Coronary artery spasm: Current knowledge and residual uncertainties

Research progress on the natural products in the intervention of myocardial infarction

Coronary heart disease is a prevalent cardiovascular ailment globally, with myocardial infarction (MI) being one of its most severe manifestations. The morbidity and mortality of MI are escalating, showing an increasing trend among younger, highly educated individuals, thereby posing a serious threat to public health. Currently, thrombolysis, percutaneous coronary intervention, and coronary artery bypass grafting are the primary clinical treatments for MI. Although these methods significantly reduce patient mortality, complications often result in poor prognoses. Due to limitations in chemical synthetic drug research, the focus has shifted towards developing herbs based on natural substances. Natural medicines represent a novel approach for safer and more effective MI management and treatment. They can control multiple pathogenic variables by targeting various pathways and systems. This paper investigates the molecular mechanisms of MI and evaluates the application of natural products and medicinal plants in MI treatment over the past 5 years, demonstrating their specific good therapeutic potential and superior tolerance. These natural therapies have been shown to mitigate myocardial cell damage caused by MI through mechanisms such as oxidative stress, inflammation, apoptosis, angiogenesis, myocardial fibrosis, autophagy, endoplasmic reticulum stress, mitophagy, and pyroptosis. This review offers the latest insights into the application of natural products and medicinal plants in MI treatment, elucidating their mechanisms of action and serving as an important reference for MI prevention.

Pharmacotherapy and cardiovascular challenges: a case report of olverembatinib-induced myocardial infarction with non-obstructive coronary arteries

The anticancer drug of tyrosine kinase-inhibitors (TKIs) has significantly improved the prognosis of patients with specific leukemia but has also increased the risk of organ adverse reactions. Herein, we present a case of a patient diagnosed with myeloproliferative neoplasms who experienced recurrent chest pain after receiving treatment with Olverembatinib. Electrocardiography and coronary angiography confirmed the diagnosis of myocardial infarction with non-obstructive coronary arteries. This case serves as a reminder for clinicians to pay more attention and actively prevent the cardiac adverse reactions of TKIs when using such medications.

Paxillin participates in the sphingosylphosphorylcholine-induced abnormal contraction of vascular smooth muscle by regulating Rho-kinase activation

BACKGROUND

The Ca2+-independent contraction of vascular smooth muscle is a leading cause of cardiovascular and cerebrovascular spasms. In the previous study, we demonstrated the involvement of Src family protein tyrosine kinase Fyn and Rho-kinase in the sphingosylphosphorylcholine (SPC)-induced abnormal and Ca2+-independent contraction of vascular smooth muscle, but the specific mechanism has not been completely clarified.

METHODS

Paxillin knockdown human coronary artery smooth muscle cells (CASMCs) and smooth muscle-specific paxillin knockout mice were generated by using paxillin shRNA and the tamoxifen-inducible Cre-LoxP system, respectively. CASMCs contraction was observed by time-lapse recording. The vessel contractility was measured by using a myography assay. Fyn, Rho-kinase, and myosin light chain activation were assessed by immunoprecipitation and western blotting. The paxillin expression and actin stress fibers were visualized by histological analysis and immunofluorescent staining.

RESULTS

The SPC-induced abnormal contraction was inhibited in paxillin knockdown CASMCs and arteries of paxillin knockout mice, indicating that paxillin is involved in this abnormal contraction. Further study showed that paxillin knockdown inhibited the SPC-induced Rho-kinase activation without affecting Fyn activation. In addition, paxillin knockdown significantly inhibited the SPC-induced actin stress fiber formation and myosin light chain phosphorylation. These results suggest that paxillin, as an upstream molecule of Rho-kinase, is involved in the SPC-induced abnormal contraction of vascular smooth muscle.

CONCLUSIONS

The present study demonstrated that paxillin participates in the SPC-induced abnormal vascular smooth muscle contraction by regulating Rho-kinase activation. Video Abstract.

Vasospastic angina: a review on diagnostic approach and management

Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.

Comparison between In-Hospital and Out-of-Hospital Acute Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study

AIMS

Risk factors and outcomes of in-hospital ST elevation myocardial infraction (STEMI) are well explored. Recent findings show that non-ST elevation myocardial infarction (NSTEMI) accounts for the majority of in-hospital infarctions (IHMIs). Our aim was to identify differences between IHMI and out-of-hospital myocardial infraction (OHMI) in terms of risk factors, treatment and outcomes, including both STEMI and NSTEMI.

METHODS

We analyzed the Regional Myocardial Infarction Registry of Saxony-Anhalt dataset. Patient characteristics, treatments and outcomes were compared between IHMI and OHMI. The association between clinical outcomes and myocardial infarction type was assessed using generalized additive models.

RESULTS

Overall, 11.4% of the included myocardial infractions were IHMI, and the majority were NSTEMI. Patients with IHMI were older and had more comorbidities than those with OHMI. Compared to OHMI, in-hospital myocardial infarction was associated with higher odds of 30-day mortality (OR = 1.85, 95% CI 1.32-2.59) and complications (OR = 2.36, 95 % CI 1.84-3.01).

