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Mehta PK, Huang J, Levit RD, Malas W, Waheed N, Bairey Merz CN. Ischemia and no obstructive coronary arteries (INOCA): A narrative review. Atherosclerosis 2022; 363:8-21. [PMID: 36423427 PMCID: PMC9840845 DOI: 10.1016/j.atherosclerosis.2022.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/30/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Myocardial ischemia with no obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is increasingly being recognized as a substantial contributor to adverse cardiovascular mortality and outcomes, including myocardial infarction and heart failure with preserved ejection fraction (HFpEF). While INOCA occurs in both women and men, women are more likely to have the finding of INOCA and are more adversely impacted by angina, with recurrent hospitalizations and a lower quality of life with this condition. Abnormal epicardial coronary vascular function and coronary microvascular dysfunction (CMD) have been identified in a majority of INOCA patients on invasive coronary function testing. CMD can co-exist with obstructive epicardial coronary artery disease (CAD), diffuse non-obstructive epicardial CAD, and with coronary vasospasm. Epicardial vasospasm can also occur with normal coronary arteries that have no atherosclerotic plaque on intravascular imaging. While all predisposing factors are not clearly understood, cardiometabolic risk factors, and endothelium dependent and independent mechanisms that increase oxidative stress and inflammation are associated with microvascular injury, CMD and INOCA. Cardiac autonomic dysfunction has also been implicated in abnormal vasoreactivity and persistent symptoms. INOCA is under-recognized and under-diagnosed, partly due to the heterogenous patient populations and mechanisms. However, diagnostic testing methods are available to guide INOCA management. Treatment of INOCA is evolving, and focuses on cardiac risk factor control, improving ischemia, reducing atherosclerosis progression, and improving angina and quality of life. This review focuses on INOCA, relations to HFpEF, available diagnostics, current and investigational therapeutic strategies, and knowledge gaps in this condition.
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Affiliation(s)
- Puja K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jingwen Huang
- J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca D Levit
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Waddah Malas
- Cardiovascular Disease Fellowship Training Program, Loyola Medical Center, Chicago, IL, USA
| | - Nida Waheed
- Cardiovascular Disease Fellowship Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
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2
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Soleymani M, Masoudkabir F, Shabani M, Vasheghani-Farahani A, Behnoush AH, Khalaji A. Updates on Pharmacologic Management of Microvascular Angina. Cardiovasc Ther 2022; 2022:6080258. [PMID: 36382021 PMCID: PMC9626221 DOI: 10.1155/2022/6080258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 10/17/2022] [Indexed: 01/14/2024] Open
Abstract
Microvascular angina (MVA), historically called cardiac syndrome X, refers to angina with nonobstructive coronary artery disease. This female-predominant cardiovascular disorder adds considerable health-related costs due to repeated diagnostic angiography and frequent hospital admissions. Despite the high prevalence of this diagnosis in patients undergoing coronary angiography, it is still a therapeutic challenge for cardiologists. Unlike obstructive coronary artery disease, with multiple evidence-based therapies and management guidelines, little is known regarding the management of MVA. During the last decade, many therapeutic interventions have been suggested for the treatment of MVA. However, there is a lack of summarization tab and update of current knowledge about pharmacologic management of MVA, mostly due to unclear pathophysiology. In this article, we have reviewed the underlying mechanisms of MVA and the outcomes of various medications in patients with this disease. Contrary to vasospastic angina in which normal angiogram is observed as well, nitrates are not effective in the treatment of MVA. Beta-blockers and calcium channel blockers have the strongest evidence of improving the symptoms. Moreover, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, estrogen, and novel antianginal drugs has had promising outcomes. Investigations are still ongoing for vitamin D, omega-3, incretins, and n-acetyl cysteine, which have resulted in beneficial initial outcomes. We believe that the employment of the available results and results of the future large-scale trials into cardiac care guidelines would help reduce the global cost of cardiac care tremendously.
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Affiliation(s)
- Mosayeb Soleymani
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsima Shabani
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ali Vasheghani-Farahani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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3
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Jovanovic I, Tesic M, Djordjevic-Dikic A, Giga V, Beleslin B, Aleksandric S, Boskovic N, Petrovic O, Marjanovic M, Vratonjic J, Paunovic I, Ivanovic B, Trifunovic-Zamaklar D. Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1134-1142. [PMID: 36218210 DOI: 10.1002/jcu.23313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 06/16/2023]
Abstract
This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.
