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Tsuda T, Patel G. Coronary microvascular dysfunction in childhood: An emerging pathological entity and its clinical implications. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100392. [PMID: 38680649 PMCID: PMC11046079 DOI: 10.1016/j.ahjo.2024.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
Coronary microvascular dysfunction (CMD) encompasses a spectrum of structural and functional alterations in coronary microvasculature resulting in impaired coronary blood flow and consequent myocardial ischemia without obstruction in epicardial coronary artery. The pathogenesis of CMD is complex involving both functional and structural alteration in the coronary microcirculation. In adults, CMD is predominantly discussed in context with anginal chest pain or existing ischemic heart disease and its risk factors. The presence of CMD suggests increased risk of adverse cardiovascular events independent of coronary atherosclerosis. Coronary microvascular dysfunction is also known in children but is rarely recognized due to paucity of concommitent coronary artery disease. Thus, its clinical presentation, underlying mechanism of impaired microcirculation, and prognostic significance are poorly understood. In this review article, we will overview variable CMD reported in children and delineate its emerging clinical significance.
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Affiliation(s)
- Takeshi Tsuda
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Gina Patel
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
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2
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Milasinovic D, Tesic M, Nedeljkovic Arsenovic O, Maksimovic R, Sobic Saranovic D, Jelic D, Zivkovic M, Dedovic V, Juricic S, Mehmedbegovic Z, Petrovic O, Trifunovic Zamaklar D, Djordjevic Dikic A, Giga V, Boskovic N, Klaric M, Zaharijev S, Travica L, Dukic D, Mladenovic D, Asanin M, Stankovic G. Correlation of Non-Invasive Transthoracic Doppler Echocardiography with Invasive Doppler Wire-Derived Coronary Flow Reserve and Their Impact on Infarct Size in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention. J Clin Med 2024; 13:2484. [PMID: 38731013 PMCID: PMC11084315 DOI: 10.3390/jcm13092484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/01/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Coronary microvascular dysfunction is associated with adverse prognosis after ST-segment elevation myocardial infarction (STEMI). We aimed to compare the invasive, Doppler wire-based coronary flow reserve (CFR) with the non-invasive transthoracic Doppler echocardiography (TTDE)-derived CFR, and their ability to predict infarct size. Methods: We included 36 patients with invasive Doppler wire assessment on days 3-7 after STEMI treated with primary percutaneous coronary intervention (PCI), of which TTDE-derived CFR was measured in 47 vessels (29 patients) within 6 h of the invasive Doppler. Infarct size was assessed by cardiac magnetic resonance at a median of 8 months. Results: The correlation between invasive and non-invasive CFR was modest in the overall cohort (rho 0.400, p = 0.005). It improved when only measurements in the LAD artery were considered (rho 0.554, p = 0.002), with no significant correlation in the RCA artery (rho -0.190, p = 0.435). Both invasive (AUC 0.888) and non-invasive (AUC 0.868) CFR, measured in the recanalized culprit artery, showed a good ability to predict infarct sizes ≥18% of the left ventricular mass, with the optimal cut off values of 1.85 and 1.80, respectively. Conclusions: In patients with STEMI, TTDE- and Doppler wire-derived CFR exhibit significant correlation, when measured in the LAD artery, and both have a similarly strong association with the final infarct size.
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Affiliation(s)
- Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Milorad Tesic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Olga Nedeljkovic Arsenovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ruzica Maksimovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dragana Sobic Saranovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Nuclear Medicine with PET, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dario Jelic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Milorad Zivkovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Vladimir Dedovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Stefan Juricic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Zlatko Mehmedbegovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Olga Petrovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Danijela Trifunovic Zamaklar
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Ana Djordjevic Dikic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Vojislav Giga
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Nikola Boskovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Marija Klaric
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Stefan Zaharijev
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Lazar Travica
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Djordje Dukic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Djordje Mladenovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Milika Asanin
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
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Almeida AG, Grapsa J, Gimelli A, Bucciarelli-Ducci C, Gerber B, Ajmone-Marsan N, Bernard A, Donal E, Dweck MR, Haugaa KH, Hristova K, Maceira A, Mandoli GE, Mulvagh S, Morrone D, Plonska-Gosciniak E, Sade LE, Shivalkar B, Schulz-Menger J, Shaw L, Sitges M, von Kemp B, Pinto FJ, Edvardsen T, Petersen SE, Cosyns B. Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology. Eur Heart J Cardiovasc Imaging 2024; 25:e116-e136. [PMID: 38198766 DOI: 10.1093/ehjci/jeae013] [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] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.
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Affiliation(s)
- Ana G Almeida
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Julia Grapsa
- Cardiology Department, Guys and St Thomas NHS Trust, London, UK
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Hospitals, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, UCLouvain, Brussels, Belgium
- Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Nina Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Bernard
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France
- Service de Cardiologie, CHRU de Tours, Tours, France
| | - Erwan Donal
- CHU Rennes, Inserm, LTSI-UMR 1099, University of Rennes, Rennes, France
| | - Marc R Dweck
- Centre for Cardiovascular Science, Chancellors Building, Little France Crescent, Edinburgh, UK
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Krassimira Hristova
- Center for Cardiovascular Diseases, Faculty of Medicine, Sofia University, Sofia, Bulgaria
| | - Alicia Maceira
- Ascires Biomedical Group, Valencia, Spain
- Department of Medicine, Health Sciences School, UCH-CEU University, Valencia, Spain
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Sharon Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, NS, Canada
| | - Doralisa Morrone
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | | | - Leyla Elif Sade
- Cardiology Department, University of Baskent, Ankara, Turkey
- UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jeanette Schulz-Menger
- Charité ECRC Medical Faculty of the Humboldt University Berlin and Helios-Clinics, Berlin, Germany
- DZHK, Partner site Berlin, Berlin, Germany
| | - Leslee Shaw
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai New York, NY, USA
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBERCV, Barcelona, Spain
| | - Berlinde von Kemp
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Fausto J Pinto
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Bernard Cosyns
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
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De Luca M, Crisci G, Armentaro G, Cicco S, Talerico G, Bobbio E, Lanzafame L, Green CG, McLellan AG, Debiec R, Caferra P, Scicali R, Cannatà A, Israr MZ, Heaney LM, Salzano A. Endothelial Dysfunction and Heart Failure with Preserved Ejection Fraction-An Updated Review of the Literature. Life (Basel) 2023; 14:30. [PMID: 38255646 PMCID: PMC10817572 DOI: 10.3390/life14010030] [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: 11/11/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Heart failure (HF) is a clinical syndrome consisting of typical symptoms and signs due to structural and/or functional abnormalities of the heart, resulting in elevated intracardiac pressures and/or inadequate cardiac output. The vascular system plays a crucial role in the development and progression of HF regardless of ejection fraction, with endothelial dysfunction (ED) as one of the principal features of HF. The main ED manifestations (i.e., impaired endothelium-dependent vasodilation, increased oxidative stress, chronic inflammation, leukocyte adhesion, and endothelial cell senescence) affect the systemic and pulmonary haemodynamic and the renal and coronary circulation. The present review is aimed to discuss the contribution of ED to HF pathophysiology-in particular, HF with preserved ejection fraction-ED role in HF patients, and the possible effects of pharmacological and non-pharmacological approaches. For this purpose, relevant data from a literature search (PubMed, Scopus, EMBASE, and Medline) were reviewed. As a result, ED, assessed via venous occlusion plethysmography or flow-mediated dilation, was shown to be independently associated with poor outcomes in HF patients (e.g., mortality, cardiovascular events, and hospitalization due to worsening HF). In addition, SGLT2 inhibitors, endothelin antagonists, endothelial nitric oxide synthase cofactors, antioxidants, and exercise training were shown to positively modulate ED in HF. Despite the need for future research to better clarify the role of the vascular endothelium in HF, ED represents an interesting and promising potential therapeutic target.