CONCLUSIONS

We provided insights on the full spectrum of IHMI, in both of its classifications. The proportion of IHMI was one ninth of all AMI cases treated in the hospital. Previously reported differences in the baseline characteristics and treatments, as well as worse clinical outcomes, in in-hospital STEMI compared to out-of-hospital STEMI persist even when including NSTEMI cases.

Acute Myocardial Infarction: Etiologies and Mimickers in Young Patients

Acute myocardial infarction is an important cause of death worldwide. While it often affects patients of older age, acute myocardial infarction is garnering more attention as a significant cause of morbidity and mortality among young patients (<45 years of age). More specifically, there is a focus on recognizing the unique etiologies for myocardial infarction in these younger patients as nonatherosclerotic etiologies occur more frequently in this population. As such, there is a potential for delayed and inaccurate diagnoses and treatments that can carry serious clinical implications. The understanding of acute myocardial infarction manifestations in young patients is evolving, but there remains a significant need for better strategies to rapidly diagnose, risk stratify, and manage such patients. This comprehensive review explores the various etiologies for acute myocardial infarction in young adults and outlines the approach to efficient diagnosis and management for these unique patient phenotypes.

Coronary Vascular (DYS) Function and Invasive Physiology Assessment: Insights into Bolus and Continuous Thermodilution Methods

A considerable number of patients with angina or myocardial ischemia have no significant coronary artery disease on invasive angiography. In recent years, several steps towards a better comprehension of the pathophysiology of these conditions, angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), have been made. Nevertheless, several gaps in knowledge still remain. This review is intended to provide a comprehensive overview of ANOCA and INOCA, with a particular focus on pathophysiology, recent diagnostic innovations, gaps in knowledge and treatment modalities.

A case report and literature review of myocardial infarction with nonobstructive coronary arteries (MINOCA) possibly due to acute coronary vasospasm induced by misoprostol

Coronary artery vasospasm (CVS), an uncommon cause of acute chest pain, can be provoked by vasoconstriction-induced medications. Misoprostol, a prostaglandin analog, is a safe medication to terminate a pregnancy. However, misoprostol can cause coronary artery vasospasm due to vasoconstrictor properties, leading to acute myocardial infarction with nonobstructive coronary arteries (MINOCA), especially in patients with a high risk for cardiovascular disease. We report a case of a 42-year-old female with a past medical history of hypertension who presented with ST-elevation myocardial infarction following the administration of a high-dose Misoprostol. The fact that coronary angiogram and intravascular ultrasound revealed normal coronary arteries suggested transient coronary vasospasm. CVS is a severe but rare cardiac adverse effect associated with high-dose misoprostol. This medication should be prescribed with caution and close monitoring, especially in those with pre-existing heart disease or cardiovascular risk factors. Our case raises awareness of severe cardiovascular complications that can be related to using misoprostol in high-risk patients.

Myocardial infarction with non-obstructive coronary arteries (MINOCA)

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is evident in up to 15% of all acute myocardial infarctions (AMI) and disproportionally affects females. Despite younger age, female predominance, and fewer cardiovascular risk factors, MINOCA patients have a worse prognosis than patients without cardiovascular disease and a similar prognosis compared to patients with MI and obstructive coronary artery disease (CAD). MINOCA is a syndrome with a broad differential diagnosis that includes both ischemic [coronary artery plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), and coronary embolism/thrombosis] and non-ischemic mechanisms (Takotsubo cardiomyopathy, myocarditis, and non-ischemic cardiomyopathy)-the latter called MINOCA mimickers. Therefore, a standardized approach that includes multimodality imaging, such as coronary intravascular imaging, cardiac magnetic resonance, and in selected cases, coronary reactivity testing, including provocation testing for coronary vasospasm, is necessary to determine underlying etiology and direct treatment. Herein, we review the prevalence, characteristics, prognosis, diagnosis, and treatment of MINOCA -a syndrome often overlooked.

Serum SELENBP1 and VCL Are Effective Biomarkers for Clinical and Forensic Diagnosis of Coronary Artery Spasm

Coronary artery spasm (CAS) plays an important role in the pathogenesis of many ischemic heart entities; however, there are no established diagnostic biomarkers for CAS in clinical and forensic settings. This present study aimed to identify such serum biomarkers by establishing a rabbit CAS provocation model and integrating quantitative serum proteomics, parallel reaction monitoring/mass spectrometry-based targeted proteomics, and partial least-squares discriminant analysis (PLS-DA). Our results suggested that SELENBP1 and VCL were potential candidate biomarkers for CAS. In independent clinical samples, SELENBP1 and VCL were validated to be significantly lower in serum but not blood cells from CAS patients, with the reasons for this possibly due to the decreased secretion from cardiomyocytes. The areas under the curve of the receiver operating characteristics (ROC) analysis were 0.9384 for SELENBP1 and 0.9180 for VCL when diagnosing CAS. The CAS risk decreased by 32.3% and 53.6% for every 10 unit increases in the serum SELENBP1 and VCL, respectively. In forensic samples, serum SELENBP1 alone diagnosed CAS-induced deaths at a sensitivity of 100.0% and specificity of 72.73%, and its combination with VCL yielded a diagnostic specificity of 100.0%, which was superior to the traditional biomarkers of cTnI and CK-MB. Therefore, serum SELENBP1 and VCL could be effective biomarkers for both the clinical and forensic diagnosis of CAS.

