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Denby KJ, Zmaili M, Datta S, Das T, Ellis S, Ziada K, Lerman A, Raphael CE. Developments and Controversies in Invasive Diagnosis of Coronary Microvascular Dysfunction in Angina With Nonobstructive Coronary Arteries. Mayo Clin Proc 2024; 99:1469-1481. [PMID: 39232622 DOI: 10.1016/j.mayocp.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 09/06/2024]
Abstract
Approximately half of all coronary angiograms performed for angina do not show obstructive coronary artery disease, and many of these patients have coronary microvascular dysfunction (CMD). Invasive testing for CMD has increased with the advent and wider availability of thermodilution systems. We review CMD pathophysiology and invasive diagnostic testing using the Doppler and thermodilution systems. We report the results of a PubMed search of invasive microvascular testing and discuss limitations of current diagnostic algorithms in the diagnosis of CMD, including controversies regarding the optimal cutoff value for abnormal coronary flow reserve, use of microvascular resistance indices, and options for increasing sensitivity of testing.
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Affiliation(s)
- Kara J Denby
- Department of Cardiovascular Medicine, Saint Alphonsus Regional Medical Center, Boise, ID
| | - Mohammad Zmaili
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Sudarshana Datta
- Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston
| | - Thomas Das
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Stephen Ellis
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Khaled Ziada
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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2
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Scala A, Marchini F, Meossi S, Zanarelli L, Sanguettoli F, Frascaro F, Bianchi N, Cocco M, Erriquez A, Tonet E, Campo G, Pavasini R. Future of invasive and non-invasive hemodynamic assessment for coronary artery disease management. Minerva Cardiol Angiol 2024; 72:385-404. [PMID: 38934267 DOI: 10.23736/s2724-5683.23.06461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Coronary artery disease represents a global health challenge. Accurate diagnosis and evaluation of hemodynamic parameters are crucial for optimizing patient management and outcomes. Nowadays a wide range of both non-invasive and invasive methods are available to assess the hemodynamic impact of both epicardial coronary stenosis and vasomotor disorders. In fact, over the years, important developments have reshaped the nature of both invasive and non-invasive diagnostic techniques, and the future holds promises for further innovation and integration. Non-invasive techniques have progressively evolved and currently a broad spectrum of methods are available, from cardiac magnetic resonance imaging with pharmacological stress and coronary computed tomography (CT) to the newer application of FFR-CT and perfusion CT. Invasive methods, on the contrary, have developed to a full-physiology approach, able not only to identify functionally significant lesions but also to evaluate microcirculation and vasospastic disease. The aim of this review is to summarize the current state-of-the-art of invasive and non-invasive hemodynamic assessment for CAD management.
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Affiliation(s)
- Antonella Scala
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Federico Marchini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Sofia Meossi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Luca Zanarelli
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Federica Frascaro
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Nicola Bianchi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Marta Cocco
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Elisabetta Tonet
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy -
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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Maayah M, Latif N, Vijay A, Gallegos CM, Cigarroa N, Posada Martinez EL, Mazure CM, Miller EJ, Spatz ES, Shah SM. Evaluating Ischemic Heart Disease in Women: Focus on Angina With Nonobstructive Coronary Arteries (ANOCA). JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102195. [PMID: 39166160 PMCID: PMC11330936 DOI: 10.1016/j.jscai.2024.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 08/22/2024]
Abstract
Ischemic heart disease (IHD) is common in women, and cardiovascular disease is a leading cause of morbidity and mortality. While obstructive coronary artery disease is the most common form of IHD, millions of women suffer from angina with nonobstructive coronary arteries (ANOCA), an umbrella term encompassing multiple nonatherosclerotic disorders of the coronary tree. The underlying pathology leading to ischemia in these syndromes may be challenging to diagnose, leaving many women without a diagnosis despite persistent symptoms that impact quality of life and adversely affect long-term cardiovascular prognosis. In the last decade, there have been significant advances in the recognition and diagnostic evaluation of ANOCA. Despite these advances, the standard approach to evaluating suspected IHD in women continues to focus predominantly on the assessment of atherosclerotic coronary artery disease, leading to missed opportunities to accurately diagnose and treat underlying coronary vasomotor disorders. The goal of this review is to describe advances in diagnostic testing that can be used to evaluate angina in women and present a pragmatic diagnostic algorithm to guide evaluation of ANOCA in symptomatic patients. The proposed approach for the assessment of ANOCA is consistent with prior expert consensus documents and guidelines but is predicated on the medical interview and pretest probability of disease to inform a personalized diagnostic strategy.
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Affiliation(s)
- Marah Maayah
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nida Latif
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aishwarya Vijay
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Cesia M. Gallegos
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Natasha Cigarroa
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Carolyn M. Mazure
- Department of Psychiatry and Women’s Health Research at Yale, Yale School of Medicine, New Haven, Connecticut
| | - Edward J. Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, Connecticut
| | - Samit M. Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
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Song ZY, Kim MH, Lee KM. Comparison of clinical outcomes in patients with mixed angina and pure vasospastic angina. Coron Artery Dis 2024; 35:270-276. [PMID: 38241035 DOI: 10.1097/mca.0000000000001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE This study investigated differences in clinical outcomes between mixed angina (MA) and pure vasospastic angina (PVA). METHODS A total of 524 vasospastic angina patients who did or did not have >50% coronary artery stenosis from January 2005 to January 2021 were divided into two groups (Group 1: PVA, N = 399; Group 2: MA, N = 125) and then three groups [Group 1: PVA, N = 399; Group 2: MA without percutaneous coronary intervention (PCI), N = 67; Group 3: MA with PCI, N = 58] for assessment. We recorded the incidence of major adverse cardiac and cerebrovascular events (MACCE: the composite of death, myocardial infarction, nonfatal stroke or rehospitalization) during 3-year clinical follow-up. RESULTS Compared to the PVA group, there were significant differences in MACCE (20.8% vs. 11.8%, P = 0.011) and rehospitalization (20.0% vs. 9.8%, P = 0.002) in the MA group. Kaplan-Meier analysis showed that patients in the MA with PCI group had the highest cumulative incidence rate of MACCE during the 3-year follow-up (log-rank P < 0.001). CONCLUSION Compared with the PVA patients, MA patients had significantly worse clinical outcomes during long-term follow-up.
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Affiliation(s)
- Zhao Yan Song
- Department of Cardiology, Dong-A University Hospital, Busan, Republic of Korea
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Boivin-Proulx LA, Marquis-Gravel G, Rousseau-Saine N, Harel F, Jolicoeur EM, Pelletier-Galarneau M. Hyperventilation testing in the diagnosis of vasospastic angina: A clinical review and meta-analysis. Eur J Clin Invest 2024; 54:e14178. [PMID: 38348627 DOI: 10.1111/eci.14178] [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: 12/15/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 05/15/2024]
Abstract
BACKGROUND Given the limited access to invasive vasospastic reactivity testing in Western Countries, there is a need to further develop alternative non-invasive diagnostic methods for vasospastic angina (VSA). Hyperventilation testing (HVT) is defined as a class IIa recommendation to diagnose VSA by the Japanese Society of Cardiology. METHODS In this systematic review and meta-analysis reported according to the PRISMA statement, we review the mechanisms, methods, modalities and diagnostic accuracy of non-invasive HVT for the diagnostic of VSA. RESULTS A total of 106 articles published between 1980 and 2022 about VSA and HVT were included in the systematic review, among which 16 were included in the meta-analysis for diagnostic accuracy. Twelve electrocardiogram-HVT studies including 804 patients showed a pooled sensitivity of 54% (95% confidence intervals [CI]; 30%-76%) and a pooled specificity of 99% (95% CI; 88%-100%). Four transthoracic echocardiography-HVT studies including 197 patients revealed a pooled sensitivity of 90% (95% CI; 82%-94%) and a pooled specificity of 98% (95% CI; 86%-100%). Six myocardial perfusion imaging-HVT studies including 112 patients yielded a pooled sensitivity of 95% (95% CI; 63%-100%) and a pooled specificity of 78% (95% CI; 19%-98%). Non-invasive HVT resulted in a low rate of adverse events, ventricular arrhythmias being the most frequently reported, and were resolved with the administration of nitroglycerin. CONCLUSIONS Non-invasive HVT offers a safe alternative with high diagnostic accuracy to diagnose VSA in patients with otherwise undiagnosed causes of chest pain.