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Affiliation(s)
- Mariarosaria De Luca
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Giulia Crisci
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100 Catanzaro, Italy
| | - Sebastiano Cicco
- Internal Medicine Unit “Guido Baccelli” and Arterial Hypertension Unit “Anna Maria Pirrelli”, Department of Precision and Regenerative Medicine and Jonic Area (DiMePReJ), University of Bari Aldo Moro, Azienda Ospedaliero-Universitaria Policlinico, 70124 Bari, Italy
| | | | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Kuggen, 417 56 Gothenburg, Sweden
| | - Lorena Lanzafame
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Christopher G. Green
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Abbie G. McLellan
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Radek Debiec
- Department of Cardiovascular Sciences, University of Leicester, Leicester (UK), IHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK
| | - Paolo Caferra
- Department of Pharmacy, University of Pisa, 56126 Pisa, Italy
| | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Antonio Cannatà
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College, London SE1 8WA, UK
| | - Muhammad Zubair Israr
- Department of Cardiovascular Sciences, University of Leicester, Leicester (UK), IHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK
| | - Liam M. Heaney
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Andrea Salzano
- Cardiac Unit, AORN A Cardarelli, 80131 Naples, Italy
- Cardiac Unit, University Hospital of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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7
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Almeida AG. MINOCA and INOCA: Role in Heart Failure. Curr Heart Fail Rep 2023; 20:139-150. [PMID: 37198520 PMCID: PMC10256635 DOI: 10.1007/s11897-023-00605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE OF REVIEW Infarction (MINOCA) and ischaemia (INOCA) with non-obstructive coronary disease are recent non-conventional presentations of coronary syndromes that are increasingly recognised in the clinical arena, particularly with the availability of new cardiovascular imaging techniques. Both are related to heart failure (HF). MINOCA is not associated with benign outcomes, and HF is among the most prevalent events. Regarding INOCA, microvascular dysfunction has also been found to associate with HF, particularly with preserved ejection fraction (HFpEF). RECENT FINDINGS Regardless of the several aetiologies underlying HF in MINOCA, it is likely related to LV dysfunction, where secondary prevention is not yet clearly established. Regarding INOCA, coronary microvascular ischaemia has been associated to endothelial dysfunction leading ultimately to diastolic dysfunction and HFpEF. MINOCA and INOCA are clearly related to HF. In both, there is a lack of studies on the identification of the risk factors for HF, diagnostic workup and, importantly, the appropriate primary and secondary prevention strategies.
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Affiliation(s)
- Ana G Almeida
- Cardiology, Heart and Vessels Department, University Hospital Santa Maria, Faculty of Medicine of Lisbon University, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal.
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8
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Severino P, D'Amato A, Prosperi S, Myftari V, Colombo L, Tomarelli E, Piccialuti A, Di Pietro G, Birtolo LI, Maestrini V, Badagliacca R, Sardella G, Fedele F, Vizza CD, Mancone M. Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): Focus on Coronary Microvascular Dysfunction and Genetic Susceptibility. J Clin Med 2023; 12:jcm12103586. [PMID: 37240691 DOI: 10.3390/jcm12103586] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
Among the most common causes of death worldwide, ischemic heart disease (IHD) is recognized to rank first. Even if atherosclerotic disease of the epicardial arteries is known as the leading cause of IHD, the presence of myocardial infarction with non-obstructive coronary artery disease (MINOCA) is increasingly recognized. Notwithstanding the increasing interest, MINOCA remains a puzzling clinical entity that can be classified by distinguishing different underlying mechanisms, which can be divided into atherosclerotic and non-atherosclerotic. In particular, coronary microvascular dysfunction (CMD), classifiable in non-atherosclerotic mechanisms, is a leading factor for the pathophysiology and prognosis of patients with MINOCA. Genetic susceptibility may have a role in primum movens in CMD. However, few results have been obtained for understanding the genetic mechanisms underlying CMD. Future studies are essential in order to find a deeper understanding of the role of multiple genetic variants in the genesis of microcirculation dysfunction. Progress in research would allow early identification of high-risk patients and the development of pharmacological, patient-tailored strategies. The aim of this review is to revise the pathophysiology and underlying mechanisms of MINOCA, focusing on CMD and actual knowledge about genetic predisposition to it.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Lorenzo Colombo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Elisa Tomarelli
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Alice Piccialuti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Gianluca Di Pietro
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Gennaro Sardella
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
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9
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Servito M, Gill I, Durbin J, Ghasemlou N, Popov AF, Stephen CD, El-Diasty M. Management of Coronary Artery Disease in CADASIL Patients: Review of Current Literature. Medicina (B Aires) 2023; 59:medicina59030586. [PMID: 36984587 PMCID: PMC10059795 DOI: 10.3390/medicina59030586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common heritable form of vascular dementia in adults. It is well-established that CADASIL results in neurocognitive dysfunction and mood disturbance. There is also cumulative evidence that CADASIL patients are more susceptible to ischemic heart disease. The aim of this study is to review the current literature regarding the incidence of coronary artery disease in CADASIL patients with a focus on the various management options and the clinical challenges associated with each of these treatment strategies. We conducted a literature search using Cochrane, MEDLINE, and EMBASE for papers that reported the occurrence of coronary artery disease in patients with CADASIL. We supplemented the search with a manual search in Google Scholar. Only case reports, case series, and original articles were included. The search resulted in six reports indicating the association between coronary artery disease and CADASIL and its management. Evidence suggests that extracranial manifestations of CADASIL may include coronary artery disease, presenting as a more extensive burden of disease in younger patients. Surgical and percutaneous revascularization strategies are feasible, but the incidence of peri-procedural stroke remains significant and should be weighed against the potential benefit derived from either of these strategies. A multidisciplinary approach to therapy, with perspectives from neurologists, cardiologists, and cardiac surgeons, is needed to provide the appropriate treatment to the CADASIL patient with severe coronary artery disease. Future studies should be directed toward the development of targeted therapies that may help with the early detection and prevention of disease progress in these patients.
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Affiliation(s)
- Maria Servito
- Department of Cardiac Surgery, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Isha Gill
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Joshua Durbin
- Division of Cardiology, Department of Medicine, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Nader Ghasemlou
- Department of Anaesthesiology, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Aron-Frederik Popov
- Department of Cardiothoracic Surgery, Helios Clinic, 53721 Siegburg, Germany
- Correspondence:
| | - Christopher D. Stephen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Mohammad El-Diasty
- Division of Cardiac Surgery, Department of Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
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10
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Heart Rate Lowering Significantly Increases Feasibility in Doppler Recording Blood Flow Velocity in Coronaries during Transthoracic Doppler Echocardiography. Diagnostics (Basel) 2023; 13:diagnostics13040670. [PMID: 36832158 PMCID: PMC9955744 DOI: 10.3390/diagnostics13040670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023] Open
Abstract
Background: Coronary blood flow Doppler recording by Transthoracic Doppler in convergent mode (E-Doppler TTE) might be further improved by lowering heart rate (HRL) down to <60 bpm, since low HR < 60 b/m causes a disproportional lengthening of the diastole, so the coronaries are still for a longer time, very much improving the Doppler signal/noise ratio. Methods: A group of 26 patients underwent E-Doppler TTE before and after HR lowering in four branches of the coronary tree, namely, the left main (LMCA); left anterior descending (LAD), subdivided into three segments: proximal, mid and distal; proximal left circumflex (LCx); and obtuse marginal (OM). Color and PW coronary Doppler signal was judged by two expert observers as undetectable (SCORE 1), weak or with clutter artifacts (SCORE 2), or well delineated (SCORE 3). In addition, local accelerated stenotic flow (AsF) was measured in the LAD before and after HRL. Results: Beta-blockers significantly decreased the mean HR from 76 ± 5 to 57 ± 6 bpm (p < 0.001). Before HRL, the Doppler quality was very poor in the proximal and mid-LAD segments (median score value = 1 in both), while in the distal LAD, it was significantly better but still suboptimal (median score value = 1.5, p = 0.009 vs. proximal and mid-LAD score). After HRL, blood flow Doppler recording in the three LAD segments was strikingly improved (median score value = 3, 3 and 3, p = ns), so the effect of HRL was more efficacious in the two more proximal LAD segments. In 10 patients undergoing coronary angiography (CA), no AsF as expression of transtenotic velocity was detected at baseline. After HRL, thanks to the better quality and length of color flow, ASF was detected in five patients while in five others, it was not in perfect agreement with CA (Spearman correlation coefficient = 1, p < 0.01). The color flow in the proximal LCx and OM was extremely poor at baseline (color flow length 0 and 0, median (interquartile range) mm, respectively) and improved considerably after HRL (color flow length 23 [13.5] and 25 [12.0] mm, respectively, p < 0.001). Conclusions: HRL greatly improved the success rate of blood flow Doppler recording in coronaries, not only in the LAD, but also in the LCx. Therefore, AsF for stenosis detection and coronary flow reserve assessment can have wider clinical applications. However, further studies with larger samples are needed to confirm these results.