Safety and prognostic relevance of acetylcholine testing in patients with stable myocardial ischaemia or myocardial infarction and non-obstructive coronary arteries

BACKGROUND

Intracoronary provocation testing with acetylcholine (ACh) is crucial for the diagnosis of functional coronary alterations in patients with suspected myocardial ischaemia and non-obstructive coronary arteries.

AIMS

Our intention was to assess the safety and predictive value for major adverse cardiovascular and cerebrovascular events (MACCE) in patients presenting with ischaemia with non-obstructive coronary arteries (INOCA) or with myocardial infarction with non-obstructive coronary arteries (MINOCA).

METHODS

We prospectively enrolled consecutive INOCA or MINOCA patients undergoing intracoronary ACh provocation testing.

RESULTS

A total of 317 patients were enrolled: 174 (54.9%) with INOCA and 143 (45.1%) with MINOCA. Of these, 185 patients (58.4%) had a positive response to the ACh test. Complications during ACh provocative testing were all mild and transient and occurred in 29 (9.1%) patients, with no difference between patients with positive or negative responses to ACh testing, nor between INOCA and MINOCA patients. A history of paroxysmal atrial fibrillation, moderate/severe diastolic dysfunction and a higher QT dispersion at baseline electrocardiogram were independent predictors of complications. MACCE occurred in 30 patients (9.5%) during a median follow-up of 22 months. The incidence of MACCE was higher among patients with a positive ACh test (24 [13.0%] vs 6 [4.5%], p=0.017), and a positive ACh test was an independent predictor of MACCE.

CONCLUSIONS

ACh provocation testing is associated with a low risk of mild and transient complications, with a similar prevalence in both INOCA and MINOCA patients. Importantly, ACh provocation testing can help to identify patients at higher risk of future clinical events, suggesting a net clinical benefit derived from its use in this clinical setting.

Cellular Mechanisms of Coronary Artery Spasm

Coronary artery spasm (CAS) is a reversible phenomenon caused by spontaneous excessive vascular smooth muscle contractility and vascular wall hypertonicity, which results in partial or complete closure of the lumen of normal or atherosclerotic coronary arteries. The clinical picture of CAS includes chest discomfort which is similar in quality to that of stable effort angina. Mechanisms underlying the development of CAS are still unclear. CAS certainly is a multifactorial disease. In this review, we paid attention to the role of the main pathophysiologic mechanisms in CAS: endothelial dysfunction, chronic inflammation, oxidative stress, smooth muscle hypercontractility, atherosclerosis and thrombosis, and mutations leading to deficient aldehyde dehydrogenase 2 (ALDH2) activity. These findings might shed novel insight on the underlying mechanisms and identify potential diagnostic and therapeutic targets for cardiovascular diseases in the future.

MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.

A Case Report of Brachiocephalic Vein Spasm Secondary to Peripherally Inserted Central Catheter

Vascular spasm is well known and studied in the arterial system. There are only a few cases reported related to central venous spasms. We present the case of a 63-year-old male with an extensive medical history, including deep vein thrombosis (DVT), who underwent peripheral insertion of a central catheter in his left upper extremity with subsequent development of left upper extremity edema. The central catheter was removed before the patient underwent a contrast-enhanced computed tomography of the chest which revealed severe narrowing of the left brachiocephalic vein, consistent with venospasm in the clinical setting. Nitroglycerin might be useful to prevent vasospasm, or it might also be used for treatment. In our case, the catheter was removed, and no subsequent treatment was necessary.

Case Report: Oxaliplatin-Induced Third-Degree Atrioventricular Block: First Discovery of an Important Side-Effect

Background

The adverse effects of anticancer therapy in patients with malignancies and cardiovascular diseases are complicated. Oxaliplatin is one of the most commonly used chemotherapy drugs for gastric and colorectal cancers, and oxaliplatin-induced cardiotoxicity has rarely been reported.

Case Summary

We report a 76-year-old man with adenocarcinoma of the esophagogastric junction and a 40-day history of non-ST-elevation myocardial infarction who exhibited a new third-degree atrioventricular block after oxaliplatin administration. We immediately withdrew oxaliplatin treatment and, to avoid future episodes, we implanted a permanent pacemaker for safety and added diltiazem hydrochloride. The third-degree atrioventricular block disappeared after oxaliplatin withdrawal. We detected no recurrence of the third-degree atrioventricular block in future chemotherapies.

Conclusions

This is the first reported oxaliplatin-induced third-degree atrioventricular block, likely mediated by coronary artery spasm. Cancer patients with acute coronary syndrome are a unique and vulnerable population, whom physicians should carefully evaluate and monitor during anticancer treatment. Remarkably, even the most common chemotherapy drugs can cause life-threatening cardiac adverse events.