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Affiliation(s)
| | | | | | - François Harel
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - E Marc Jolicoeur
- CHUM Research Center and Cardiovascular Center, Montreal, Quebec, Canada
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Marino AG, Gentile G, Lenci L, De Benedetto F, Tremamunno S, Cambise N, Belmusto A, Di Renzo A, Tinti L, De Vita A, Lanza GA. Comparison of Baseline and Post-Nitrate Exercise Testing in Patients with Angina but Non-Obstructed Coronary Arteries with Different Acetylcholine Test Results. J Clin Med 2024; 13:2181. [PMID: 38673454 PMCID: PMC11050539 DOI: 10.3390/jcm13082181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/07/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Intracoronary acetylcholine testing may induce epicardial coronary artery spasm (CAS) or coronary microvascular spasm (CMVS) in patients with angina syndromes but non-obstructive coronary artery disease, but their causal role in individual patients is not always clear. In this prospective, observational single-center study, we aimed to assess whether (1) the induction of myocardial ischemia/angina by electrocardiogram (ECG) exercise stress test (EST) differs between patients showing different results in response to acetylcholine testing (i.e., CAS, CMVS, or no spasm); (2) the preventive administration of short-acting nitrates has any different effects on the EST of those patients who showed a positive basal EST. We expected that if exercise-induced angina and/or ischemic ECG changes are related to CAS, they should improve after nitrates administration, whereas they should not significantly improve if they are caused by CMVS. Methods: We enrolled 81 patients with angina syndromes and non-obstructive coronary artery disease, who were divided into three groups according to acetylcholine testing: 40 patients with CAS (CAS-group), 14 with CMVS (CMVS-groups), and 27 with a negative test (NEG-group). All patients underwent a basal EST (B-EST). Patients with a positive B-EST repeated the test 24-48 h later, 5 min after the administration of short-acting nitrates (N-EST). Results: There were no significant differences among the groups in terms of the B-EST results. B-EST was positive in eight (20%) patients in the CAS-group, seven (50%) in the CMVS-group, and six (22%) in the NEG-group (p = 0.076). N-EST, performed in eight, six, and five of these patients, also showed similar results in the three groups. Furthermore, the N-EST results also did not significantly differ compared to B-EST in any group, remaining positive in seven (87.5%), four (66.7%), and four (80%) patients in the CAS-group, CMVS-group, and NEG-group, respectively (p = 0.78). Conclusions: Our data show that patients with angina and non-obstructive coronary artery disease show largely comparable results of the ECG exercise stress test and similar poor effects of short-acting nitrates on abnormal ECG exercise stress test results. On the whole, our findings suggest caution in attributing to the results of Ach testing a definite causal role for the clinical syndrome in individual patients.
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Affiliation(s)
- Angelo Giuseppe Marino
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Gentile
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ludovica Lenci
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabio De Benedetto
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Saverio Tremamunno
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nello Cambise
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonietta Belmusto
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio Di Renzo
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Lorenzo Tinti
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio De Vita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Gaetano Antonio Lanza
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
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7
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Rinaldi R, Colucci M, Torre I, Ausiello D, Bonanni A, Basile M, Salzillo C, Sanna T, Liuzzo G, Leone AM, Burzotta F, Trani C, Lanza GA, Niccoli G, Crea F, Montone RA. Predicting the response to acetylcholine in ischemia or infarction with non-obstructive coronary arteries: The ABCD score. Atherosclerosis 2024; 391:117503. [PMID: 38447435 DOI: 10.1016/j.atherosclerosis.2024.117503] [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: 11/19/2023] [Revised: 01/19/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response. METHODS We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort). RESULTS 551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652-0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626-0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test. CONCLUSIONS The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.
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Affiliation(s)
- Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Michele Colucci
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Ilaria Torre
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Davide Ausiello
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alice Bonanni
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mattia Basile
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Carmine Salzillo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Tommaso Sanna
- 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
| | - Giovanna Liuzzo
- 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
| | - Antonio M Leone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- 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
| | - Carlo Trani
- 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
| | - Gaetano A Lanza
- 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
| | | | - 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
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Qiu Z, Wang Y, Liu Y, Zhou Z, Wang Z. Diagnostic value of angiography-derived index of microcirculatory resistance (AMR) for coronary microcirculatory dysfunction (CMD) and its prognostic significance in patients with chronic coronary syndromes in the smoking population. Medicine (Baltimore) 2024; 103:e37022. [PMID: 38335436 PMCID: PMC10860928 DOI: 10.1097/md.0000000000037022] [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: 08/24/2023] [Revised: 11/24/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024] Open
Abstract
This study aims to analyze the prognostic significance of angiographic microvascular resistance (AMR) derived from functional coronary angiography in diagnosing coronary microvascular dysfunction (CMD) among patients with chronic coronary syndrome (CCS), particularly focusing on the prognostic significance of CMD in smokers. Additionally, this study assesses the prognostic significance of the diagnostic accuracy of the AMR index for CMD in CCS patients within the smoking population. Seventy-five CCS patients were studied for IMR measurement between June 2018 and December 2020, classified into CMD and non-CMD groups. Pearson correlation analyzed AMR and IMR relationship, while ROC curves determined AMR's predictive value for CMD with optimal cutoff value. An additional 223 CCS patients were included for AMR measurements. The study's primary endpoint was MACE occurrence, followed up through telephone calls. COX one-way analysis and Kaplan-Meier analysis evaluated the association between AMR and MACE risk. In the study, 52% of patients were diagnosed with CMD, and the AUC under the AMR curve for predicted IMR ≥ 25 was 0.90 (95% CI: 0.79-0.95). The CMD group had a higher proportion of female patients, smokers, and those with hypertension and diabetes mellitus compared to the non-CMD group (all P < .05). The CMD group exhibited higher AMR values than the non-CMD group (3.20 ± 0.5 vs 1.95 ± 0.45, P < .01), with a significant correlation between AMR and IMR (R2 = 0.81, P < .001). The ROC curve illustrated AMR's effectiveness in diagnosing CMD in CCS patients, using IMR as the gold standard, with the optimal cutoff value of AMR = 2.6mmHgs/cm (sensitivity: 90.5%, specificity: 81.5%). Patients with AMR ≥ 2.6mmHgs/cm had a higher risk of MACE events (HR = 6.00; 95% CI: 1.59-22.67). AMR in patients with CCS was significantly correlated with IMR and demonstrated good diagnostic accuracy. AMR ≥ 2.6 mm Hg*s/cm was associated with an increased risk of MACE occurrence and served as a valuable prognostic factor. In patients with CCS, AMR has a high diagnostic performance, In patients with CCS who smoke, impaired coronary microvascular function as assessed by AMR is significant and is an independent predictor of MACE.