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11
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Rehan R, Yong A, Ng M, Weaver J, Puranik R. Coronary microvascular dysfunction: A review of recent progress and clinical implications. Front Cardiovasc Med 2023; 10:1111721. [PMID: 36776251 PMCID: PMC9908997 DOI: 10.3389/fcvm.2023.1111721] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
The coronary microcirculation plays a cardinal role in regulating coronary blood flow to meet the changing metabolic demands of the myocardium. Coronary microvascular dysfunction (CMD) refers to structural and functional remodeling of the coronary microcirculation. CMD plays a role in the pathogenesis of obstructive and non-obstructive coronary syndromes as well as myocardial diseases, including heart failure with preserved ejection fraction (HFpEF). Despite recent diagnostic advancements, CMD is often under-appreciated in clinical practice, and may allow for the development of novel therapeutic targets. This review explores the diagnosis and pathogenic role of CMD across a range of cardiovascular diseases, its prognostic significance, and the current therapeutic landscape.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Martin Ng
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - James Weaver
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia,*Correspondence: Rajesh Puranik,
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12
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Zhu H, Wang H, Zhu X, Chen Q, Fang X, Xu X, Ping Y, Gao B, Tong G, Ding Y, Chen T, Huang J. The Importance of Integrated Regulation Mechanism of Coronary Microvascular Function for Maintaining the Stability of Coronary Microcirculation: An Easily Overlooked Perspective. Adv Ther 2023; 40:76-101. [PMID: 36279093 DOI: 10.1007/s12325-022-02343-7] [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: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 01/25/2023]
Abstract
Coronary microvascular dysfunction (CMD) refers to a group of disorders affecting the structure and function of coronary microcirculation and is associated with an increased risk of major adverse cardiovascular events. At present, great progress has been made in the diagnosis of CMD, but there is no specific treatment for it because of the complexity of CMD pathogenesis. Vascular dysfunction is one of the important causes of CMD, but previous reviews mostly considered microvascular dysfunction as a whole abnormality so the obtained conclusions are skewed. The coronary microvascular function is co-regulated by multiple mechanisms, and the mechanisms by which microvessels of different luminal diameters are regulated vary. The main purpose of this review is to revisit the mechanisms by which coronary microvessels at different diameters regulate coronary microcirculation through integrated sequential activation and briefly discuss the pathogenesis, diagnosis, and treatment progress of CMD from this perspective.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xinyu Zhu
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Qilan Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaojiang Fang
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Yan Ping
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Beibei Gao
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Guoxin Tong
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Yu Ding
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China.
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13
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Ang DTY, Berry C, Kaski JC. Phenotype-based management of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:3332-3340. [PMID: 35672569 PMCID: PMC9834338 DOI: 10.1007/s12350-022-03000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/10/2022] [Indexed: 01/22/2023]
Abstract
40-70% of patients undergoing invasive coronary angiography with signs and symptoms of ischemia are found to have no obstructive coronary artery disease (INOCA). When this heterogeneous group undergo coronary function testing, approximately two-thirds have demonstrable coronary microvascular dysfunction (CMD), which is independently associated with adverse prognosis. There are four distinct phenotypes, or subgroups, each with unique pathophysiological mechanisms and responses to therapies. The clinical phenotypes are microvascular angina, vasospastic angina, mixed (microvascular and vasospastic), and non-cardiac symptoms (reclassification as non-INOCA). The Coronary Vasomotor Disorders International Study Group (COVADIS) have proposed standardized criteria for diagnosis. There is growing awareness of these conditions among clinicians and within guidelines. Testing for CMD can be done using invasive or non-invasive modalities. The CorMicA study advocates the concept of 'functional angiography' to guide stratified medical therapy. Therapies broadly fall into two categories: those that modulate cardiovascular risk and those to alleviate angina. Management should be tailored to the individual, with periodic reassessment for efficacy. Phenotype-based management is a worthy endeavor for both patients and clinicians, aligning with the concept of 'precision medicine' to improve prognosis, symptom burden, and quality of life. Here, we present a contemporary approach to the phenotype-based management of patients with INOCA.
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Affiliation(s)
- Daniel Tze Yee Ang
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
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14
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Zagatina A, Kalinina E, Caprnda M, Gaspar L, Gazdikova K, Ullrich D, Prosecky R, Rodrigo L, Kruzliak P. Prognostic value of Doppler echocardiographic coronary flow velocity assessment at rest in elderly patients. Acta Cardiol 2022; 78:409-416. [PMID: 36189872 DOI: 10.1080/00015385.2022.2121538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Atherosclerosis and coronary artery disease (CAD) are a common condition and cause of death in the elderly population. There are difficulties with risk assessment in the elderly as the objectification of their symptomatic status can be challenging due to neuromuscular weakness, physical deconditioning or neurological, orthopaedic, peripheral vascular, or respiratory limitations. Non-invasive coronary artery velocity assessment by Doppler method at rest could be helpful in the elderly population. To evaluate the prognostic role of coronary artery ultrasound assessment in a non-selected elderly population in everyday clinical practice. METHODS One hundred forty-five patients, aged ≥75years (99 women; 80 ± 4 years), formed the study group. Left coronary artery flows were scanned in addition to conventional echocardiography. During a median follow-up of 26 months, 16 deaths and 2 non-fatal MI occurred. RESULTS In multivariable analysis, maximal coronary velocity was the only independent predictor for mortality (heart rate [HR]: 1.02, 95%, CI: 1.01-1.04, p < .0005) and for mortality/MI (HR: 1.02, 95%, CI: 1.01-1.03, p < .0001). The value of 110 cm/s maximal coronary flow velocity (CFL) in the proximal segments of left arteries was the best predictor for death, sensitivity 50%, specificity 90%, p < .005. The annual mortality rate was 16.6% persons/year for patients with elevated CFL ≥110 cm/s. The value 81 cm/s was the best predictor for death/MI, sensitivity 61%, specificity 80%, p < .0005; annual mortality rate was 11.2% persons/year for patients with elevated CFL ≥81 cm/s (p < .0001). CONCLUSION Doppler CFL scanning during routine echocardiography is a feasible and valuable tool for assessment of short-term prognosis in elderly patients.
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Affiliation(s)
- Angela Zagatina
- Cardiology Department, Cardiocenter "Medika," St. Petersburg, Russian Federation.,Cardiology Department, Saint Petersburg State University Hospital, St. Petersburg, Russian Federation
| | - Elena Kalinina
- Cardiology Department, Cardiocenter "Medika," St. Petersburg, Russian Federation.,Cardiology Department, Saint Petersburg State University Hospital, St. Petersburg, Russian Federation
| | - Martin Caprnda
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Ludovit Gaspar
- Faculty of Health Sciences, University of Ss. Cyril and Methodius in Trnava, Trnava, Slovakia
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia.,Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - David Ullrich
- Cardiology Department, University of Defence, Brno, Czechia
| | - Robert Prosecky
- 2nd Department of Internal Medicine, Faculty of Medicine, Masaryk University and St. Annés University Hospital, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Luis Rodrigo
- Faculty of Medicine, University of Oviedo and Central University Hospital of Asturias (HUCA), Oviedo, Spain
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15
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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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16
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Bradley C, Berry C. Definition and epidemiology of coronary microvascular disease. J Nucl Cardiol 2022; 29:1763-1775. [PMID: 35534718 PMCID: PMC9345825 DOI: 10.1007/s12350-022-02974-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/17/2022] [Indexed: 11/18/2022]
Abstract
Ischemic heart disease remains one of the leading causes of death and disability worldwide. However, most patients referred for a noninvasive computed tomography coronary angiogram (CTA) or invasive coronary angiogram for the investigation of angina do not have obstructive coronary artery disease (CAD). Approximately two in five referred patients have coronary microvascular disease (CMD) as a primary diagnosis and, in addition, CMD also associates with CAD and myocardial disease (dual pathology). CMD underpins excess morbidity, impaired quality of life, significant health resource utilization, and adverse cardiovascular events. However, CMD often passes undiagnosed and the onward management of these patients is uncertain and heterogeneous. International standardized diagnostic criteria allow for the accurate diagnosis of CMD, ensuring an often overlooked patient population can be diagnosed and stratified for targeted medical therapy. Key to this is assessing coronary microvascular function-including coronary flow reserve, coronary microvascular resistance, and coronary microvascular spasm. This can be done by invasive methods (intracoronary temperature-pressure wire, intracoronary Doppler flow-pressure wire, intracoronary provocation testing) and non-invasive methods [positron emission tomography (PET), cardiac magnetic resonance imaging (CMR), transthoracic Doppler echocardiography (TTDE), cardiac computed tomography (CT)]. Coronary CTA is insensitive for CMD. Functional coronary angiography represents the combination of CAD imaging and invasive diagnostic procedures.
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Affiliation(s)
- Conor Bradley
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- NHS Golden Jubilee Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
- NHS Golden Jubilee Hospital, Clydebank, United Kingdom.
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, Scotland, United Kingdom.
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17
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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18
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Chua J, Le T, Sim YC, Chye HY, Tan B, Yao X, Wong D, Ang BWY, Toh D, Lim H, Bryant JA, Wong TY, Chin CWL, Schmetterer L. Relationship of Quantitative Retinal Capillary Network and Myocardial Remodeling in Systemic Hypertension. J Am Heart Assoc 2022; 11:e024226. [PMID: 35253475 PMCID: PMC9075291 DOI: 10.1161/jaha.121.024226] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background
This study examined the associations between quantitative optical coherence tomography angiography (OCTA) parameters and myocardial abnormalities as documented on cardiovascular magnetic resonance imaging in patients with systemic hypertension.