Coronary Artery Spasm: Risk Factors, Pathophysiological Mechanisms and Novel Diagnostic Approaches

Coronary artery spasm (CAS) is a transient reversible subtotal or complete occlusion induced by coronary hypercontraction and the critical cause of myocardial ischaemia with non-obstructive coronary arteries. During the past decades, our knowledge of the risk factors and pathophysiological mechanisms of CAS have been increasingly progressed, and various diagnostic approaches, including imaging technologies and novel biomarkers, have been proposed to serve well to diagnose CAS clinically. This review aims to summarize these research progresses on the risk factors of CAS and introduce current knowledge about the mechanisms accounting for CAS, including endothelial dysfunction, vascular smooth muscle cell hyperreactivity, and adventitial and perivascular adipose tissue inflammation. We also gathered the recently evolved diagnostic approaches and analyzed their advantages/disadvantages, in purpose of enhancing the diagnostic yield on the basis of ensuring accuracy.

Nilotinib related acute myocardial infarction with nonobstructive coronary arteries: a case report and literature review

BACKGROUND

Myocardial Ischemia with No Obstructive Coronary Artery Disease (MINOCA) is a common cause of type 2 acute myocardial infarction (AMI) which requires careful differential diagnosis. Coronary artery spasm (CAS) syndrome is one etiology that can lead to MINOCA. Nilotinib, a targeted treatment for chronic myeloid leukemia (CML), has been reported to be related with increased risk of adverse vascular events.

CASE PRESENTATION

A 67-year-old male patient was admitted to hospital with acute chest pain. He had a past medical history of CML and a history of treatment with nilotinib for 12 months. Coronary angiography (CAG) showed no significant stenosis. Since the onset of angina was generally in the early morning, and ECG and echocardiography suggested right coronary artery (RCA) disease, an ergonovine provocation test was performed to confirm the diagnosis of CAS. After intracoronary administration of ergonovine, middle and distal RCA showed over 90% vasoconstriction. Nilotinib related MINOCA, CAS and CML were diagnosed. Lifestyle changes (cessation of smoking), anti-spasmodics, statin treatment and adjustment of the nilotinib dose (from 200 mg bid, to 150 mg bid) were recommended for this patient. Six-month's follow-up showed good recovery with no onsets of angina.

CONCLUSIONS

Physicians should be vigilant to adverse vascular events when treating patients who have been prescribed nilotinib. It is suggested that in patients with MINOCA who have a history of treatment with nilotinib, CAS-induced MINOCA should be included in the differential diagnosis. Further studies are needed to clarify the mechanism and to find better management.

Detection of early myocardial cell death in owl monkeys (Aotus nancymai) using complement component C9 immunohistochemistry in formalin-fixed paraffin-embedded heart tissues: A retrospective study

BACKGROUND

Owl monkeys are commonly used in biomedical research which is affected by the high incidence of cardiomyopathy in this species. Occasionally, owl monkeys with no clinical signs of heart disease are found dead and at necropsy show no, or very mild, cardiomyopathy. A possible explanation for sudden death is acute myocardial infarction; however, early myocardial changes may be difficult to assess by conventional stains and light microscopy.

METHODS

Complement component C9 immunohistochemistry was performed in paraffin-embedded heart tissue samples from owl monkeys who died suddenly, or were euthanized due to sickness, to determine whether these animals suffered from acute myocardial infarcts.

RESULTS AND CONCLUSION

C9 deposits were found in the myocardium of 19 out of 20 (95%) animals. The findings in this study suggest owl monkeys suffer from acute myocardial infarcts, and complement component C9 immunohistochemistry may be a useful diagnostic tool.

Recurrent syncope and ventricular arrhythmias induced by coronary artery spasm

We present a case of recurrent coronary artery spasm induced ventricular arrhythmias. A 73-year-old female developed a syncopal episode requiring brief cardiopulmonary resuscitation (CPR) with later spontaneous resolution and bradycardia. During admission, the patient had a recurrent syncopal episode while in supine position. Upon reviewing cardiac monitor, it was noted that the syncope coincided with a series of recorded arrhythmias. Invasive cardiac angiogram revealed a non-obstructive lesion at the right coronary artery with no other abnormalities suggesting spastic activity as the source of the arrhythmia. Subsequently, the patient successfully underwent an Implantable Cardioverter- Defibrillator (ICD) placement and stenting in the right coronary. Patient symptoms resolved and no further arrhythmias were detected in the ICD recording.

Outpatient Management of Patients With Angina With No Obstructive Coronary Arteries: How to Come to a Proper Diagnosis and Therapy

Two-thirds of women and one-third of men who undergo a clinically indicated coronary angiography for stable angina, have no obstructive coronary artery disease (CAD). Coronary vascular dysfunction is a highly prevalent underlying cause of angina in these so called “Angina with No Obstructive Coronary Arteries (ANOCA)” patients, foremost in middle aged women. Coronary vascular dysfunction encompasses various endotypes, namely epicardial and microvascular coronary spasms, impaired vasodilatation, and increased microvascular resistance. ANOCA patients, especially those with underlying coronary vascular dysfunction, have an adverse cardiovascular prognosis, poor physical functioning, and a reduced quality of life. Since standard ischemia detection tests and coronary angiograms are not designed to diagnose coronary vascular dysfunction, this ischemic heart disease is often overlooked and hence undertreated. But adequate diagnosis is vital, so that treatment can be started to reduce symptoms, reduce healthcare costs and improve quality of life and cardiovascular prognosis. The purpose of this review is to give a contemporary overview of ANOCA with focus on coronary vascular dysfunction. We will provide a possible work-up of patients suspected of coronary vascular dysfunction in the outpatient clinical setting, based on the latest scientific insights and international consensus documents. We will discuss the value of ischemia detection testing, and non-invasive and invasive methods to diagnose coronary vascular dysfunction. Furthermore, we will go into pharmacological and non-pharmacological therapeutic options including anti-anginal regimens and lifestyle interventions.

Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA): a Review of the Present and Preview of the Future

PURPOSE OF REVIEW

The syndrome of myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is not uncommon and has multiple potential coronary etiologies. With the use of more sensitive cardiac biomarkers and advanced cardiovascular imaging, MINOCA presentations have gain increasing attention among researchers and cardiologists. Despite the presence of a myocardial infarction and elevated future risk, many patients are sent home with little or no cardio-protective treatment and no explanation for their symptoms. In this review, we emphasized the importance of MINOCA treatment based on the underlying etiology.

RECENT FINDINGS

As there are multiple pathophysiological mechanisms potentially involved in MINOCA, it should be considered a working diagnosis until there is a better understanding regarding the underlying cause. It is critical to use multimodality imaging when treating patients with MINOCA to help determine the underlying etiology and rule out mimics of MINOCA, so that therapies appropriate to the etiology can be provided. A more systematic approach to managing patients with MINOCA should result in better treatment and an improved prognosis for these patients.

Pitavastatin Combined with Ezetimibe Treatment was an Effective Approach to Non-IRA Lesion of ST-segment Elevation Myocardial Infarction Patients with Primary Percutaneous Coronary Intervention

OBJECTIVE

ST-Segment Elevation Myocardial Infarction (STEMI) patients with the multivessel disease have distinctive plaque characteristics in non-IRA lesions. Intensive statin therapy was a potential approach to treat STEMI patients with the non-IRA disease. However, there is still poor evidence about the therapeutic effect. In this study, we have evaluated the detailed therapeutic effect of statin plus ezetimibe intensive therapy.

METHODS

For STEMI patients with non-IRA disease undergoing primary Percutaneous Coronary Intervention (PCI), 183 control STEMI patients without non-IRA disease undergoing primary PCI, and 200 STEMI patients with non-IRA disease undergoing primary PCI were introduced into this study. 200 STEMI patients with non-IRA disease undergoing primary PCI were divided into Normal group, Intensive group, Normal & Combined group, and Intensive & Combined group. The baseline information for each participant was recorded. Meanwhile, the physiological and biochemical indicators of each member with different treatments were collected after one-year follow-up.

RESULTS

For STEMI patients with non-IRA disease undergoing primary PCI, no differences could be detected in multiple indexes such as OCT examination results, age, stroke, etc. However, diabetes mellitus, smoking, and coronary Gensini score were different between different groups (P<0.05). After one year follow-up, cholesterol, low-density lipoprotein, coronary Gensini score, thin-cap fibroatheroma, length of non-infarcted arterial lesions, non-infarct artery lesion range, myocardial infarction again, and revascularization again were significantly different between different groups (P<0.05).

CONCLUSION

The results mentioned above suggested that pitavastatin combined with ezetimibe was an effective approach for STEMI patients with non-IRA disease undergoing primary PCI. The results obtained in this study have provided a novel method for the treatment of STEMI patients with non-IRA disease undergoing primary PCI.

The Smoking Paradox: A Twist in the Tale of Vasospastic Angina

Cigarette smoking is undoubtedly the single most important risk factor and trigger for vasospastic angina, a condition also known as Prinzmetal angina secondary to coronary artery vasospasm. Even decades before vasospastic angina was first described by Dr. Myron Prinzmetal and his colleagues in 1959, there had been suspected connections between smoking and coronary artery vasospasm in what was alluded to then as "tobacco angina." The intimate relationship between smoking and vasospastic angina has since been extensively researched and validated through decades of epidemiological and clinical studies. The fact that smoking would aggravate vasospastic angina comes with very little surprise, as it has been shown to adversely impact many of the disease processes thought to underlie vasospastic angina, including autonomic dysfunction, endothelial dysfunction, smooth muscle hyperactivity, and genetic susceptibility. While avoidance of smoking is the first logical step in managing smokers with vasospastic angina, there have been reported cases of vasospastic angina paradoxically triggered by smoking cessation or relieved with smoking resumption or nicotine replacement therapy. Thus, there appears to be patient-specific factors that could significantly alter the close connection between smoking and vasospastic angina, warranting further mechanistic investigations. In this review, we will examine this complicated relationship between smoking and vasospastic angina from multiple perspectives (historical, mechanistic, and clinical) and call attention to the "smoking paradox," which, with further elucidation, may provide additional insight into the complex mechanisms of VSA and potentially new strategies to treat medically refractory VSA, at least in selected individuals.

Alternate recurrent coronary artery spasm and stress cardiomyopathy: a case report

Background

Coronary artery spasm (CAS) and stress cardiomyopathy (SC) have different characteristic clinical manifestations in the case of suspicious myocardial infarction with nonobstructive coronary arteries. Established recurrence rates of both conditions have been reported, however, alternate recurrent CAS and SC in the same individual have not been described.