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Affiliation(s)
- Zhongjue Qiu
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yong Wang
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
- Center for Post-Doctoral Studies, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yang Liu
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhou Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen Wang
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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9
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Henning RJ. The diagnosis and treatment of women with recurrent cardiac ischemia and normal coronary arteries. Curr Probl Cardiol 2024; 49:102124. [PMID: 37802164 DOI: 10.1016/j.cpcardiol.2023.102124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Cardiac disease is the leading cause of death in women. Among women with recurrent chest pain, abnormal electrocardiograms, and/or stress tests who undergo coronary angiography, as many as 50% have normal or <50% coronary artery obstructive disease. Pharmacologic stress assessment of coronary artery flow reserve in these women frequently demonstrates an inability to increase blood flow to >2.5 times normal flow. Contributory factors include abnormal epicardial or microvascular reactivity, microvascular remodeling or rarefaction, autonomic dysfunction, or coronary plaque rupture/erosion. Assessment is necessary of serum biomarkers and coronary artery flow reserve, fractional flow reserve, microvascular resistance, and epicardial/microvascular spasm. Aggressive treatment of women with positive tests is necessary because these women have an increased incidence of recurrent chest pain, repeated hospitalizations and coronary angiograms, and cardiac death.
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Affiliation(s)
- Robert J Henning
- University of South Florida, 13201 Bruce B. Downs Blvd. Tampa, Florida 33612-3805, United States.
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10
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Abouzid MR, Eldahtoury S, Elshafei SM, Devi S, Saleh A, Esteghamati S, Kamel I. Efficacy of Angiotensin-Converting Enzyme Inhibitors in Coronary Microvascular Dysfunction: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cureus 2024; 16:e52684. [PMID: 38260109 PMCID: PMC10801115 DOI: 10.7759/cureus.52684] [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] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Coronary microvascular dysfunction (CMD) is becoming increasingly recognized as an important contributor to the development of ischemic heart diseases. Without obstructive coronary artery disease, the physiological function of the coronary microcirculation can be altered by structural, functional, and molecular factors, leading to myocardial ischemia. CMD can significantly impact the quality of life and prognosis and imposes a huge financial burden on healthcare systems and people. This meta-analysis aims to investigate the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) for treating CMD. A systematic literature review identified randomized controlled trials (RCTs) comparing ACEIs with placebo in CMD patients. Review Manager, 5.3 for Windows, was utilized. Using the Mantel-Haenszel (M-H) method, improvement in coronary flow reserve (CFR) and systolic blood pressure events was pooled as mean difference (MD) in a meta-analysis model with a fixed effect model, whereas the number of chest pain episodes was pooled as MD with a random effect model. Five randomized controlled trials involving 209 patients were included in the analysis. The analysis demonstrated a statistically significant improvement in CFR in the ACEIs group compared to the placebo group (MD -0.3, 95% CI -0.61 to 0.01, P = 0.05). However, there was no significant difference in the number of chest pain episodes between the ACEIs and placebo groups (MD 1.79, 95% CI -3.99 to 7.58, P = 0.54). Similarly, no significant difference in blood pressure change was observed between the two groups (MD 4.02, 95% CI -3.25 to 11.28, P = 0.28). In conclusion, the appropriate treatment for CMD is a source of contention because adequate data is lacking. Our findings suggest that ACEIs may have a positive effect on improving CFR in patients with microvascular angina. However, ACEIs did not demonstrate a significant impact on the number of chest pain episodes or systolic blood pressure in this patient population. Further research, including RCTs with larger sample sizes and longer follow-up durations, is warranted to provide more conclusive evidence on the role of ACEIs in CMD management.
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Affiliation(s)
- Mohamed R Abouzid
- Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, USA
| | - Samar Eldahtoury
- Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, USA
| | | | - Sunita Devi
- Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, USA
| | - Amr Saleh
- Internal Medicine, Mansoura University, Mansoura, EGY
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12
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Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis 2024; 18:17539447241230400. [PMID: 38343041 PMCID: PMC10860484 DOI: 10.1177/17539447241230400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
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.
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Affiliation(s)
- Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Brown
- Cardiovascular Care Partnership, British Cardiovascular Society, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Medical School, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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13
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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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14
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Kaski JC, Lluch N, Lopez-Sendon JL, Gorog DA, Antorrena-Miranda I, Avanzas P, Herrero Puente P, Sionis A, González-Juanatey JR, Íñiguez A, Cordero A, Ako E, Fernández-Avilés F, Atienza F, Recio-Mayoral A, Wu AHB, Crea F, Storey R, Badimon L, Cubedo J. Changes in circulating ApoJ-Glyc levels in patients with suspected acute coronary syndrome: The EDICA trial. Int J Cardiol 2023; 391:131291. [PMID: 37619880 DOI: 10.1016/j.ijcard.2023.131291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Myocardial ischemia induces intracellular accumulation of non-glycosylated apolipoprotein J that results in a reduction of circulating glycosylated ApoJ (ApoJ-Glyc). The latter has been suggested to be a marker of transient myocardial ischemia. OBJECTIVE This proof-of-concept clinical study aimed to assess whether changes in circulating ApoJ-Glyc could detect myocardial ischemia in patients attending the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). METHODS In suspected ACS patients, EDICA (Early Detection of Myocardial Ischemia in Suspected Acute Coronary Syndromes by ApoJ-Glyc a Novel Pathologically based Ischemia Biomarker), a multicentre, international, cohort study assessed changes in 2 glycosylated variants of ApoJ-Glyc, (ApoJ-GlycA2 and ApoJ-GlycA6), in serum samples obtained at ED admission (0 h), and 1 h and 3 h thereafter, blinded to the clinical diagnosis (i.e. STEMI, NSTEMI, unstable angina, non-ischemic). RESULTS 404 patients were recruited; 291 were given a clinical diagnosis of "non-ischemic" chest pain and 113 were considered to have had an ischemic event. ApoJ-GlycA6 was lower on admission in ischemic compared with "non-ischemic" patients (66 [46-90] vs. 73 [56-95] μg/ml; P = 0.04). 74% of unstable angina patients (all with undetectable hs-Tn), had ischemic changes in ApoJ-Glyc at 0 h and 89% at 1 h. Initially low ApoJ-Glyc levels in 62 patients requiring coronary revascularization increased significantly after successful percutaneous intervention. CONCLUSIONS Circulating ApoJ-Glyc concentrations decrease early in ED patients with myocardial ischemia compared with "non-ischemic" patients, even in the absence of troponin elevations. ApoJ-Glyc may be a useful marker of myocardial ischemia in the ED setting.
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Affiliation(s)
- Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom; GlyCardial Diagnostics, S.L., Barcelona, Spain
| | - Nuria Lluch
- GlyCardial Diagnostics, S.L., Barcelona, Spain
| | | | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London
| | | | - Pablo Avanzas
- Interventional Cardiology Unit, Hospital Universitario Central de Asturias, Department of Medicine, University of Oviedo, Oviedo, Spain Sanitaria del Principado de Asturias, Spain
| | - Pablo Herrero Puente
- Emergency Department, University Central Hospital of Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Spain
| | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | | | - Andrés Íñiguez
- Department of Cardiology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain
| | - Emmanuel Ako
- Chelsea & Westminster Hospital, London, United Kingdom
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | | | - Alan H B Wu
- Clinical Chemistry and Toxicology Laboratories, San Francisco General Hospital and Dept. Lab. Medicine, University of California, San Francisco, USA
| | - Filippo Crea
- Università Cattolica del Sacro Cuore, and Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Robert Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Lina Badimon
- GlyCardial Diagnostics, S.L., Barcelona, Spain; Cardiovascular-Program-ICCC, IR-Hospital Santa Creu i Sant Pau, IIB-Sant Pau, 08025 Barcelona, Spain; Cardiovascular Research, Universitat Autònoma de Barcelona, Barcelona, Spain
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15
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Mohammed AQ, Abdu FA, Liu L, Yin G, Mareai RM, Mohammed AA, Xu Y, Che W. Coronary microvascular dysfunction and myocardial infarction with non-obstructive coronary arteries: Where do we stand? Eur J Intern Med 2023; 117:8-20. [PMID: 37482469 DOI: 10.1016/j.ejim.2023.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/15/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
In the past decade, scientific and clinical research has provided a translational perspective on myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). MINOCA is characterized by clinical documentation of an acute MI but angiography shows no significant coronary artery obstruction (stenosis <50%). The prevalence of MINOCA is estimated to range from approximately 6 to 10% among MI patients, and those with this condition have a poor prognosis, experiencing high rates of mortality, rehospitalization, and socioeconomic burden. MINOCA represents a major unmet need in cardiovascular medicine, with uncertain clinical management. It is a complex condition that can be caused by various factors, including atherosclerosis, plaque rupture, coronary vasospasm, and microvascular dysfunction. Effective management of MINOCA depends on identifying the underlying mechanism of the infarction, thus a systematic diagnostic approach is recommended. Contemporary data shows that a significant number of patients exhibit structural and functional abnormalities in coronary microcirculation, which is referred to as coronary microvascular dysfunction (CMD). CMD plays a crucial role in patients with signs and symptoms of myocardial ischemia and non-obstructive coronary artery stenosis, including MINOCA. Furthermore, conducting a thorough evaluation of coronary function can have significant prognostic and therapeutic implications, since personalized patient management strategies based on this assessment have been shown to improve symptoms and prognosis. Therefore, an accurate and timely diagnosis of CMD is essential for effective patient management, which can be achieved through various invasive and non-invasive methods. This review will discuss the pathophysiological understanding, current diagnostic techniques, and management strategies of patients with MINOCA and CMD.