Methods and Results
We conducted a cross‐sectional study of 118 adults with hypertension (197 eyes). Patients underwent cardiovascular magnetic resonance imaging and OCTA (PLEX Elite 9000, Carl Zeiss Meditec). Associations between OCTA parameters (superficial and deep retinal capillary density) and adverse cardiac remodeling (left ventricular mass, remodeling index, interstitial fibrosis, global longitudinal strain, and presence of left ventricular hypertrophy) were studied using multivariable linear regression analysis with generalized estimating equations. Of the 118 patients with hypertension enrolled (65% men; median [interquartile range] age, 59 [13] years), 29% had left ventricular hypertrophy. After adjusting for age, sex, systolic blood pressure, diabetes, and signal strength of OCTA scans, patients with lower superficial capillary density had significantly higher left ventricular mass (β=−0.150; 95% CI, −0.290 to −0.010), higher interstitial volume (β=−0.270; 95% CI, −0.535 to −0.0015), and worse global longitudinal strain (β=−0.109; 95% CI, −0.187 to −0.032). Lower superficial capillary density was found in patients with hypertension with replacement fibrosis versus no replacement fibrosis (16.53±0.64 mm
‐1
versus 16.96±0.64 mm
‐1
;
P
=0.003).
Conclusions
We showed significant correlations between retinal capillary density and adverse cardiac remodeling markers in patients with hypertension, supporting the notion that the OCTA could provide a non‐invasive index of microcirculation alteration for vascular risk stratification in people with hypertension.
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Affiliation(s)
- Jacqueline Chua
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- Academic Clinical Program Duke‐NUS Medical School National University of Singapore Singapore Singapore
- SERI‐NTU Advanced Ocular Engineering (STANCE) Singapore Singapore
| | - Thu‐Thao Le
- Academic Clinical Program Duke‐NUS Medical School National University of Singapore Singapore Singapore
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Yin Ci Sim
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
| | - Hui Yi Chye
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
| | - Bingyao Tan
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- SERI‐NTU Advanced Ocular Engineering (STANCE) Singapore Singapore
- School of Chemical and Biomedical Engineering Nanyang Technological University Singapore
| | - Xinwen Yao
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- SERI‐NTU Advanced Ocular Engineering (STANCE) Singapore Singapore
- School of Chemical and Biomedical Engineering Nanyang Technological University Singapore
| | - Damon Wong
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- SERI‐NTU Advanced Ocular Engineering (STANCE) Singapore Singapore
- School of Chemical and Biomedical Engineering Nanyang Technological University Singapore
| | - Briana W. Y. Ang
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Desiree‐Faye Toh
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Huishan Lim
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Jennifer A. Bryant
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Tien Yin Wong
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- Academic Clinical Program Duke‐NUS Medical School National University of Singapore Singapore Singapore
| | - Calvin Woon Loong Chin
- Academic Clinical Program Duke‐NUS Medical School National University of Singapore Singapore Singapore
- National Heart Research Institute SingaporeNational Heart Centre Singapore Singapore Singapore
| | - Leopold Schmetterer
- Singapore Eye Research InstituteSingapore National Eye Centre Singapore Singapore
- Academic Clinical Program Duke‐NUS Medical School National University of Singapore Singapore Singapore
- SERI‐NTU Advanced Ocular Engineering (STANCE) Singapore Singapore
- School of Chemical and Biomedical Engineering Nanyang Technological University Singapore
- Department of Clinical Pharmacology Medical University Vienna Vienna Austria
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19
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Abouelnour A, Gori T. Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies. Biomedicines 2021; 9:biomedicines9121774. [PMID: 34944590 PMCID: PMC8698648 DOI: 10.3390/biomedicines9121774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.
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Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Cardiovascular Institute, Assiut University, Assiut 71515, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Correspondence:
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20
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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: 203] [Impact Index Per Article: 67.7] [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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21
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Carbone A, D'Andrea A, Sperlongano S, Tagliamonte E, Mandoli GE, Santoro C, Evola V, Bandera F, Morrone D, Malagoli A, D'Ascenzi F, Bossone E, Cameli M. Echocardiographic assessment of coronary microvascular dysfunction: Basic concepts, technical aspects, and clinical settings. Echocardiography 2021; 38:993-1001. [PMID: 33948990 PMCID: PMC8252466 DOI: 10.1111/echo.15059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023] Open
Abstract
Coronary flow reserve is the capacity of the coronary circulation to augment the blood flow in response an increase in myocardial metabolic demands and has a powerful prognostic significance in different clinical situations. It might assess with invasive and noninvasive technique. Transthoracic echocardiography Doppler is an emerging diagnostic technique, noninvasive, highly feasible, safe for patient and physician, without radiation, and able to detect macrovascular and microvascular anomalies in the coronary circulation. This review aims to describe the benefit and limits of echocardiographic assessment of coronary flow reserve.
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Affiliation(s)
- Andreina Carbone
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Simona Sperlongano
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Ercole Tagliamonte
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Evola
- Department of Clinical and Experimental Medicine, University of Palermo, Palermo, Italy
| | - Francesco Bandera
- Heart Failure Unit, Chair of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Health Science, University of Milan, Milan, Italy
| | - Doralisa Morrone
- Cardiothoracic Department, Cisanello Hospital, University of Pisa, Pisa, Italy
| | | | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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22
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Transthoracic Assessment of Coronary Flow Velocity Reserve: A Practical Approach to Diagnostic Testing in Patients with Angina and No Obstructive Coronary Artery Disease. J Interv Cardiol 2021. [DOI: 10.1155/2021/6689312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
More than half of the patients with symptoms suggestive of myocardial ischemia presenting at invasive angiography have no obstructive coronary artery disease (CAD). A large proportion of these patients have ischemia caused by coronary microvascular dysfunction, a condition associated with adverse cardiovascular prognosis. Measurement of coronary flow velocity reserve by transthoracic Doppler echocardiography is a feasible and reproducible method for the evaluation of coronary microvascular function. This review provides a practical overview of the method in a clinical setting of angina and noobstructive CAD, including technical details and prognostic significance.
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23
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Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
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24
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Kono T, Uetani T, Inoue K, Nagai T, Nishimura K, Suzuki J, Tanabe Y, Kido T, Kurata A, Mochizuki T, Ogimoto A, Okura T, Higaki J, Yamaguchi O, Ikeda S. Diagnostic accuracy of stress myocardial computed tomography perfusion imaging to detect myocardial ischemia: a comparison with coronary flow velocity reserve derived from transthoracic Doppler echocardiography. J Cardiol 2020; 76:251-258. [PMID: 32354493 DOI: 10.1016/j.jjcc.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Our aim was to evaluate the ability of adenosine triphosphate (ATP)-stress myocardial computed tomography perfusion (CTP) imaging to detect myocardial ischemia in the left anterior descending artery (LAD) territory, and to compare this method with coronary flow velocity reserve (CFVR) measured by transthoracic Doppler echocardiography (TTDE). METHODS ATP-stress CTP and CFVR were performed in 50 patients with stable angina pectoris. Myocardial ischemia assessed from CTP imaging was defined as qualitative visual perfusion defects and reduced myocardial blood flow (MBF) based on quantitative assessment. A cut-off value of CFVR of 2.0 was used. RESULTS The mean CFVR was 1.9 ± 0.6 in ischemic regions by CTP, whereas it was 2.9 ± 0.8 in non-ischemic regions (p < 0.001). CTP imaging could accurately predict CFVR <2.0 with 84.0% diagnostic accuracy (94.7% sensitivity, 77.4% specificity, 72.0% positive predictive value, and 96.0% negative predictive value). When receiver operating characteristic curve analysis of the MBF data was performed to detect CFVR <2.0, the area under the curve was 0.89, and the optimal MBF cut-off value was 1.43 mL/g/min. CONCLUSIONS This study suggests that qualitative and quantitative assessment of ATP-stress CTP exhibits a good correlation with CFVR for evaluation of myocardial ischemia.
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Affiliation(s)
- Tamami Kono
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Teruyoshi Uetani
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan.
