding during symptomatic crises: This suggests that H2 S donors may correct the pathophysiological anomalies underlying CAS.
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Affiliation(s)
- Hasan Imam
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - Thanh H Nguyen
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - Irene Stafford
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - Saifei Liu
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - Tamila Heresztyn
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - Yuliy Y Chirkov
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
| | - John D Horowitz
- Cardiology Research Laboratory, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia
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Increased Rate of Hospitalization With Prinzmetal Angina: What Exactly Is Happening? Am J Med 2020; 133:e162-e163. [PMID: 32331575 DOI: 10.1016/j.amjmed.2019.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 01/22/2023]
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Elbadawi A, Elgendy IY, Saad M, Mahmoud K, Abbott JD, Jneid H, Bhatt DL. The Reply. Am J Med 2020; 133:e164-e165. [PMID: 32331576 DOI: 10.1016/j.amjmed.2019.09.009] [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: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Marwan Saad
- Division of Cardiovascular Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Karim Mahmoud
- Department of Internal Medicine, Houston Medical Center, Warner Robins, Ga
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, Texas
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
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Ozdemir D, Kishor J, Hall JM, Chadow H, Rafii SE. A Rare Case of Vasospastic Angina Presenting with Inferior Lead ST-segment Elevation and Ventricular Fibrillation in the Absence of Coronary Obstruction: A Case Report. Cureus 2019; 11:e6332. [PMID: 31942263 PMCID: PMC6959840 DOI: 10.7759/cureus.6332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Vasospastic angina (VSA) is a variant form of angina pectoris, which occurs at night or at rest, with transient electrocardiogram modifications and preserved exercise capacity. Its association with stable angina, sudden cardiac death, acute coronary syndrome, arrhythmia, and syncope has previously been established. Its presentation can occur with or without existing coronary artery disease and may present with focal or diffuse alteration and dysfunction of the coronary vasculature. VSA diagnosis involves patient response to nitrates, transient ischemic electrocardiogram (ECG) changes, and coronary artery spasms. The mechanisms proposed to constitute the substrate for susceptibility to VSA include vascular smooth muscle cell hyperreactivity, endothelial dysfunction, magnesium deficiency, low-grade inflammation, altered autonomic nervous system response, hypothyroidism, and oxidative stress. Herein, we present the rare case of a patient with ST-segment elevation in the inferior leads, increased troponin, and an episode of ventricular fibrillation initially thought to be due to lateral wall ST-elevation myocardial infarction (STEMI), although it was revealed to be vasospastic angina. We will also review the literature. Vasospastic angina remains underdiagnosed and a timely diagnosis is crucial to prevent major cardiac events. In patients with diffuse ST-segment elevation on ECG (independently of angiographic findings), VSA should be considered as one of the differential diagnoses and treated if found to be the cause of pathological changes.
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Affiliation(s)
- Derman Ozdemir
- Internal Medicine, Saba University School of Medicine, Saba, NLD
| | - Joshi Kishor
- Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Julia M Hall
- Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Hal Chadow
- Cardiology, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Shahrokh E Rafii
- Cardiology, Brookdale University Hospital and Medical Center, Brooklyn, USA
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