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Affiliation(s)
- Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China.
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16
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Civieri G, Kerkhof PLM, Montisci R, Iliceto S, Tona F. Sex differences in diagnostic modalities of coronary artery disease: Evidence from coronary microcirculation. Atherosclerosis 2023; 384:117276. [PMID: 37775426 DOI: 10.1016/j.atherosclerosis.2023.117276] [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: 03/24/2023] [Revised: 06/16/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
Although atherosclerosis is usually considered a disease of the large arteries, risk factors for atherosclerosis also trigger structural and functional abnormalities at a microvascular level. In cardiac disease, microvascular dysfunction is especially relevant in women, among whom the manifestation of ischemic disease due to impaired coronary microcirculation is more common than in men. This sex-specific clinical phenotype has important clinical implications and, given the higher pre-test probability of coronary microvascular dysfunction in females, different diagnostic modalities should be used in women compared to men. In this review, we summarize invasive and non-invasive diagnostic modalities to assess coronary microvascular function, ranging from catheter-based evaluation of endothelial function to Doppler echocardiography and positron emission tomography. Moreover, we discuss different clinical settings in which microvascular disease plays an important role, underlining the importance of choosing the right diagnostic modality depending on the sex of the patients.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Peter L M Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, the Netherlands
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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17
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Allbritton-King JD, García-Cardeña G. Endothelial cell dysfunction in cardiac disease: driver or consequence? Front Cell Dev Biol 2023; 11:1278166. [PMID: 37965580 PMCID: PMC10642230 DOI: 10.3389/fcell.2023.1278166] [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: 08/15/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
The vascular endothelium is a multifunctional cellular system which directly influences blood components and cells within the vessel wall in a given tissue. Importantly, this cellular interface undergoes critical phenotypic changes in response to various biochemical and hemodynamic stimuli, driving several developmental and pathophysiological processes. Multiple studies have indicated a central role of the endothelium in the initiation, progression, and clinical outcomes of cardiac disease. In this review we synthesize the current understanding of endothelial function and dysfunction as mediators of the cardiomyocyte phenotype in the setting of distinct cardiac pathologies; outline existing in vivo and in vitro models where key features of endothelial cell dysfunction can be recapitulated; and discuss future directions for development of endothelium-targeted therapeutics for cardiac diseases with limited existing treatment options.
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Affiliation(s)
- Jules D. Allbritton-King
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Guillermo García-Cardeña
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
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18
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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19
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Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, Jeremias A, Albadri A, Blair JA, Kearney KE, Wei J, Park K, Barseghian El-Farra A, Holoshitz N, Janaszek KB, Kesarwani M, Lerman A, Prasad M, Quesada O, Reynolds HR, Savage MP, Smilowitz NR, Sutton NR, Sweeny JM, Toleva O, Henry TD, Moses JW, Fearon WF, Tremmel JA. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1245-1263. [PMID: 37704315 DOI: 10.1016/j.jacc.2023.06.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 09/15/2023]
Abstract
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
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Affiliation(s)
- Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Jay Widmer
- Baylor Scott and White Health, Temple, Texas, USA
| | - Yuhei Kobayashi
- New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Steven E S Miner
- Southlake Regional Medical Centre, Newmarket, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen Jeremias
- St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Ahmed Albadri
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John A Blair
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kathleen E Kearney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Noa Holoshitz
- Ascension Columbia St Mary's, Milwaukee, Wisconsin, USA
| | | | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael P Savage
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph M Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olga Toleva
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Jeffery W Moses
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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20
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He Z, Xu X, Zhao Q, Ding H, Wang DW. Vasospastic angina: Past, present, and future. Pharmacol Ther 2023; 249:108500. [PMID: 37482097 DOI: 10.1016/j.pharmthera.2023.108500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/22/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.
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Affiliation(s)
- Zuowen He
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan 430030, China
| | - Xin Xu
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan 430030, China
| | - Qu Zhao
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan 430030, China
| | - Hu Ding
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan 430030, China
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan 430030, China.
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21
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Marano P, Wei J, Merz CNB. Coronary Microvascular Dysfunction: What Clinicians and Investigators Should Know. Curr Atheroscler Rep 2023; 25:435-446. [PMID: 37338666 PMCID: PMC10412671 DOI: 10.1007/s11883-023-01116-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Abnormal structure and function of the coronary microvasculature have been implicated in the pathophysiology of multiple cardiovascular disease processes. This article reviews recent research progress related to coronary microvascular dysfunction (CMD) and salient clinical takeaways. RECENT FINDINGS CMD is prevalent in patients with signs and symptoms of ischemia and no obstructive epicardial coronary artery disease (INOCA), particularly in women. CMD is associated with adverse outcomes, including most frequently the development of heart failure with preserved ejection fraction. It is also associated with adverse outcomes in patient populations including hypertrophic cardiomyopathy, dilated cardiomyopathy, and acute coronary syndromes. In patients with INOCA, stratified medical therapy guided by invasive coronary function testing to define the subtype of CMD leads to improved symptoms. There are invasive and non-invasive methodologies to diagnose CMD that provide prognostic information and mechanistic information to direct treatment. Available treatments improve symptoms and myocardial blood flow; ongoing investigations aim to develop therapy to improve adverse outcomes related to CMD.
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Affiliation(s)
- Paul Marano
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA.
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
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22
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Ong P, Hubert A, Schwidder M, Beltrame JF. Coronary Spasm: Ethnic and Sex Differences. Eur Cardiol 2023; 18:e43. [PMID: 37456767 PMCID: PMC10345948 DOI: 10.15420/ecr.2023.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/29/2023] [Indexed: 07/18/2023] Open
Abstract
Coronary spasm (CS), which may occur at the epicardial (focal or diffuse spasm) and/or microvascular (microvascular spasm) level, is a well-established cause of myocardial ischaemia, in particular in patients with anginal chest pain despite unobstructed coronary arteries. The diagnosis of CS can be confirmed during coronary angiography by an additional provocation test with vasoactive substances such as acetylcholine. Due to partially inconsistent data from large clinical studies, especially between Asian and white CS patients, ethnic differences concerning the prevalence and angiographic patterns of CS seem to exist. Furthermore, several studies in patients with coronary vasomotor disorders pointed towards differences among male and female CS patients. This article gives an overview of ethnic- and sex-related differences in patients with CS.