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kazuhisa Nishimura
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jun Suzuki
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yuki Tanabe
- Department of Radiology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akira Kurata
- Department of Radiology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Teruhito Mochizuki
- Department of Radiology, Ehime University Graduate School of Medicine, Toon, Japan
| | | | - Takafumi Okura
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jitsuo Higaki
- Department of Cardiology, South Matsuyama Hospital, Matsuyama, Japan
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
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25
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Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116:841-855. [DOI: 10.1093/cvr/cvz339] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, Australia
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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26
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Kellermair J, Kiblboeck D, Blessberger H, Kammler J, Reiter C, Steinwender C. Reversible impairment of coronary flow reserve in acute myocarditis. Microcirculation 2018; 25:e12491. [PMID: 30027659 DOI: 10.1111/micc.12491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/18/2018] [Accepted: 07/13/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Acute myocarditis is accompanied by an impaired coronary microcirculation. These microcirculatory disturbances are not well defined, and data are derived from complex invasive measurements. Therefore, this study aimed to evaluate the inflammation-induced microcirculatory dysfunction including its reversibility and association with markers of inflammation severity (extent of LGE on CMR imaging and laboratory markers of myocardial necrosis) using the noninvasive technique of echocardiographic CFR measurement. METHODS Patients (n = 14) with clinically suspected acute myocarditis in the absence of coronary artery disease were prospectively enrolled, and echocardiographic CFR was determined by measuring peak diastolic coronary blood flow velocity at rest (PDV1) and under adenosine-induced hyperemia (PDV2) at baseline and 3-month follow-up. RESULTS Eight of 14 (57.1%) patients showed an impaired baseline CFR (PDV2/PDV1 < 2). These patients were characterized by higher levels of cardiac troponin T (0.55 ± 0.39 vs 0.18 ± 0.08; P = 0.008) and larger areas of LGE on CMR. At 3-month follow-up, CFR was normal in all patients. CONCLUSION A reversibly impaired coronary microcirculation is a frequent finding in acute myocarditis and is associated with markers of inflammation severity. Echocardiographic CFR measurement represents a feasible and safe method for its assessment.
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Affiliation(s)
- Joerg Kellermair
- Institute of Cardiovascular-metabolic Research (ICMR), Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe.,Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe
| | - Daniel Kiblboeck
- Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe
| | - Hermann Blessberger
- Institute of Cardiovascular-metabolic Research (ICMR), Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe.,Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe
| | - Juergen Kammler
- Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe.,Paracelsus Medical University Salzburg, Salzburg, Austria, Europe
| | - Christian Reiter
- Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe
| | - Clemens Steinwender
- Institute of Cardiovascular-metabolic Research (ICMR), Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe.,Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria, Europe.,Paracelsus Medical University Salzburg, Salzburg, Austria, Europe
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27
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Fiorentini S, Saxhaug LM, Bjastad T, Holte E, Torp H, Avdal J. Maximum velocity estimation in coronary arteries using 3D tracking Doppler. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2018; 65:1102-1110. [PMID: 29993929 DOI: 10.1109/tuffc.2018.2827241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Several challenges currently prevent the use of Doppler echocardiography to assess blood flow in the coronary arteries. Due to the anatomy of the coronary tree, out-of-plane flow and high beam-to-flow angles easily occur. Transit time broadening in regions with high velocities leads to overestimation of the maximum velocity envelope, which is a standard clinical parameter for flow quantification. In this work, a commercial ultrasound system was locally modified to perform trans-thoracic, 3D high frame-rate imaging of the coronary arteries. The imaging sequence was then combined with 3D tracking Doppler for retrospective estimation of maximum velocities. Results from simulations showed that 3D tracking Doppler delivers sonograms with better velocity resolution and spectral SNR compared to conventional PW Doppler. Results were confirmed using in vitro recordings. Further simulations based on realistic coronary flow data showed that 3D tracking Doppler can provide improved performance compared to PW Doppler, suggesting a potential benefit on patients. In vivo feasibility of the method was also shown in a healthy volunteer.
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28
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Tesic M, Djordjevic-Dikic A, Giga V, Stepanovic J, Dobric M, Jovanovic I, Petrovic M, Mehmedbegovic Z, Milasinovic D, Dedovic V, Zivkovic M, Juricic S, Orlic D, Stojkovic S, Vukcevic V, Stankovic G, Nedeljkovic M, Ostojic M, Beleslin B. Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients with Nonculprit Stenosis of Intermediate Severity Early after Primary Percutaneous Coronary Intervention. J Am Soc Echocardiogr 2018; 31:880-887. [PMID: 29625885 DOI: 10.1016/j.echo.2018.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of nonculprit coronary stenosis during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction may be beneficial, but the mode and timing of the intervention are still controversial. The aim of this study was to examine the significance and prognostic value of preserved coronary flow velocity reserve (CFVR) in patients with nonculprit intermediate stenosis early after primary percutaneous coronary intervention. METHODS Two hundred thirty patients with remaining intermediate (50%-70%) stenosis of non-infarct-related arteries, in whom CFVR was performed within 7 days after primary percutaneous coronary intervention, were prospectively enrolled. Twenty patients with reduced CFVR and positive results on stress echocardiography or impaired fractional flow reserve underwent revascularization and were not included in further analysis. The final study population of 210 patients (mean age, 58 ± 10 years; 162 men) was divided into two groups on the basis of CFVR: group 1, CFVR > 2 (n = 174), and group 2, CFVR ≤ 2 (n = 36). Cardiac death, nonfatal myocardial infarction, and revascularization of the evaluated vessel were considered adverse events. RESULTS Mean follow-up duration was 47 ± 16 months. Mean CFVR for the whole group was 2.36 ± 0.40. There were six adverse events (3.4%) related to the nonculprit coronary artery in group 1, including one cardiac death, one ST-segment elevation myocardial infarction, and four revascularizations. In group 2, there were 30 adverse events (83.3%, P < .001 vs group 1), including two cardiac deaths, two ST-segment elevation myocardial infarctions, and 26 revascularizations. CONCLUSIONS In patients with CFVR > 2 of the intermediate nonculprit coronary lesion, deferral of revascularization is safe and associated with excellent long-term clinical outcomes.
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Affiliation(s)
- Milorad Tesic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Stepanovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Dobric
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Jovanovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Petrovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Zlatko Mehmedbegovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Vladimir Dedovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Milorad Zivkovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Stefan Juricic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Orlic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sinisa Stojkovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan Vukcevic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Goran Stankovic
- School of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Milan Nedeljkovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miodrag Ostojic
- School of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
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29
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Holte E, Kleveland O, Ueland T, Kunszt G, Bratlie M, Broch K, Michelsen AE, Bendz B, Amundsen BH, Aakhus S, Damås JK, Gullestad L, Aukrust P, Wiseth R. Effect of interleukin-6 inhibition on coronary microvascular and endothelial function in myocardial infarction. Heart 2017; 103:1521-1527. [PMID: 28432157 DOI: 10.1136/heartjnl-2016-310875] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Interleukin-6 (IL-6) is a driver of inflammation and associated endothelial cell activation in acute coronary syndromes. We evaluated the effect of the IL-6 receptor antagonist tocilizumab on coronary microvascular function and endothelial dysfunction measured by coronary flow reserve (CFR) and markers of endothelial cell activation in patients with non-ST-elevation myocardial infarction (NSTEMI). METHODS This substudy was part of a two-centre, double-blind, randomised, placebo-controlled trial evaluating the effect of a single dose of tocilizumab in NSTEMI. Markers of endothelial cell activation (vascular cell adhesion molecule (VCAM)-1, intercellular adhesion molecule-1 and von Willebrand factor) were assessed in 117 patients. In 42 of these patients, 20 assigned to placebo and 22 to tocilizumab, we measured CFR. Blood samples were obtained at seven consecutive time points between day 1 and 3. CFR was measured by transthoracic echocardiography during hospitalisation and after 6 months. RESULTS Tocilizumab did not affect CFR during hospitalisation (tocilizumab: 3.4±0.8 vs placebo: 3.3±1.2, p=0.80). CFR improved significantly in both groups at 6 months. Patients in the tocilizumab group had significantly higher area under the curve for VCAM-1 (median 622 vs 609 ng/mL/hour, tocilizumab and placebo respectively, p=0.003). There were inverse correlations between VCAM-1 and CFR in the placebo (hospitalisation: r=-0.74, p<0.01, 6 months: r=-0.59, p<0.01), but not in the tocilizumab group (hospitalisation: r=0.20, p=0.37, 6 months r=-0.28, p=0.20). CONCLUSIONS Tocilizumab did not affect CFR during hospitalisation or after 6 months. Tocilizumab increased VCAM-1 levels during hospitalisation, but this was not associated with reduced CFR in these patients.