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Affiliation(s)
- Ivana Jovanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Milorad Tesic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Olga Petrovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Marjanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Ivana Paunovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Branislava Ivanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Trifunovic-Zamaklar
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Wiśniewski OW, Dydowicz F, Salamaga S, Skulik P, Migaj J, Kałużna-Oleksy M. Risk Factors Predisposing to Angina in Patients with Non-Obstructive Coronary Arteries: A Retrospective Analysis. J Pers Med 2022; 12:jpm12071049. [PMID: 35887545 PMCID: PMC9318432 DOI: 10.3390/jpm12071049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022] Open
Abstract
No hemodynamically significant atherosclerotic plaques are observed in up to 30% of patients reporting angina and undergoing coronary angiography. To investigate risk factors associated with non-obstructive coronary artery disease (NOCAD), we analyzed the medical records of, consecutively, 136 NOCAD subjects and 128 patients with significant stenosis in at least one coronary artery (the OCAD group). The blood concentrations of the TC (4.40 [3.78−5.63] mmol/L vs. 4.12 [3.42−5.01] mmol/L; p = 0.026), LDL-C (2.32 [1.80−3.50] mmol/L vs. 2.10 [1.50−2.70] mmol/L; p = 0.003), non-HDL-C (2.89 [2.29−4.19] mmol/L vs. 2.66 [2.06−3.39] mmol/L; p = 0.045), as well as the LDL-C/HDL-C ratio (1.75 [1.22−2.60] vs. 1.50 [1.10−1.95]; p = 0.018) were significantly increased in the NOCAD patients compared to the OCAD group due to the lower prevalence and intensity of the statin therapy in the NOCAD individuals (p < 0.001). Moreover, the abovementioned lipid parameters appeared to be valuable predictors of NOCAD, with the LDL-C (OR = 1.44; 95%CI = 1.14−1.82) and LDL-C/HDL-C (OR = 1.51; 95%CI = 1.13−2.02) showing the highest odds ratios. Furthermore, multivariable logistic regression models determined female sex as the independent risk factor for NOCAD (OR = 2.37; 95%CI = 1.33−4.20). Simultaneously, arterial hypertension substantially lowered the probability of NOCAD (OR = 0.21; 95%CI = 0.10−0.43). To conclude, female sex, the absence of arterial hypertension, as well as increased TC, LDL-C, non-HDL, and LDL-C/HDL-C ratio are risk factors for NOCAD in patients reporting angina, potentially as a result of poor hypercholesterolemia management.
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Affiliation(s)
- Oskar Wojciech Wiśniewski
- Faculty of Medicine, Poznan University of Medical Sciences, 10 Fredry Street, 61-701 Poznan, Poland; (F.D.); (S.S.); (P.S.)
- Correspondence:
| | - Franciszek Dydowicz
- Faculty of Medicine, Poznan University of Medical Sciences, 10 Fredry Street, 61-701 Poznan, Poland; (F.D.); (S.S.); (P.S.)
| | - Szymon Salamaga
- Faculty of Medicine, Poznan University of Medical Sciences, 10 Fredry Street, 61-701 Poznan, Poland; (F.D.); (S.S.); (P.S.)
| | - Przemysław Skulik
- Faculty of Medicine, Poznan University of Medical Sciences, 10 Fredry Street, 61-701 Poznan, Poland; (F.D.); (S.S.); (P.S.)
| | - Jacek Migaj
- 1st Department of Cardiology, Poznan University of Medical Sciences, 1/2 Dluga Street, 61-848 Poznan, Poland; (J.M.); (M.K.-O.)
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, Poznan University of Medical Sciences, 1/2 Dluga Street, 61-848 Poznan, Poland; (J.M.); (M.K.-O.)
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Rubidium-82 Positron Emission Tomography With Intravenous Ergonovine to Diagnose Vasospastic Angina. Can J Cardiol 2021; 37:1661-1664. [PMID: 33812038 DOI: 10.1016/j.cjca.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/20/2022] Open
Abstract
The gold standard to diagnose vasospastic angina is intracoronary reactivity testing, which is performed selectively at dedicated centres. Noninvasive imaging with single-photon emission computerized tomography (SPECT) or echocardiography does not enable accurate localization of spasm or quantification of change in myocardial perfusion in response to an abnormal vasoreactivity. Rubidium-82 positron emission tomography myocardial perfusion imaging (82Rb PET-MPI) with intravenous ergonovine was used to diagnose refractory vasospastic angina in a patient with a complex ischemic syndrome, recent coronary stenting, and persistent atypical angina despite maximal tolerable doses of guideline-directed medical therapy.