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Affiliation(s)
- Peter Ong
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - Astrid Hubert
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - Maike Schwidder
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth HospitalAdelaide, Australia
- Discipline of Medicine, University of AdelaideAdelaide, Australia
- Central Adelaide Local Health NetworkAdelaide, Australia
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23
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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: 7] [Impact Index Per Article: 7.0] [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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24
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Guo Y, Xia C, Zhong Y, Wei Y, Zhu H, Ma J, Li G, Meng X, Yang C, Wang X, Wang F. Machine learning-enhanced echocardiography for screening coronary artery disease. Biomed Eng Online 2023; 22:44. [PMID: 37170232 PMCID: PMC10176743 DOI: 10.1186/s12938-023-01106-x] [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: 02/08/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Since myocardial work (MW) and left atrial strain are valuable for screening coronary artery disease (CAD), this study aimed to develop a novel CAD screening approach based on machine learning-enhanced echocardiography. METHODS This prospective study used data from patients undergoing coronary angiography, in which the novel echocardiography features were extracted by a machine learning algorithm. A total of 818 patients were enrolled and randomly divided into training (80%) and testing (20%) groups. An additional 115 patients were also enrolled in the validation group. RESULTS The superior diagnosis model of CAD was optimized using 59 echocardiographic features in a gradient-boosting classifier. This model showed that the value of the receiver operating characteristic area under the curve (AUC) was 0.852 in the test group and 0.834 in the validation group, with high sensitivity (0.952) and low specificity (0.691), suggesting that this model is very sensitive for detecting CAD, but its low specificity may increase the high false-positive rate. We also determined that the false-positive cases were more susceptible to suffering cardiac events than the true-negative cases. CONCLUSIONS Machine learning-enhanced echocardiography can improve CAD detection based on the MW and left atrial strain features. Our developed model is valuable for estimating the pre-test probability of CAD and screening CAD patients in clinical practice. TRIAL REGISTRATION Registered as NCT03905200 at ClinicalTrials.gov. Registered on 5 April 2019.
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Affiliation(s)
- Ying Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Chenxi Xia
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - You Zhong
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Yiliang Wei
- Jiangsu Key Laboratory of Phylogenomics and Comparative Genomics, School of Life Sciences, Jiangsu Normal University, Xuzhou, 221116, Jiangsu, People's Republic of China
- Department of Immunology, Biochemistry and Molecular Biology, 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, Tianjin Key Laboratory of Medical Epigenetics, Tianjin Medical University, Tianjin, 300070, People's Republic of China
| | - Huolan Zhu
- Department of Gerontology, Shaanxi Provincial People's Hospital, Shaanxi Provincial Clinical Research Center for Geriatric Medicine, No. 256 Youyi West Road, Xi'an, China
| | - Jianqiang Ma
- Keya Medical Technology Co., Ltd, Beijing, People's Republic of China
| | - Guang Li
- Keya Medical Technology Co., Ltd, Beijing, People's Republic of China
| | - Xuyang Meng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Chenguang Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Xiang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Fang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
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25
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Sanip Z, Pahimi N, Bokti NA, Yusof Z, Mohamed MS, W Isa WYH, Rasool AH. Impaired peripheral microvascular reactivity in patients with nonobstructive coronary artery disease. Microcirculation 2023; 30:e12807. [PMID: 37080549 DOI: 10.1111/micc.12807] [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: 11/09/2022] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE This study aimed to determine whether peripheral microvascular reactivity is impaired in patients with nonobstructive coronary artery disease (NOCAD). METHODS Stable patients presenting with angina were recruited and, based on results from coronary angiography, were categorized into OCAD (coronary stenosis of ≥50%) and NOCAD (stenosis <50%) groups. A control group with no history of angina was also recruited. Forearm skin microvascular reactivity was measured using the laser Doppler blood perfusion monitor and the process of postocclusive skin reactive hyperemia (PORH). RESULTS Patients were categorized into OCAD (n = 42), NOCAD (n = 40), and control (n = 39) groups. Compared with the control group, the PORH perfusion percent change (PORH% change) was significantly lower in the OCAD and NOCAD groups. No significant differences were noted between the OCAD and NOCAD groups. Additionally, the NOCAD group without any coronary obstruction takes a longer time to reach peak perfusion and had lower PORH% change compared with the nonangina control group. CONCLUSION Angina patients with NOCAD have microvascular dysfunction as demonstrated by reduced magnitude of reperfusion with an ischemic stimulus. NOCAD patients without coronary obstruction also displayed a slower response to reperfusion.
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Affiliation(s)
- Zulkefli Sanip
- Central Research Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Nurnajwa Pahimi
- Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Nur Adilah Bokti
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Cardiology Unit, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Zurkurnai Yusof
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Cardiology Unit, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | | | - W Yus Haniff W Isa
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Cardiology Unit, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Aida Hanum Rasool
- Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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26
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Hung MJ, Yeh CT, Kounis NG, Koniari I, Hu P, Hung MY. Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review. Int J Mol Sci 2023; 24:ijms24087530. [PMID: 37108691 PMCID: PMC10145866 DOI: 10.3390/ijms24087530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.
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Affiliation(s)
- Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung, Chang Gung University College of Medicine, Keelung City 24201, Taiwan
| | - Chi-Tai Yeh
- Department of Medical Research and Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Continuing Education Program of Food Biotechnology Applications, College of Science and Engineering, National Taitung University, Taitung 95092, Taiwan
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, 26221 Patras, Greece
| | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Patrick Hu
- Department of Internal Medicine, School of Medicine, University of California, Riverside, Riverside, CA 92521, USA
- Department of Cardiology, Riverside Medical Clinic, Riverside, CA 92506, USA
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, No.291, Zhongzheng Rd., Zhonghe District, New Taipei City 23561, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 23561, Taiwan
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27
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Godo S, Takahashi J, Shiroto T, Yasuda S, Shimokawa H. Coronary Microvascular Spasm: Clinical Presentation and Diagnosis. Eur Cardiol 2023; 18:e07. [PMID: 37377449 PMCID: PMC10291603 DOI: 10.15420/ecr.2022.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/13/2022] [Indexed: 06/29/2023] Open
Abstract
Professor Maseri pioneered the research and treatment of coronary vasomotion abnormalities represented by coronary vasospasm and coronary microvascular dysfunction (CMD). These mechanisms can cause myocardial ischaemia even in the absence of obstructive coronary artery disease, and have been appreciated as an important aetiology and therapeutic target with major clinical implications in patients with ischaemia with non-obstructive coronary artery disease (INOCA). Coronary microvascular spasm is one of the key mechanisms responsible for myocardial ischaemia in patients with INOCA. Comprehensive assessment of coronary vasomotor reactivity by invasive functional coronary angiography or interventional diagnostic procedure is recommended to identify the underlying mechanisms of myocardial ischaemia and to tailor the best treatment and management based on the endotype of INOCA. This review highlights the pioneering works of Professor Maseri and contemporary research on coronary vasospasm and CMD with reference to endothelial dysfunction, Rho-kinase activation and inflammation.
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Affiliation(s)
- Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
- Graduate School, International University of Health and WelfareNarita, Japan
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28
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Woudstra J, Vink CEM, Schipaanboord DJM, Eringa EC, den Ruijter HM, Feenstra RGT, Boerhout CKM, Beijk MAM, de Waard GA, Ong P, Seitz A, Sechtem U, Piek JJ, van de Hoef TP, Appelman Y. Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis. Front Cardiovasc Med 2023; 10:1129159. [PMID: 36993994 PMCID: PMC10041338 DOI: 10.3389/fcvm.2023.1129159] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Background Coronary artery spasm (CAS), encompassing epicardial and microvascular spasm, is increasingly recognized as cause of angina in patients with non-obstructive coronary artery disease (ANOCA). However, various spasm provocation testing protocols and diagnostic criteria are used, making diagnosis and characterization of these patients difficult and interpretation of study results cumbersome. This review provides a structured overview of the prevalence, characterization and prognosis of CAS worldwide in men and women. Methods A systematic review identifying studies describing ANOCA patients with CAS was performed. Multiple outcomes (prevalence, clinical features, and prognosis) were assessed. Data, except for prognosis were pooled and analysed using random effects meta-analysis models. Results Twenty-five publications (N = 14.554) were included (58.2 years; 44.2% women). Percentages of epicardial constriction to define epicardial spasm ranged from >50% to >90%. Epicardial spasm was prevalent in 43% (range 16-73%), with a higher prevalence in Asian vs. Western World population (52% vs. 33%, p = 0.014). Microvascular spasm was prevalent in 25% (range 7-39%). Men were more likely to have epicardial spasm (61%), women were more likely to have microvascular spasm (64%). Recurrent angina is frequently reported during follow-up ranging from 10 to 53%. Conclusion CAS is highly prevalent in ANOCA patients, where men more often have epicardial spasm, women more often have microvascular spasm. A higher prevalence of epicardial spasm is demonstrated in the Asian population compared to the Western World. The prevalence of CAS is high, emphasizing the use of unambiguous study protocols and diagnostic criteria and highlights the importance of routine evaluation of CAS in men and women with ANOCA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272100.