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Affiliation(s)
- Espen Holte
- Clinic of Cardiology, St Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, Norway
| | - Ola Kleveland
- Clinic of Cardiology, St Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, Norway
| | - Thor Ueland
- K.G. Jebsen Thrombosis Research and Expertise Centre, University of Tromsø, Tromsø, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway.,K.G. Jebsen Centre of Inflammatory Research, University of Oslo, Oslo, Norway
| | - Gabor Kunszt
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Marte Bratlie
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- K.G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Annika E Michelsen
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Brage H Amundsen
- Clinic of Cardiology, St Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, Norway
| | - Svend Aakhus
- Clinic of Cardiology, St Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, Norway
| | - Jan Kristian Damås
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology NTNU, Trondheim, Norway
| | - Lars Gullestad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Pål Aukrust
- K.G. Jebsen Thrombosis Research and Expertise Centre, University of Tromsø, Tromsø, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,K.G. Jebsen Centre of Inflammatory Research, University of Oslo, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, Norway
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30
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Tremblay-Darveau C, Williams R, Sheeran PS, Milot L, Bruce M, Burns PN. Concepts and Tradeoffs in Velocity Estimation With Plane-Wave Contrast-Enhanced Doppler. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2016; 63:1890-1905. [PMID: 27824566 DOI: 10.1109/tuffc.2016.2596581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
While long Doppler ensembles are, in principle, beneficial for velocity estimates, short acoustic pulses must be used in microbubble contrast-enhanced (CE) Doppler to mitigate microbubble destruction. This introduces inherent tradeoffs in velocity estimates with autocorrelators, which are studied here. A model of the autocorrelation function adapted to the microbubble Doppler signal accounting for transit time, the echo frequency uncertainty, and contrast-agent destruction is derived and validated in vitro. It is further demonstrated that a local measurement of the center frequency of the microbubble echo is essential in order to avoid significant bias in velocity estimates arising from the linear and nonlinear frequency-dependent scattering of microbubbles and compensate for the inherent speckle nature of the received echo frequency. For these reasons, broadband Doppler estimators (2-D autocorrelator and Radon projection) are better suited than simpler narrow-band estimators (1-D autocorrelator and 1-D Fourier transform) for CE flow assessment. A case study of perfusion in a VX-2 carcinoma using CE plane-wave Doppler is also shown. We demonstrate that even when considering all uncertainties associated with microbubble-related decorrelation (destruction, pulse bandwidth, transit time, and flow gradient) and the need for real-time imaging, a coefficient of variation of 4% on the axial velocity is achievable with plane-wave imaging.
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31
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Rabkin SW, Shiekh IA, Wood DA. The Impact of Left Ventricular Mass on Diastolic Blood Pressure Targets for Patients With Coronary Artery Disease. Am J Hypertens 2016; 29:1085-93. [PMID: 27312942 DOI: 10.1093/ajh/hpw044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/11/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Defining the optimal diastolic blood pressure (DBP) for patients with hypertension and coronary artery disease (CAD) is an ongoing challenge in part because of the concern that low DBP may have adverse cardiac effects (the J curve hypothesis). METHODS Left ventricular mass (LV mass) was measured on the echocardiogram of individuals (N = 92) with CAD who had coronary blood flow (CBF) in the left anterior descending (LAD) artery estimated from artery diameter and DBP distal to coronary stenosis. RESULTS CBF approached 0 in a small but defined proportion of persons at DBP of 70mm Hg. CBF was significantly lower in persons with higher LV mass (above the median of 83g/m(2)) when DBP was ≥75mm Hg. Higher electrocardiogram QRS voltage (sum of S V1 and R in V6), in the absence of LV hypertrophy (LVH), identified persons with significantly lower CBF at DBP ≥ 80mm Hg. In multivariate analysis, LV mass was a significant CBF determinant after adjusting for DBP and CAD severity. LV mass has a major impact on CBF when DBP is >70mm Hg, while DBP is the primary determinant of CBF when DBP is ≤70mm Hg. Multivariate analysis confirmed a significant interaction between LV mass and DBP. CONCLUSIONS DBP ≤ 70mm Hg is associated with a progressively greater proportion in whom CBF in the LAD approaches 0. For DBP > 70mm Hg, persons with higher LV mass, even in the absence of LVH, have lower CBF, suggesting LV mass is an important consideration when DBP is reduced in patients with CAD.
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Affiliation(s)
- Simon W Rabkin
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Imran Amin Shiekh
- Fiona Stanley Hospital (Cardiology), Perth, Western Australia, Australia
| | - David A Wood
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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32
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Michelsen MM, Pena A, Mygind ND, Frestad D, Gustafsson I, Hansen HS, Kastrup J, Bech J, Høst N, Prescott E. Coronary Flow Velocity Reserve Assessed by Transthoracic Doppler: The iPOWER Study: Factors Influencing Feasibility and Quality. J Am Soc Echocardiogr 2016; 29:709-16. [DOI: 10.1016/j.echo.2016.02.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Indexed: 01/07/2023]
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33
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Banovic M, Brkovic V, Nedeljkovic I, Nedeljkovic M, Popovic D, Djordjevic-Dikic A, Ristic A, Nikolic S, Beleslin B. Diabetes mellitus and coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries. Diab Vasc Dis Res 2016; 13:220-7. [PMID: 26993497 DOI: 10.1177/1479164115627107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND AIM Coronary flow reserve is impaired in asymptomatic patients with aortic stenosis and has a prognostic value. We investigated whether the type II diabetes mellitus additionally impairs microvascular circulation assessed by coronary flow reserve in patients with asymptomatic severe aortic stenosis, normal left ventricular ejection fraction and nonobstructed coronary arteries. METHODS A total of 128 patients, mean age of 66.35 ± 10.51 (58.6% males), with severe aortic stenosis and normal left ventricular ejection fraction were enrolled in this study. Patients with diabetes mellitus, those who were treated for diabetes mellitus or had documentation confirming the diagnosis of diabetes mellitus, were considered. All patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis >50% in diameter), standard transthoracic Doppler-echocardiographic study and adenosine stress transthoracic echocardiography for coronary flow reserve measurement. RESULTS Diabetes mellitus was present in 26 patients (20.31%). There was no significant difference in aortic stenosis severity between diabetic and non-diabetic patients [aortic valve area (0.81 ± 0.18 vs 0.85 ± 0.15 cm(2)) and Vmax (4.20 ± 0.57 vs 4.21 ± 0.48 m/s)]. Mean coronary flow reserve in diabetic patients was 1.98 ± 0.48, while mean coronary flow reserve in non-diabetic patients was 2.64 ± 0.54 (p < 0.01). Diabetes mellitus was independent predictor of coronary flow reserve [B = -0.636, 95% confidence interval (-0.916 to -0.368), p < 0.001]. CONCLUSION Diabetes mellitus additionally impairs coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries.
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Affiliation(s)
- Marko Banovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Voin Brkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Milan Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Dejana Popovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Arsen Ristic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Branko Beleslin
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
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34
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Holte E, Vegsundvåg J, Hegbom K, Hole T, Wiseth R. Transthoracic Doppler for detection of stenoses in the three main coronary arteries by use of stenotic to prestenotic velocity ratio and aliased coronary flow. Eur Heart J Cardiovasc Imaging 2015; 16:1323-30. [PMID: 26113119 DOI: 10.1093/ehjci/jev158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/25/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Our aim was to determine the feasibility and accuracy of diagnosing significant coronary artery stenoses using peak stenotic to prestenotic velocity ratio (pSPVR) measurements when compared with results from quantitative coronary angiography and coronary flow velocity reserve (CFVR) assessed by transthoracic echocardiography (TTE). METHODS AND RESULTS One hundred and eight patients scheduled for coronary angiography were studied using transthoracic Doppler echocardiography. Stenoses were identified by local colour aliasing by colour flow Doppler, and further evaluated by pSPVR, using a pSPVR of ≥2.0 as a cut-off for significant stenosis. When pSPVR could not be measured, local mosaic coronary flow pattern at Nyquist limit ≥0.48 m/s was used. Sixty-five lesions suggestive of stenosis were found by TTE. Combining findings of pSPVR ≥2.0 and local mosaic flow at Nyquist limit ≥0.48 m/s, the sensitivity and specificity of demonstrating significant stenoses (diameter stenosis, 50-99%) in the left main coronary artery (LM), left anterior descending coronary (LAD), left circumflex coronary (Cx), and right coronary artery (RCA) were 75 and 98%, 74 and 95%, 40 and 87%, and 34 and 98%, respectively. The pSPVR did not differ significantly between arteries with reduced and normal CFVR, with a cut-off of CFVR <2.0. CONCLUSIONS Findings of pSPVR ≥2.0 or localized colour flow aliasing are useful in the non-invasive diagnosis of significant coronary disease in the three main coronary arteries, with high specificity for detecting significant stenoses. These findings showed high sensitivity for identifying significant stenoses in the LM and LAD, but showed lower ability to detect those lesions in the Cx and RCA.