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Evaluation of serum platelet-derived growth factor receptor-ß and brain-derived neurotrophic factor levels in microvascular angina. Anatol J Cardiol 2020; 24:397-404. [PMID: 33253128 PMCID: PMC7791298 DOI: 10.14744/anatoljcardiol.2020.44388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Microvascular angina (MVA) is a coronary microcirculation disease. Research on microcirculatory dysfunction has revealed several biomarkers involved in the etiopathogenesis of MVA. Platelet-derived growth factor receptor β (PDGFR-β) and brain-derived neurotrophic factor (BDNF) are 2 biomarkers associated with microcirculation, particularly pericytes function. The aim of this study was to investigate the role of PDGFR-β and BDNF in MVA. Methods: Ninety-one patients (median age, 56 y; age range, 40–79 y; 36 men) with MVA and 61 control group subjects (median age, 52 y; age range, 38–76 y; 29 men) were included in the study. Serum concentrations of PDGFR-β and BDNF were measured with commercially available enzyme-linked immunosorbent assay kits. Results: PDGFR-β [2.82 ng/ml; interquartile range (IQR), 0.57–7.79 ng/ml vs. 2.27 ng/ml; IQR, 0.41–7.16 ng/ml; p<0.0005] and BDNF (2.41 ng/ml; IQR, 0.97–7.97 ng/ml vs. 1.92 ng/ml; IQR, 1.07–6.67 ng/ml; p=0.023) concentrations were significantly higher in patients with MVA compared with the controls. PDGFR-β correlated positively with age (r=0.26, p=0.001), low-density lipoprotein (r=0.18; p=0.02), and BDNF (r=0.47; p<0.001), and BDNF showed a significant positive correlation with age (r=0.20; p=0.01). In binary logistic regression analysis, high-sensitivity C-reactive protein, uric acid, and PDGFR-β values were found to be independent predictors of MVA. Conclusion: MVA is associated with higher PDGFR-β and BDNF levels. This association may indicate an abnormality in microvascular function. Future studies are required to determine the role of these biomarkers in the pathogenesis of MVA. (Anatol J Cardiol 2020; 24: 397-404)
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7
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Gelley G, Zarrabian M, Passmore S. Emergency Department Clinician Experiences and Perceptions Regarding Noncardiac Chest Pain: A Cross-Sectional Survey. J Manipulative Physiol Ther 2019; 42:159-166. [PMID: 31029468 DOI: 10.1016/j.jmpt.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 11/17/2017] [Accepted: 02/26/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objectives of this study are to report the responses of emergency department (ED) clinicians regarding the characteristics and management of patients with noncardiac chest pain (NCCP) and to explore clinician experiences with the current standard of care and whether nonpharmacologic or nonsurgical referral options would be considered. METHODS A cross-sectional survey was delivered to 40 ED clinicians from hospitals in Winnipeg, Manitoba from 2012 to 2013. Data were reduced descriptively and thematically summarized to assess the characteristics of patients with NCCP along with the responses of ED clinicians regarding the management of NCCP. RESULTS The survey response was 27 (67.5% response rate). They reported that patients with NCCP comprised a considerable amount of ED care and are a variable and heterogeneous population. Respondents agreed (63.0%) that onsite and on-call providers for NCCP referral would assist in patient management. Further, ED clinicians (66.7%) would consider referring patients with NCCP to a nonpharmacologic, nonsurgical clinical research study. CONCLUSION Clinicians in this study wanted better access to on-site referrals and outpatient clinics for patients experiencing NCCP after discharge and would consider nonpharmacologic or nonsurgical referral.
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Affiliation(s)
- Geoffrey Gelley
- Rady Faculty of Health Sciences, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Mohammad Zarrabian
- Section of Orthopedic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven Passmore
- Rady Faculty of Health Sciences, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Faculty of Kinesiology & Recreation Management, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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Aslan G, Polat V, Bozcali E, Opan S, Çetin N, Ural D. Evaluation of serum sST2 and sCD40L values in patients with microvascular angina. Microvasc Res 2018; 122:85-93. [PMID: 30502363 DOI: 10.1016/j.mvr.2018.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 11/14/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Coronary microvascular dysfunction plays a major role in the pathogenesis of microvascular angina (MVA). Along with endothelial dysfunction, microvascular atherosclerosis and inflammation seem to contribute to the development of coronary microvascular dysfunction. Serum soluble ST2 (sST2) and serum soluble CD40 ligand (sCD40L) are two biomarkers associated with inflammation and atherosclerosis. The aim of this study was to investigate the role of these biomarkers in the pathogenesis of MVA and determine their possible association with coronary microvascular dysfunction. METHODS A total of 152 patients were included in the study. Ninety-one patients with MVA {median age 56 years (40-79), of which 55 are women} and sixty-one controls {median age 52 (38-76), of which 29 are women} were included in the study. Serum concentration of sST2 and sCD40L were measured with a commercially available ELISA kit. RESULTS Serum sST2 (median 13.6 ng/ml; interquartile range (IQR), 3.5-63.8 ng/ml vs median 10.6 ng/ml; IQR, 2.9-34.2 ng/ml, p < 0.0005) and sCD40L (median 5.3 ng/ml; IQR, 0.5-20.6 ng/ml vs median 2.2 ng/ml; IQR, 0.7-10.8 ng/ml, p < 0.0005) were significantly higher in patients with MVA compared to controls. Analysis of the associations between these biomarkers and potential contributors of MVA revealed that serum sST2 showed a positive correlation with LDL-cholesterol (r = 0.19, p = 0.016) and serum sCD40L concentrations correlated positively with hs-CRP (r = 0.22, p = 0.005). In logistic regression analysis, sCD40L and hs-CRP but not sST2 were found to be significantly associated with MVA. CONCLUSION Higher serum concentrations of sST2 and sCD40L in MVA patients may be associated with inflammatory activation and coronary microvascular dysfunction. Larger studies are required for understanding their role in the pathogenesis of inflammatory and possibly fibrotic process in MVA patients.