Case presentation

A 59-year-old man suffered from atypical chest pain in the first episode, acute heart attack in the second and third episodes (totally 3 times over a period of approximately 5 years). During the first episode, he visited our hospital with mild paroxysmal chest pain without obvious inducement for approximately 2 years. He was underdiagnosed at that time without other obvious findings except the poor R wave progression in V1–3 leads revealed in electrocardiogram. At 4 months after the first episode, he suffered from a heart attack (the second episode) and was diagnosed with SC based on the coronary angiography (CAG) and left ventriculography findings of nonobstructive coronary arteries combined with a classic apical ballooning shape. At 31 months after the second episode, he suffered another heart attack (the third episode) and was diagnosed with CAS based on the CAG results of recoverable severe multivessel stenoses. During the episodes, partial reversible nature of apical hypokinesis was observed in echocardiogram. In retrospect, the patient suffered silent CAS in the first episode, SC in the second episode, and severe multivessel CAS in the third episode.

Conclusion

The unusual presentations observed in this case have not been reported. This case suggests that cardiologists should be aware of the possibility of alternate recurrent CAS and SC in the same individual. Provocative tests for spasm and cardiac magnetic resonance imaging might help gain more insights into this issue.

Optical coherence tomography: fundamentals and clinical utility

Although coronary angiography is the standard method employed to assess the severity of coronary artery disease and to guide treatment strategies, it provides only 2D image of the intravascular lesions. In contrast, intravascular imaging modalities such as optical coherence tomography (OCT) produce cross-sectional images of the coronary arteries at a far greater spatial resolution, capable of accurately determining vessel size as well as plaque morphology, eliminating many of the disadvantages inherent to angiography. This review will discuss the role of OCT in the catherization laboratory for the assessment and management of coronary disease.

Mendelian randomization case-control PheWAS in UK Biobank shows evidence of causality for smoking intensity in 28 distinct clinical conditions

BACKGROUND

Smoking is one of the greatest threats to public health worldwide. We integrated phenome-wide association study (PheWAS) and Mendelian randomization (MR) approaches to explore causal effects of genetically predicted smoking intensity across the human disease spectrum.

METHODS

We conducted PheWAS case-control analyses in 152,483 ever smokers of White-British ancestry, aged 39-73 years. Disease diagnoses were based on hospital inpatient and mortality registrations. Smoking intensity was instrumented by four genetic variants, and disease risks estimated for one cigarette per day heavier intakes. Associations passing the FDR threshold (p<0•0025) were assessed for causality using several complementary MR approaches.

FINDINGS

Genetically instrumented smoking intensity was associated with 48 conditions, with MR supporting a possible causal effect for 28 distinct outcomes. Each cigarette smoked per day elevated the odds of respiratory diseases by 5% to 33% (nine distinct diseases, including pneumonia, emphysema, obstructive chronic bronchitis, pleurisy, pulmonary collapse, respiratory failure) and the odds of circulatory disease by 5% to 23% (seven diseases, including atherosclerosis, myocardial infarction, congestive heart failure, arterial embolisms). Further effects were seen for cancer within the respiratory system and other neoplasms, renal failure, septicaemia, and retinal disorders. No associations were observed in sensitivity analyses on 185,002 never smokers.

INTERPRETATION

These genetic data demonstrate the substantial adverse health impacts by smoking intensity and suggest notable increases in the risks of several diseases. Public health initiatives should highlight the damage caused by smoking intensity and the potential benefits of reducing or ideally quitting smoking.

Refractory Vasospastic Angina and Sudden Cardiac Arrest: Is Implantable Cardioverter Defibrillator Indicated and Is It Always Protective?

Vasospastic angina (VSA) is characterized by episodic chest pain associated with transient ST-segment abnormalities on electrocardiogram, secondary to vasospasm of the epicardial coronary artery. We report the rare case of a 46-year-old female with refractory VSA secondary to multivessel coronary vasospasm causing an anterior myocardial infarction. She succumbed secondary to ventricular tachycardia (VT) storm, in spite of being on maximally tolerated medical therapy and having an implantable cardioverter defibrillator (ICD) for secondary prevention of VT. Contemporary guidelines recommend ICD implantation (class IIa) in VSA patients who survived sudden cardiac arrest (SCA), if they are already on optimal medical therapy or if medical therapy is not tolerated. Whether ICD implantation is appropriate in VSA patients with aborted SCA, even before assessing the response to medical therapy, is not well known and requires further studies. 

Successful cryoablation of left ventricular summit premature ventricular contractions via the coronary sinus

The left ventricular summit (LVS) is a challenging location for catheter-based percutaneous ablation due to its anatomical location. There have been case reports of cryoablations performed in this region, but the technique may be underutilized when radiofrequency ablation fails. A 45-year-old male was found to have 25 000 premature ventricular contractions (PVCs) a day despite previous ablation and a reduced ejection fraction of 40% despite medical therapy. Coronary sinus epicardial mapping revealed the coronary sinus distal region generated activations earlier than the QRS onset by 28 ms. Two separate, 4-minute cryoablations were delivered that suppressed the PVCs within 5 seconds. Alternate energy modalities such as cryo may offer a safer and more viable approach for ablation of LVS in select patients.