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Affiliation(s)
- Espen Holte
- Department of Internal Medicine, Ålesund Hospital, Ålesund, Norway Department of Cardiology, Trondheim University Hospital, 7006 Trondheim, Norway
| | | | - Knut Hegbom
- Department of Cardiology, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Torstein Hole
- Department of Internal Medicine, Ålesund Hospital, Ålesund, Norway Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Rune Wiseth
- Department of Cardiology, Trondheim University Hospital, 7006 Trondheim, Norway Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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35
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Incremental Value of Coronary Flow Velocity Reserve, Measured by Transthoracic Echocardiography, Compared with Computed Tomography Angiography Alone, for Detecting Flow-Limiting Coronary Stenoses. J Am Soc Echocardiogr 2014; 27:1230-7. [DOI: 10.1016/j.echo.2014.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Indexed: 02/03/2023]
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36
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Baykan AO, Yüksel Kalkan G, Gür M, Uçar H, Acele A, Şeker T, Şen Ö, Kaypakli O, Harbalioğlu H, Çayli M. Coronary Flow Velocity Reserve in Patients with Ascending Aorta Aneurysm. Echocardiography 2014; 32:975-82. [DOI: 10.1111/echo.12782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ahmet Oytun Baykan
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Gülhan Yüksel Kalkan
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Mustafa Gür
- Department of Cardiology; Kafkas University School of Medicine; Kars Turkey
| | - Hakan Uçar
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Armağan Acele
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Taner Şeker
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Ömer Şen
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Onur Kaypakli
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Hazar Harbalioğlu
- Department of Cardiology; Adana Numune Training and Research Hospital; Adana Turkey
| | - Murat Çayli
- Department of Cardiology; Dicle University School of Medicine; Diyarbakir Turkey
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Kakuta K, Dohi K, Yamada T, Yamanaka T, Kawamura M, Nakamori S, Nakajima H, Tanigawa T, Onishi K, Yamada N, Nakamura M, Ito M. Detection of coronary artery disease using coronary flow velocity reserve by transthoracic Doppler echocardiography versus multidetector computed tomography coronary angiography: influence of calcium score. J Am Soc Echocardiogr 2014; 27:775-85. [PMID: 24679739 DOI: 10.1016/j.echo.2014.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND There have been no clinical data specifying the degree of calcium deposition at which coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography surpasses 320-row multidetector computed tomographic coronary angiography (CTCA) in detecting obstructive coronary artery disease. METHODS One hundred seventy patients who underwent invasive coronary angiography, transthoracic Doppler echocardiography, and CTCA were prospectively enrolled. Coronary artery stenosis was defined as percentage diameter stenosis ≥ 50% on invasive coronary angiography. CFVR < 2.0 and narrowing ≥ 50% measured with CTCA were the thresholds indicating the presence of coronary artery stenosis. The degree of coronary artery calcification was also assessed using the Agatston calcium score method by computed tomography. RESULTS The majority of patients (89%) were classified as having either high or intermediate pretest probability of coronary artery disease. Significant coronary artery stenoses by invasive coronary angiography were found in 71 patients and 104 vessels. Although the overall diagnostic performance of CTCA was comparable with that of CFVR measurement for detecting coronary artery stenosis, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification. Receiver operating characteristic curve analysis indicated that only CFVR measurement is diagnostically accurate when calcium scores are >319 in the patient-based assessment, 189 for the left anterior descending coronary artery, 98 for the left circumflex coronary artery and 282 for the right coronary artery. CONCLUSIONS Transthoracic Doppler echocardiography and 320-row multidetector CTCA successfully diagnosed significant coronary artery stenosis with high feasibility and accuracy. However, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification, and therefore the diagnostic performance of CFVR measurement for detecting coronary artery stenosis surpassed that of CTCA when the calcium score exceeded specified cutoff values.
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Affiliation(s)
- Kentaro Kakuta
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Tomomi Yamada
- Department of Translational Medical Science, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Yamanaka
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Masaki Kawamura
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Nakajima
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Tanigawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Katsuya Onishi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mashio Nakamura
- Department of Clinical Cardiovascular Research, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
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Carlsson M, Jögi J, Markenroth Bloch K, Hedén B, Ekelund U, Ståhlberg F, Arheden H. Submaximal adenosine‐induced coronary hyperaemia with 12 h caffeine abstinence: implications for clinical adenosine perfusion imaging tests. Clin Physiol Funct Imaging 2014; 35:49-56. [DOI: 10.1111/cpf.12125] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 12/11/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Marcus Carlsson
- Department of Clinical Physiology and Nuclear Medicine Lund University Hospital Lund University Lund Sweden
| | - Jonas Jögi
- Department of Clinical Physiology and Nuclear Medicine Lund University Hospital Lund University Lund Sweden
| | - Karin Markenroth Bloch
- Philips Healthcare Lund Sweden
- Department of Medical Radiation Physics Lund University Lund Sweden
| | - Bo Hedén
- Department of Clinical Physiology and Nuclear Medicine Lund University Hospital Lund University Lund Sweden
| | - Ulf Ekelund
- Department of Emergency Medicine Lund University Hospital Lund University Lund Sweden
| | - Freddy Ståhlberg
- Department of Medical Radiation Physics Lund University Lund Sweden
- Department of Diagnostic Radiology Lund University Hospital Lund University Lund Sweden
| | - Håkan Arheden
- Department of Clinical Physiology and Nuclear Medicine Lund University Hospital Lund University Lund Sweden
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Takemoto K, Hirata K, Wada N, Shiono Y, Komukai K, Tanimoto T, Ino Y, Kitabata H, Takarada S, Nakamura N, Kubo T, Tanaka A, Imanishi T, Akasaka T. Acceleration time of systolic coronary flow velocity to diagnose coronary stenosis in patients with microvascular dysfunction. J Am Soc Echocardiogr 2013; 27:200-7. [PMID: 24345631 DOI: 10.1016/j.echo.2013.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to test whether acceleration time of systolic coronary flow velocity could contribute to the diagnosis of coronary stenosis in patients with microvascular dysfunction, on the basis of the hypothesis that systolic coronary flow is less influenced by microvascular function because of compressed myocardium. METHODS Coronary flow velocity was assessed in the left anterior descending coronary artery during hyperemia with intravenous adenosine by echocardiography in 502 patients who were scheduled for coronary angiography because of coronary artery disease and significant valvular disease. Coronary flow velocity reserve (CFVR) and the percentage acceleration time (%AT), as the percentage of the time from the beginning to the peak of systolic coronary flow over systolic time during hyperemia, were calculated. The diagnostic ability of CFVR and %AT for angiographic coronary artery stenosis was then analyzed. As invasive substudies, fractional flow reserve and %AT by a dual-sensor (pressure and Doppler velocity) guidewire were measured simultaneously with %AT on transthoracic echocardiography (n = 14). RESULTS Patients with coronary stenosis had significantly lower CFVR (1.7 ± 0.4) and greater %AT (65 ± 9%) compared with those without stenosis (2.6 ± 0.6 and 50 ± 13%, respectively). Percentage acceleration time by Doppler echocardiography was in good agreement with %AT (r = 0.98) and fractional flow reserve (r = 0.74) invasively measured by dual-sensor guidewire. Cutoff values of CFVR and %AT were determined as 2.0 and 60% in receiver operating characteristic curve analysis. The sensitivity, specificity, and accuracy of CFVR to detect coronary stenosis were 71.1%, 77.3%, and 75.4%, while those of %AT were 83.4%, 71.8%, and 75.4%, respectively. In addition, %AT provided high accuracy to detect coronary stenosis, especially in patients with previous myocardial infarctions, valvular disease, and left ventricular hypertrophy (81.1%, 84.1%, and 73.4%, respectively). CONCLUSIONS The %AT of systolic coronary flow velocity is a promising marker to diagnose coronary stenosis in patients with microvascular dysfunction.