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Affiliation(s)
- Gamze Aslan
- Department of Cardiology, Koc University School of Medicine and Hospital, Istanbul, Turkey.
| | - Veli Polat
- Department of Cardiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Evin Bozcali
- Department of Cardiology, Koc University School of Medicine and Hospital, Istanbul, Turkey
| | - Selçuk Opan
- Department of Cardiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Nurcan Çetin
- Duzen Laboratory, Cemal Sahir Sok. No: 14, 34383 Mecidiyekoy, Istanbul, Turkey
| | - Dilek Ural
- Department of Cardiology, Koc University School of Medicine and Hospital, Istanbul, Turkey
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9
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Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation. Can J Cardiol 2018; 34:468-476. [DOI: 10.1016/j.cjca.2018.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/16/2017] [Accepted: 01/01/2018] [Indexed: 12/13/2022] Open
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10
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Wittekoek ME, Piek JJ. Non-obstructive cardiovascular disease: a new challenge for invasive cardiology? Neth Heart J 2018; 26:1-2. [PMID: 29188539 PMCID: PMC5758453 DOI: 10.1007/s12471-017-1062-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - J J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, The Netherlands
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11
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Sarapultsev PA, Sarapultsev AP. Stress cardiomyopathy: Is it limited to Takotsubo syndrome? Problems of definition. Int J Cardiol 2016; 221:698-718. [PMID: 27424315 DOI: 10.1016/j.ijcard.2016.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/04/2016] [Indexed: 02/09/2023]
Abstract
In 2006, Takotsubo syndrome (TTC) was described as a distinct type of stress-induced cardiomyopathy (stress cardiomyopathy). However, when thinking about Takotsubo cardiomyopathy from the viewpoints of the AHA and ESC classifications, 2 possible problems may arise. The first potential problem is that a forecast of disease outcome is lacking in the ESC classification, whereas the AHA only states that 'outcome is favorable with appropriate medical therapy'. However, based on the literature data, one can make a general conclusion that occurrence of myocardial lesions in TTC (i.e., myocardial fibrosis and contraction-band necrosis) causes the same effects as in other diseases with similar levels of myocardial damage and should not be considered to have a lesser impact on mortality. To summarise, TTC can cause not only severe complications such as pulmonary oedema, cardiogenic shock, and dangerous ventricular arrhythmias, but also damage to the myocardium, which can result in the development of potentially fatal conditions even after the disappearance of LV apical ballooning. The second potential problem arises from the definition of TTC as a stress cardiomyopathy in the AHA classification. In fact, the main factors leading to TTC are stress and microvascular anginas, since, as has been already discussed, coronary spasm can cause myocardium stunning, resulting in persistent apical ballooning. Thus, based on this review, 3 distinct types of stress cardiomyopathies exist (variant angina, microvascular angina, and TTC), with poor prognosis. Adding these diseases to the classification of cardiomyopathies will facilitate diagnosis and preventive prolonged treatment, which should include intensive anti-stress therapy.
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Affiliation(s)
- Petr A Sarapultsev
- Federal State Autonomous Educational Institution of Higher Professional Education, Ural Federal University named after the first President of Russia B. N. Yeltsin, Russia; Institute of Immunology and Physiology of the Ural Branch of the RAS, Russia
| | - Alexey P Sarapultsev
- Federal State Autonomous Educational Institution of Higher Professional Education, Ural Federal University named after the first President of Russia B. N. Yeltsin, Russia; Institute of Immunology and Physiology of the Ural Branch of the RAS, Russia.
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12
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Abstract
Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.
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Affiliation(s)
- Shilpa Agrawal
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Puja K Mehta
- Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
| | - C Noel Bairey Merz
- Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA
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13
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Chambers JB, Marks EM, Hunter MS. The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed? Heart 2015; 101:1240-9. [PMID: 25882503 DOI: 10.1136/heartjnl-2014-306277] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/08/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- J B Chambers
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK
| | - E M Marks
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M S Hunter
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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14
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Abstract
Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.
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Affiliation(s)
- Shilpa Agrawal
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Puja K Mehta
- Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
| | - C Noel Bairey Merz
- Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA
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