Coronary Artery Spasm: New Insights

Coronary artery spasm (CAS) defined by a severe reversible diffuse or focal vasoconstriction is the most common diagnosis among INOCA (ischemia with no obstructive coronary artery disease) patients irrespective to racial, genetic, and geographic variations. However, the prevalence of CAS tends to decrease in correlation with the increasing use of medicines such as calcium channel blockers, angiotensin converting enzyme inhibitor, and statins, the controlling management of atherosclerotic risk factors, and the decreased habitude to perform a functional reactivity test in highly active cardiac catheterization centers. A wide spectrum of clinical manifestations from silent disease to sudden cardiac death was attributed to this complex entity with unclear pathophysiology. Multiple mechanisms such as the autonomic nervous system, endothelial dysfunction, chronic inflammation, oxidative stress, and smooth muscle hypercontractility are involved. Regardless of the limited benefits proffered by the newly emerged cardiac imaging modalities, the provocative test remains the cornerstone diagnostic tool for CAS. It allows to reproduce CAS and to evaluate reactivity to nitrates. Different invasive and noninvasive therapeutic approaches are approved for the management of CAS. Long-acting nondihydropyridine calcium channel blockers are recommended for first line therapy. Invasive strategies such as PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft) have shown benefits in CAS with significant atherosclerotic lesions. Combination therapies are proposed for refractory cases.

Severe Prinzmetal's Angina Inducing Ventricular Fibrillation Cardiac Arrest

Prinzmetal's angina is a vascular spasm of the coronary artery that can mimic acute coronary syndrome. It is rarely responsible for ventricular arrhythmias and cardiac arrest; however, survivors with these complications are at increased risk for recurrent ventricular arrhythmias and sudden cardiac death. This is true despite the presence of normal cardiac function and optimal medical therapy. Thus, this select population should be considered for an implantable cardioverter defibrillator (ICD). In this case vignette, we describe a healthy 48-year-old female with ventricular fibrillation arrest, followed by recurrent ventricular tachyarrhythmias caused by Prinzmetal's angina.

Diagnosis of myocardial infarction at autopsy: AECVP reappraisal in the light of the current clinical classification

Ischemic heart disease is one of the leading causes of morbidity and death worldwide. Consequently, myocardial infarctions are often encountered in clinical and forensic autopsies, and diagnosis can be challenging, especially in the absence of an acute coronary occlusion. Precise histopathological identification and timing of myocardial infarction in humans often remains uncertain while it can be of crucial importance, especially in a forensic setting when third person involvement or medical responsibilities are in question. A proper post-mortem diagnosis requires not only up-to-date knowledge of the ischemic coronary and myocardial pathology, but also a correct interpretation of such findings in relation to the clinical scenario of the deceased. For these reasons, it is important for pathologists to be familiar with the different clinically defined types of myocardial infarction and to discriminate myocardial infarction from other forms of myocardial injury. This article reviews present knowledge and post-mortem diagnostic methods, including post-mortem imaging, to reveal the different types of myocardial injury and the clinical-pathological correlations with currently defined types of myocardial infarction.

Myocardial Infarction with Non-Obstructive Coronary Arteries: Contemporary Diagnostic and Management Approaches

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is diagnosed in the absence of anatomically significant stenoses (<50% of lumen diameter) on coronary angiography and characterized by heterogeneity of etiologic factors. Recently, the mechanisms of MINOCA as well as the performance of diagnostic algorithms and therapeutic strategies have been extensively studied. The purpose of this review is to reflect the current concepts regarding the etiology and pathogenesis of MINOCA, diagnostic work-up methods and individualized treatment approaches. The article covers contemporary epidemiologic data, demographic and clinical patients’ characteristics and principal causes of MINOCA. We discuss aspects of disease definition and classification of related conditions involving troponin increase in the presence of normal coronary arteries. The importance of management strategy personalization for individual patients is stressed alongside stratification of risks of recurrent cardiovascular events. This review reflects key points from international consensus statements published by leading experts and suggests promising directions for future research.

Therapeutic Potential of Biochanin-A Against Isoproterenol-Induced Myocardial Infarction in Rats

BACKGROUND

This study determined the effect of Biochanin A (BCA) on isoproterenol (ISO) induced Myocardial Infarction (MI) in male Wistar rats.

METHODS

Animals (weighing 150-180 g) were divided into four groups, with six animals in each group and pretreated with BCA (10mg/kg Body Weight [BW]) and ɑ-tocopherol (60mg/kg BW) for 30 days; and ISO (20mg/kg BW) was administrated subcutaneously on the 31st and 32nd day.

RESULTS

ISO-induced MI rats demonstrated the significant elevation of serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, lactate dehydrogenase, creatine kinase-MB and cardiac troponin; however, concomitant pretreatment with BCA protected the rats from cardiotoxicity caused by ISO. Activities of antioxidant enzymes, such as superoxide dismutase, catalase, glutathione peroxidase, glutathione-S-transferase and glutathione reductase significantly reduced in the heart with ISO-induced MI. Pretreatment with BCA produced a marked reversal of these antioxidant enzymes related to MI-induced by ISO.