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Affiliation(s)
- Kazushi Takemoto
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kumiko Hirata
- Department of Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Nozomi Wada
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutsugu Shiono
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kenichi Komukai
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Tanimoto
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasushi Ino
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hironori Kitabata
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shigeho Takarada
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Nobuo Nakamura
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Kubo
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Tanaka
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Toshio Imanishi
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Akasaka
- Department of Medicine, Wakayama Medical University, Wakayama, Japan
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Tesic M, Djordjevic-Dikic A, Beleslin B, Trifunovic D, Giga V, Marinkovic J, Petrovic O, Petrovic M, Stepanovic J, Dobric M, Vukcevic V, Stankovic G, Seferovic P, Ostojic M, Vujisic-Tesic B. Regional difference of microcirculation in patients with asymmetric hypertrophic cardiomyopathy: transthoracic Doppler coronary flow velocity reserve analysis. J Am Soc Echocardiogr 2013; 26:775-82. [PMID: 23643850 DOI: 10.1016/j.echo.2013.03.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate, by noninvasive coronary flow velocity reserve (CFVR), whether patients with asymmetric hypertrophic cardiomyopathy (HC), with or without left ventricular outflow tract obstruction, demonstrate significant regional differences of CFVR. METHODS We evaluated 61 patients with HC (27 men; mean age 49 ± 16 years), including 20 patients with hypertrophic obstructive cardiomyopathy (HOCM) and 41 patients without obstruction (HCM). The control group included 20 age- and sex-matched subjects. Transthoracic Doppler echocardiography CFVR of the left anterior descending coronary artery (LAD) and the posterior descending coronary artery (PD) were performed, including calculation of relative CFVR as the ratio between CFVR LAD and CFVR PD. RESULTS Compared with the controls, all the patients with HC had lower CFVR LAD (2.12 ± 0.53 vs 3.34 ± 0.67; P < .001) and CFVR PD (2.29 ± 0.49 vs 3.21 ± 0.65; P < .001). CFVR LAD in HOCM group in comparison with the HCM group was significantly lower (1.93 ± 0.42 vs 2.22 ± 0.55; P = .047), due to higher basal diastolic coronary flow velocities (0.40 ± 0.09 vs 0.33 ± 0.07 m/sec; P = .002), with similar hyperemic diastolic flow velocities (0.71 ± 0.16 vs 0.76 ± 0.19 m/sec; P = .330), respectively. There was no significant difference in CFVR PD between patients with HOCM and those with HCM (2.33 ± 0.46 vs 2.27 ± 0.50; P = .636), respectively. Relative CFVR was lower in the HOCM group compared with the HCM group (0.84 ± 0.16 vs 0.98 ± 0.14; P = .001). By multivariable regression analysis, left ventricular outflow tract gradient was the independent predictor of CFVR LAD (B = -0.24; P = .008) and relative CFVR (B = -0.34; P = .016). CONCLUSIONS CFVR LAD and relative CFVR were significantly lower in patients with HOCM compared with patients with HCM. Regional differences of CFVR are present only in patients with significant left ventricular outflow tract obstruction, which suggests that obstruction per se, by increasing wall stress in basal conditions, leads to higher basal diastolic coronary flow velocities and results in lower CFVR in LAD compared with PD.
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Affiliation(s)
- Milorad Tesic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia.
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Analysis of coronary flow haemodynamics in homozygous familial hypercholesterolaemic adolescents with aortic supravalvular stenosis. Cardiol Young 2013; 23:219-24. [PMID: 22647298 DOI: 10.1017/s1047951112000704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To study coronary artery haemodynamics in adolescents with homozygous familial hypercholesterolaemia and aortic supravalvular stenosis. METHODS Patients diagnosed with familial hypercholesterolaemia who were younger than 16 years and who had undergone transthoracic echocardiography from 2007 to 2010 were included in this study. We included patients with homozygous familial hypercholesterolaemia and aortic supravalvular stenosis and those with heterozygous familial hypercholesterolaemia. All patients underwent stress echocardiography, and left anterior descending coronary artery flow was successfully detected. Coronary flow velocity reserve was calculated as the ratio of hyperaemic mean diastolic flow velocity after injection of adenosine to basal mean diastolic flow velocity. Changes in coronary haemodynamics and the relationship between lipid concentrations were determined. RESULTS A total of 11 patients with homozygous familial hypercholesterolaemia were enrolled in this study. Lipid concentrations were measured, and the mean coronary flow velocity reserve was 1.97 plus or minus 0.51. Seven children were included in the group of patients with heterozygous familial hypercholesterolaemia. In these children, the mean coronary flow velocity reserve was 3.08 plus or minus 0.84. CONCLUSION The coronary flow velocity reserve of homozygous familial hypercholesterolaemic patients is lower than that of heterozygous familial hypercholesterolaemic patients, and it is associated with a high concentration of low-density lipoprotein cholesterol. Aortic stenosis and plaques compromised the ostia of the coronary artery and caused increased basal mean diastolic coronary velocity with blunted increase in peak velocity, which decreased the coronary flow velocity reserve.
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Holte E, Vegsundvåg J, Hegbom K, Hole T, Wiseth R. Transthoracic Doppler Echocardiography for Detection of Stenoses in the Left Coronary Artery by Use of Poststenotic Coronary Flow Profiles: A Comparison with Quantitative Coronary Angiography and Coronary Flow Reserve. J Am Soc Echocardiogr 2013; 26:77-85. [DOI: 10.1016/j.echo.2012.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Indexed: 10/27/2022]
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Giga V, Dobric M, Beleslin B, Sobic-Saranovic D, Tesic M, Djordjevic-Dikic A, Stepanovic J, Nedeljkovic I, Artiko V, Obradovic V, Seferovic PM, Ostojic M. Estimation of infarct size using transthoracic Doppler echocardiographic measurement of coronary flow reserve in infarct related and reference coronary artery. Int J Cardiol 2012; 168:169-75. [PMID: 23058345 DOI: 10.1016/j.ijcard.2012.09.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 07/17/2012] [Accepted: 09/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients in chronic phase of myocardial infarction (MI) have decreased coronary flow reserve (CFR) in infarct related artery (IRA) that is proportional to the extent of microvascular/myocardial damage. We proposed a novel model for the assessment of microvascular damage and infarct size using Doppler echocardiography evaluation of CFRs of the IRA (LAD) and reference artery (RCA). METHODS Our study included 34 consecutive patients (28 men, mean age 50 ± 11 years) with first anterior STEMI and single vessel disease successfully treated with primary PCI. All patients underwent SPECT MPI for the assessment of infarct size (expressed as a percentage of myocardium with fixed perfusion abnormalities) and CFR evaluation of LAD and RCA. CFR derived percentage of microvascular damage (CFR PMD) was calculated as: CFR PMD=(CFR RCA-CFR LAD)/(CFR RCA-1)×100 (%). RESULTS CFR PMD correlated significantly with all parameters evaluating the severity of myocardial damage including: peak CK activity (r=0.632, p<0.001), WMSI (r=0.857, p<0.001), ejection fraction (r=-0.820, p<0.001), left ventricular end diastolic (r=0.757, p<0.001) and end systolic volume (r=0.794, p<0.001). Most importantly, CFR PMD (22 ± 17%) correlated significantly with infarct size by SPECT MPI (21 ± 17%) (r=0.874, p<0.001). CONCLUSIONS CFR PMD derived from the proposed model was significantly related to echocardiographic and enzymatic parameters of infarct size, as well as to myocardial damage assessed by SPECT MPI in patients with successfully reperfused first anterior STEMI.
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Affiliation(s)
- Vojislav Giga
- Clinic for Cardiology, Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia.
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Kakuta K, Dohi K, Yamada T, Yamanaka T, Kawamura M, Nakamori S, Nakajima H, Tanigawa T, Onishi K, Yamada N, Nakamura M, Nobori T, Ito M. Comparison of coronary flow velocity reserve measurement by transthoracic Doppler echocardiography with 320-row multidetector computed tomographic coronary angiography in the detection of in-stent restenosis in the three major coronary arteries. Am J Cardiol 2012; 110:13-20. [PMID: 22459305 DOI: 10.1016/j.amjcard.2012.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 02/21/2012] [Accepted: 02/21/2012] [Indexed: 11/27/2022]
Abstract
We sought to compare the diagnostic accuracy and feasibility of coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography (TTDE) and 320-row multidetector computed tomographic coronary angiography (CTCA) for predicting in-stent restenosis (ISR). We enrolled 126 consecutive patients with 309 implanted coronary stents in the 3 major coronary arteries. TTDE and CTCA were performed within the 2-week period before follow-up invasive coronary angiography. Binary ISR was defined as percent diameter stenosis ≥50% on invasive coronary angiogram. A CFVR <2.0 using TTDE and a narrowing of ≥50% measured with CTCA were the thresholds indicating the presence of binary ISR. Presence of ISR using invasive coronary angiography was observed in 26 (8%) stents and 26 (14%) vessels. Feasibilities of CFVR measurement and CTCA for predicting ISR in the 3 major vessels were 94% and 91%, respectively. A CFVR <2.0 revealed a 95% diagnostic accuracy with sensitivity of 87%, specificity of 96%, positive predictive value of 77%, and negative predictive value of 98%. Diagnostic accuracy of CTCA was comparable to that of CFVR measurement; however, CTC angiographic results were confounded by metal artifacts in the assessment of small-diameter stents. In conclusion, noninvasive CFVR measurement has high feasibility and accuracy for predicting ISR and is comparable to 320-row CTCA.
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Affiliation(s)
- Kentaro Kakuta
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
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Clinical Applications of Transthoracic Doppler Echocardiographic Coronary Flow Reserve Measurements in the Left Anterior Descending Coronary Artery. J Med Ultrasound 2011. [DOI: 10.1016/j.jmu.2011.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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