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Affiliation(s)
- Janneke Woudstra
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Diantha J M Schipaanboord
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Rutger G T Feenstra
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Coen K M Boerhout
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Marcel A M Beijk
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Peter Ong
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Andreas Seitz
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Tim P van de Hoef
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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29
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Crooijmans C, Jansen TPJ, Konst RE, Woudstra J, Appelman Y, den Ruijter HM, Onland-Moret NC, Meeder JG, de Vos AMJ, Paradies V, Woudstra P, Sjauw KD, van 't Hof A, Meuwissen M, Winkler P, Boersma E, van de Hoef TP, Maas AHEM, Dimitriu-Leen AC, van Royen N, Elias-Smale SE, Damman P. Design and rationale of the NetherLands registry of invasive Coronary vasomotor Function Testing (NL-CFT). Int J Cardiol 2023; 379:1-8. [PMID: 36863419 DOI: 10.1016/j.ijcard.2023.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/02/2023] [Accepted: 02/12/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Angina without angiographic evidence of obstructive coronary artery disease (ANOCA) is a highly prevalent condition with insufficient pathophysiological knowledge and lack of evidence-based medical therapies. This affects ANOCA patients prognosis, their healthcare utilization and quality of life. In current guidelines, performing a coronary function test (CFT) is recommended to identify a specific vasomotor dysfunction endotype. The NetherLands registry of invasive Coronary vasomotor Function testing (NL-CFT) has been designed to collect data on ANOCA patients undergoing CFT in the Netherlands. METHODS The NL-CFT is a web-based, prospective, observational registry including all consecutive ANOCA patients undergoing clinically indicated CFT in participating centers throughout the Netherlands. Data on medical history, procedural data and (patient reported) outcomes are gathered. The implementation of a common CFT protocol in all participating hospitals promotes an equal diagnostic strategy and ensures representation of the entire ANOCA population. A CFT is performed after ruling out obstructive coronary artery disease. It comprises of both acetylcholine vasoreactivity testing as well as bolus thermodilution assessment of microvascular function. Optionally, continuous thermodilution or Doppler flow measurements can be performed. Participating centers can perform research using own data, or pooled data will be made available upon specific request via a secure digital research environment, after approval of a steering committee. CONCLUSION NL-CFT will be an important registry by enabling both observational and registry based (randomized) clinical trials in ANOCA patients undergoing CFT.
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Affiliation(s)
- C Crooijmans
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - T P J Jansen
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - R E Konst
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - J Woudstra
- Dept. of Cardiology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Y Appelman
- Dept. of Cardiology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - H M den Ruijter
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - N C Onland-Moret
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J G Meeder
- Dept. of Cardiology, Viecuri Medical Center, Venlo, the Netherlands
| | - A M J de Vos
- Dept. of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - V Paradies
- Dept. of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - P Woudstra
- Dept. of Cardiology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - K D Sjauw
- Dept. of Cardiology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - A van 't Hof
- Dept. of Cardiology, MUMC, Maastricht, the Netherlands; Dept. of Cardiology, Zuyderland, Heerlen, the Netherlands; CArdiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - M Meuwissen
- Dept. of Cardiology, Amphia Hospital, Breda, the Netherlands
| | - P Winkler
- Dept. of Cardiology, Zuyderland, Heerlen, the Netherlands
| | - E Boersma
- Dept. of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - T P van de Hoef
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A H E M Maas
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | | | - N van Royen
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | | | - P Damman
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands.
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30
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Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
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31
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Ngo V, Tavoosi A, Natalis A, Harel F, Jolicoeur EM, Beanlands RSB, Pelletier-Galarneau M. Non-invasive diagnosis of vasospastic angina. J Nucl Cardiol 2023; 30:167-177. [PMID: 35322379 DOI: 10.1007/s12350-022-02948-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
Vasospastic angina (VSA), or variant angina, is an under-recognized cause of chest pain and myocardial infarction, especially in Western countries. VSA leads to a declined quality of life and is associated with increased morbidity and mortality. Currently, the diagnosis of VSA relies on invasive testing that requires the direct intracoronary administration of ergonovine or acetylcholine. However, invasive vasoreactivity testing is underutilized. Several non-invasive imaging alternatives have been proposed to screen for VSA. This review aims to discuss the strengths and limitations of available non-invasive imaging tests for vasospastic angina.
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Affiliation(s)
- Vincent Ngo
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC, H1T1C8, Canada
| | - Anahita Tavoosi
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alexandre Natalis
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Harel
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC, H1T1C8, Canada
| | - E Marc Jolicoeur
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert S B Beanlands
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
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32
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Li Y, Xu W, Guo L. Anxiety is associated with coronary microvascular dysfunction: Results from the CAMADA study. Microcirculation 2023; 30:e12798. [PMID: 36633351 DOI: 10.1111/micc.12798] [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: 10/03/2022] [Revised: 11/25/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) is an important component of ischemic heart disease. Here, we assessed the associations between anxiety/depression and CMD using coronary microvascular function indicators. METHODS The study included 81 patients (26 males and 55 females) with nonobstructive coronary artery disease. The symptoms of anxiety and depression were measured with Self-rating Anxiety Scale and Self-rating Depression Scale. Coronary microvascular function was assessed using coronary flow reserve (CFR) measured by transthoracic Doppler echocardiography. RESULTS The anxiety group had significantly lower CFR than that in the no-anxiety group (2.97 ± 0.63 vs. 3.40 ± 0.61, p = .029). In bivariate correlation analysis, anxiety was negatively associated with CFR (r = -.333, p = .002). In the multiple linear regression model, after adjusting for age, sex, BMI, hypertension, dyslipidemia, smoking status, and family history of premature coronary heart disease, anxiety was negatively associated with CFR (β = -.314, p = .008). When both anxiety and depression were included in the multiple linear regression model, anxiety was also negatively associated with CFR (β = -.345, p = .012). CONCLUSION Anxiety patients had lower CFR, anxiety was independently associated with CFR. Psychological disorders may play an important role in coronary microvascular dysfunction.