CONCLUSION

In conclusion, this study suggested that BCA exerts cardioprotective effects through modulating lipid peroxidation, enhancing antioxidants, and detoxifying enzyme systems.

[Prinzmetal angina. Questions of pathogenesis, clinic, diagnosis and treatment]

Current problems of Prinzmetal angina (vasospastic angina, variant angina) considers in this review. Attention is drawn to early diagnosis, which should be comprehensive, taking into account possible atypical courses and the development of complications. The important role of electrocardiographic monitoring (including using implantable recorders) is highlighted. It is emphasized that patients with cardiac arrhythmias, syncope are at high risk of developing sudden cardiac death. In this category of patients, it is recommended to timely determine the indications for implantation of a cardioverter - defibrillator. Authors consider the prospects of using new methods of treatment of angina pectoris.

Unexpected complications of vasospastic coronary artery disease and its successful management

Vasospastic coronary artery disease (CAD) usually occurs during the percutaneous interventions and responds to conventional medical treatment. However, in rare conditions, it may be resistant to medical treatment, resulting in lethal complications, including acute myocardial infarction, ventricular arrhythmia, cardiopulmonary arrest, cardiogenic shock, and acute pulmonary edema. In this case report, a 44-year-old woman was admitted to the hospital with a diagnosis of non-ST-segment elevation myocardial infarction. During a diagnostic coronary angiography and in-hospital stays, multiple catastrophic complications due to vasospastic CAD occurred, and we were able to demonstrate a successful management strategy of these complications.

Coronary Artery Spasm, Coronary Reactivity, and Their Psychological Context

Symptomatic individuals suspected of having myocardial ischemia often have no obstructive atherosclerotic narrowing of epicardial coronary arteries. Abnormal coronary vascular reactivity and, in particular, coronary artery vasospasm (CAS) may be an explanation in a subset of these patients. Psychological factors play an important role in ischemic heart disease, but their role in CAS is not clear; autonomic dysfunction and increased inflammation are two prevailing pathophysiological mechanisms implicated in abnormal coronary reactivity resulting from mental health conditions. Interrelationships between psychological factors, abnormal coronary reactivity, and sex/gender differences are poorly defined in the etiology of CAS. In this issue of Psychosomatic Medicine (2019;81:237-245), Hung et al. report a frequency of less than 0.1% of new-onset CAS in the Taiwanese population, with higher occurrence in women and younger individuals. Patients with CAS had a higher prevalence of previous anxiety and depression compared with those with coronary artery disease and controls, with no sex differences. In this editorial comment, we discuss the potential reasons for underreporting of CAS and the challenges regarding the use of administrative health records for psychosomatic research. In this editorial, a model is presented to explain the association between emotional stressors and mental health factors with CAS, including the role of sympathetic nervous system activation, inflammation, oxidative stress, endothelial dysfunction, and smooth muscle cell dysregulation.

Marijuana-associated ST-elevation myocardial infarction: is this a benign drug

Marijuana is the most commonly used psychoactive drug in the USA. A 35-year-old man with a medical history of marijuana abuse is admitted to the hospital due to crushing substernal chest pain. ECG shows evolving ST-segment elevation with a rise in cardiac enzymes, consistent with ST-elevation myocardial infarction. A urine toxicology screen is positive for cannabis and negative for cocaine and other stimulant drugs. An emergent cardiac catheterisation reveals no evidence of coronary artery disease or thrombosis. A diagnosis of coronary vasospasm is strongly considered, and the patient is started on calcium channel blocker, with a resolution of symptoms and ECG changes. Marijuana-induced coronary spasm causing myocardial infarction has rarely been reported. Marijuana is becoming a social norm in adolescents and there remains a misconception that it is harmless and even beneficial. Increasing drug abuse remains a public health concern, necessitating population education by physicians for safer healthcare practices.

Coronary stenosis as a modifier of the effect of cold spells on the risk of sudden cardiac death: a case-crossover study in Finland

OBJECTIVE

To test the a priori hypothesis that the association between cold spells and ischaemic sudden cardiac death (SCD) is modified by the severity of coronary stenosis.

METHODS

The home coordinates of 2572 autopsy-verified cases of ischaemic SCD aged ≥35 in the Province of Oulu, Finland, were linked to 51 years of weather data. Cold spell was statistically defined for each home address as unusually cold weather pertinent to the location and time of year. We estimated the occurrence of cold spells during the hazard period (7 days preceding death) and reference periods (the same calendar days over 51 years) in a case-crossover setting applying conditional logistic regression, controlling for temporal trends and stratifying by severity of coronary stenosis.

RESULTS

The association between cold spells and ischaemic SCD was stronger among patients with 75%-95% stenosis (OR 2.03; 95% CI 1.31 to 3.17), and weaker to non-existent among patients with <75% stenosis (OR 0.97; 95% CI 0.37 to 2.55) or coronary total occlusion (100% stenosis) (OR 1.01; 95% CI 0.52 to 1.96). Lack of calcium-channel blockers and statin therapy seemed to accentuate the role of stenosis during cold spells.

CONCLUSIONS

We provide evidence that the association between cold spells and ischaemic SCD is modified by the severity of coronary stenosis. The findings suggest that disturbances in coronary circulation play part in the pathogenesis of SCD during cold weather.