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Affiliation(s)
- Ying Li
- Department of Geriatrics, Peking University Third Hospital, Beijing, China
| | - Weixian Xu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
| | - Lijun Guo
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
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33
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Schindler TH, Fearon WF, Pelletier-Galarneau M, Ambrosio G, Sechtem U, Ruddy TD, Patel KK, Bhatt DL, Bateman TM, Gewirtz H, Shirani J, Knuuti J, Gropler RJ, Chareonthaitawee P, Slart RHJA, Windecker S, Kaufmann PA, Abraham MR, Taqueti VR, Ford TJ, Camici PG, Schelbert HR, Dilsizian V. PET for Detection and Reporting Coronary Microvascular Dysfunction: A JACC: Cardiovascular Imaging Expert Panel Statement. JACC Cardiovasc Imaging 2023; 16:536-548. [PMID: 36881418 DOI: 10.1016/j.jcmg.2022.12.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 12/02/2022] [Indexed: 02/11/2023]
Abstract
Angina pectoris and dyspnea in patients with normal or nonobstructive coronary vessels remains a diagnostic challenge. Invasive coronary angiography may identify up to 60% of patients with nonobstructive coronary artery disease (CAD), of whom nearly two-thirds may, in fact, have coronary microvascular dysfunction (CMD) that may account for their symptoms. Positron emission tomography (PET) determined absolute quantitative myocardial blood flow (MBF) at rest and during hyperemic vasodilation with subsequent derivation of myocardial flow reserve (MFR) affords the noninvasive detection and delineation of CMD. Individualized or intensified medical therapies with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, angiotensin II type 1-receptor blockers, beta-blockers, ivabradine, or ranolazine may improve symptoms, quality of life, and outcome in these patients. Standardized diagnosis and reporting criteria for ischemic symptoms caused by CMD are critical for optimized and individualized treatment decisions in such patients. In this respect, it was proposed by the cardiovascular council leadership of the Society of Nuclear Medicine and Molecular Imaging to convene thoughtful leaders from around the world to serve as an independent expert panel to develop standardized diagnosis, nomenclature and nosology, and cardiac PET reporting criteria for CMD. This consensus document aims to provide an overview of the pathophysiology and clinical evidence of CMD, its invasive and noninvasive assessment, standardization of PET-determined MBFs and MFR into "classical" (predominantly related to hyperemic MBFs) and "endogen" (predominantly related to resting MBF) normal coronary microvascular function or CMD that may be critical for diagnosis of microvascular angina, subsequent patient care, and outcome of clinical CMD trials.
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Affiliation(s)
- Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | | | - Giuseppe Ambrosio
- University of Perugia School of Medicine Ospedale S. Maria della Misericordia Perugia, Italy
| | - Udo Sechtem
- Cardiologicum Stuttgart, Stuttgart, Baden-Wuerttemberg, Germany
| | | | - Krishna K Patel
- Icahn School of Medicine at Mount Sinai, Zena, New York, New York, USA; Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Timothy M Bateman
- Saint-Lukes Health System and the Mid-America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Henry Gewirtz
- Cardiac Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jamshid Shirani
- Cardiology, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Juhani Knuuti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | | | - Riemer H J A Slart
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Maria R Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, California, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thomas J Ford
- The University of Newcastle, Faculty of Medicine, Newcastle, Australia
| | - Paolo G Camici
- San Raffaele Hospital, Milan Italy; Vita Salute University, Milan, Italy
| | - Heinrich R Schelbert
- Department of Molecular Imaging and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Yamanaka T, Ueki T, Mase M, Inoue K. Arbitrary Ca 2+ regulation for endothelial nitric oxide, NFAT and NF-κB activities by an optogenetic approach. Front Pharmacol 2023; 13:1076116. [PMID: 36703743 PMCID: PMC9871596 DOI: 10.3389/fphar.2022.1076116] [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: 10/21/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
Modern western dietary habits and low physical activity cause metabolic abnormalities and abnormally elevated levels of metabolites such as low-density lipoprotein, which can lead to immune cell activation, and inflammatory reactions, and atherosclerosis. Appropriate stimulation of vascular endothelial cells can confer protective responses against inflammatory reactions and atherosclerotic conditions. This study aims to determine whether a designed optogenetic approach is capable of affecting functional changes in vascular endothelial cells and to evaluate its potential for therapeutic regulation of vascular inflammatory responses in vitro. We employed a genetically engineered, blue light-activated Ca2+ channel switch molecule that utilizes an endogenous store-operated calcium entry system and induces intracellular Ca2+ influx through blue light irradiation and observed an increase in intracellular Ca2+ in vascular endothelial cells. Ca2+-dependent activation of the nuclear factor of activated T cells and nitric oxide production were also detected. Microarray analysis of Ca2+-induced changes in vascular endothelial cells explored several genes involved in cellular contractility and inflammatory responses. Indeed, there was an increase in the gene expression of molecules related to anti-inflammatory and vasorelaxant effects. Thus, a combination of human blue light-activated Ca2+ channel switch 2 (hBACCS2) and blue light possibly attenuates TNFα-induced inflammatory NF-κB activity. We propose that extrinsic cellular Ca2+ regulation could be a novel approach against vascular inflammation.
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Affiliation(s)
- Tomoyasu Yamanaka
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takatoshi Ueki
- Department of Integrative Anatomy, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Koichi Inoue
- Department of Integrative Anatomy, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan,*Correspondence: Koichi Inoue,
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35
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Aélion H, Picard F, Jégou A, Allouch P, Varenne O. Abnormal epicardial coronary vasomotor reactivity is associated with altered outcomes. Arch Cardiovasc Dis 2023; 116:33-40. [PMID: 36526570 DOI: 10.1016/j.acvd.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence and significance of abnormal epicardial coronary vasomotor reactivity (ACVR) in patients with symptoms compatible with myocardial ischaemia remains ill-defined. Our diagnostic strategy is to perform a provocative test (PT) in every patient presenting with chest pain at rest, for whom coronary angiography does not reveal significant epicardial coronary artery disease (≥70% stenosis by visual assessment). AIM To evaluate such a strategy in terms of incidence of ACVR, PT safety and patient outcomes. METHODS The present study was a retrospective observational study with a median clinical follow-up of 5years. The primary outcome was incidence of ACVR in patients with PT. Risk factors for ACVR and clinical follow-up were obtained, and the rate of major adverse cardiovascular and cerebrovascular events (MACCE; death, cardiovascular mortality, myocardial infarction, stroke and coronary revascularization) was reported. RESULTS ACVR was documented in 294 (12.4%) of the 2379 patients with PT, out of the 13,654 patients undergoing angiography. Patients with ACVR were more often female (43.9% vs. 30.0%; P<0.0001), current smokers (37.4% vs. 8.7%; P<0.0001) and had a suspected acute coronary syndrome (36.7% vs. 29.1%; P=0.005) at admittance compared with patients without ACVR. During clinical follow-up, MACCE occurred more frequently in patients with (9.8%) than in those without (3.7%) ACVR (hazard ratio [HR] 4.15, 95% confidence interval [CI] 2.62-6.57; P<0.0001), including more myocardial infarctions (4.0% vs. 0.4%; HR 17.8, 95% CI 6.41-49.5; P<0.0001) and more myocardial revascularizations (6.1% vs. 1.1%; HR 9.36, 95% CI 4.67-18.74; P<0.0001) compared with patients with normal PT at baseline. CONCLUSIONS ACVR is frequent in patients with symptoms compatible with myocardial ischaemia at rest, with no significant coronary stenosis. PT is a safe strategy to identify a population at high risk of recurrent ischaemic events.
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Affiliation(s)
- Hélène Aélion
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France
| | - Fabien Picard
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France; Paris Sudden Death Expertise Centre, 75015 Paris, France
| | - Arnaud Jégou
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Philippe Allouch
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Olivier Varenne
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France; Paris Sudden Death Expertise Centre, 75015 Paris, France.
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36
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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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37
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Damman P, Elias-Smale SE, Jansen TPJ, Konst RE, Dimitriu-Leen AC, Hartzema M, van Royen N, Maas AHEM. Contemporary and future invasive coronary vasomotor function testing and treatment in patients with ischaemia with no obstructive coronary arteries. Eur Heart J Suppl 2022; 24:H18-H24. [PMID: 36382006 PMCID: PMC9650459 DOI: 10.1093/eurheartjsupp/suac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In the current review, we emphasize the importance of diagnostics and therapy in patients with ischaemia with no obstructive coronary arteries (INOCA). The importance of the diagnostic coronary function test (CFT) procedure is described, including future components including angiography-derived physiology and invasive continuous thermodilution. Furthermore, the main components of treatment are discussed. Future directions include the national registration ensuring a high quality of INOCA care, besides a potential source to improve our understanding of pathophysiology in the various phenotypes of coronary vascular dysfunction, the diagnostic CFT procedure, and treatment.
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Affiliation(s)
- Peter Damman
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | | | - Mariëlle Hartzema
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
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Soleymani M, Masoudkabir F, Shabani M, Vasheghani-Farahani A, Behnoush AH, Khalaji A. Updates on Pharmacologic Management of Microvascular Angina. Cardiovasc Ther 2022; 2022:6080258. [PMID: 36382021 PMCID: PMC9626221 DOI: 10.1155/2022/6080258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 10/17/2022] [Indexed: 01/14/2024] Open
Abstract
Microvascular angina (MVA), historically called cardiac syndrome X, refers to angina with nonobstructive coronary artery disease. This female-predominant cardiovascular disorder adds considerable health-related costs due to repeated diagnostic angiography and frequent hospital admissions. Despite the high prevalence of this diagnosis in patients undergoing coronary angiography, it is still a therapeutic challenge for cardiologists. Unlike obstructive coronary artery disease, with multiple evidence-based therapies and management guidelines, little is known regarding the management of MVA. During the last decade, many therapeutic interventions have been suggested for the treatment of MVA. However, there is a lack of summarization tab and update of current knowledge about pharmacologic management of MVA, mostly due to unclear pathophysiology. In this article, we have reviewed the underlying mechanisms of MVA and the outcomes of various medications in patients with this disease. Contrary to vasospastic angina in which normal angiogram is observed as well, nitrates are not effective in the treatment of MVA. Beta-blockers and calcium channel blockers have the strongest evidence of improving the symptoms. Moreover, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, estrogen, and novel antianginal drugs has had promising outcomes. Investigations are still ongoing for vitamin D, omega-3, incretins, and n-acetyl cysteine, which have resulted in beneficial initial outcomes. We believe that the employment of the available results and results of the future large-scale trials into cardiac care guidelines would help reduce the global cost of cardiac care tremendously.
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Affiliation(s)
- Mosayeb Soleymani
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsima Shabani
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ali Vasheghani-Farahani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Travieso A, Jeronimo-Baza A, Faria D, Shabbir A, Mejia-Rentería H, Escaned J. Invasive evaluation of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:2474-2486. [PMID: 35618991 PMCID: PMC9553758 DOI: 10.1007/s12350-022-02997-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022]
Abstract
Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Adrian Jeronimo-Baza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Daniel Faria
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Asad Shabbir
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Hernan Mejia-Rentería
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain.
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Prakash RO, Chakrala TS, Feuer DS, Valdes CA, Pepine CJ, Keeley EC. Critical role of the coronary microvasculature in heart disease: From pathologic driving force to "innocent" bystander. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100215. [PMID: 38558907 PMCID: PMC10978433 DOI: 10.1016/j.ahjo.2022.100215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 04/04/2024]
Abstract
The coronary microvasculature is responsible for providing oxygen and nutrients to myocardial tissue. A healthy microvasculature with an intact and properly functioning endothelium accomplishes this by seemless changes in vascular tone to match supply and demand. Perturbations in the normal physiology of the microvasculature, including endothelial and/or vascular smooth muscle dysfunction, result in impaired function (vasoconstriction, antithrombotic, etc.) and structural (hypertrophic, fibrotic) abnormalities that lead to microvascular ischemia and potential organ damage. While coronary microvascular dysfunction (CMD) is the primary pathologic driving force in ischemia with non-obstructive coronary artery disease (INOCA), angina with no obstructive coronary arteries (ANOCA), and myocardial infarction with non-obstructed coronary arteries (MINOCA), it may be a bystander in many cardiac disorders which later become pathologically associated with signs and/or symptoms of myocardial ischemia. Importantly, regardless of the primary or secondary basis of CMD in the heart, it is associated with important increases in morbidity and mortality. In this review we discuss salient features pertaining to known pathophysiologic mechanisms driving CMD, the spectrum of heart diseases where it places a critical role, invasive and non-invasive diagnostic testing, management strategies, and the gaps in knowledge where future research efforts are needed.
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Affiliation(s)
- Roshni O. Prakash
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Teja S. Chakrala
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Daniel S. Feuer
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carlos A. Valdes
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carl J. Pepine
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ellen C. Keeley
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
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Clinical Outcomes and Provoked Epicardial Spasm Phenotypes via Intracoronary Acetylcholine Testing in 680 Patients with Angina and Nonobstructive Coronary Arteries. Life (Basel) 2022; 12:life12101465. [PMID: 36294900 PMCID: PMC9605297 DOI: 10.3390/life12101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Epicardial spasm (ES) phenotypes may be related to the prognosis in patients with coronary spastic angina. Objectives: The purpose of this study was to elucidate the relationship between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection and prognosis in patients with angina and nonobstructive coronary artery disease (ANOCAD). Methods: This was a retrospective, observational, single-center study of 680 patients with ANOCAD. ACh spasm provocation tests on both coronary arteries were performed without administering nitroglycerine to relieve provoked spasm in a first-attempt artery. ACh was injected in incremental doses of 20/50/100/200 μg into the left coronary artery and 20/50/80 μg into the right coronary artery. Positive ES was defined as ≥90% stenosis and usual chest pain and ischemic ECG changes. Results: Provoked positive ES was observed in 310 patients (46%), including 85 patients (13%) with focal spasm, 150 patients (22%) with diffuse spasm, and 75 patients (11%) with combined spasm (diffuse spasm and focal spasm), whereas the remaining 370 patients (54%) had no provoked spasm. An unclassified ACh test was observed in 186 patients (27%), while 184 patients (27%) had a complete negative ACh test. The clinical outcomes in patients with complete negative ES were satisfactory compared with those with positive ES and unclassified ACh test results. The prognosis in patients with an unclassified ACh test was not different from those with a positive ES. Furthermore, prognosis in patients with ES phenotypes was not different among the three groups. Conclusions: There was no correlation between provoked ES phenotypes via intracoronary ACh testing and prognosis in patients with ANOCAD; however, clinical outcomes in patients with positive ES and unclassified ACh tests were worse compared to those with complete negative ACh tests. We should focus on the treatments in patients with unclassified ACh tests as well as those with ESs.
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Sex Difference in Coronary Artery Spasm Tested by Intracoronary Acetylcholine Provocation Test in Patients with Nonobstructive Coronary Artery Disease. J Interv Cardiol 2022; 2022:5289776. [PMID: 36131847 PMCID: PMC9481410 DOI: 10.1155/2022/5289776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Cardiovascular diseases manifest differently in men and women. The purpose of this study is to compare the sex difference in the characteristics of coronary artery spasm (CAS) in patients with nonobstructive cardiovascular disease (NOCVD) and the clinical outcomes in accordance with sex in CAS patients. Methods The study analysed 5,491 patients with NOCVD who underwent an acetylcholine provocation test from November 2004 to May 2014 for evaluation of chest pain. CAS was defined as greater than 70% of luminal narrowing of the artery during the acetylcholine provocation test. Results The patients were divided into men (n = 2,506) and women (n = 2,985). Mean follow-up days were 1,218 ± 577 days. To adjust for confounding factors, the propensity score matching (PSM) analysis was performed in all patients and among the CAS patients. After PSM analysis, a total of 1,201 pairs in all patients and a total of 713 pairs in CAS patients were generated. In all patients, women showed significantly less incidence of CAS compared with men (62.3% vs 50.9%, P < 0.01). Myocardial bridge (MB) and moderate stenosis were less prevalent in women, while transient ST elevation and ischemic chest pain during provocation were more frequent in women. In CAS patients, men had a higher incidence of multivessel spasm than women (35.7% vs. 29.7%, P < 0.01). Old age, dyslipidemia, and MB were independent risk factors of CAS in both men and women. In CAS patients, there was no statistical differences for various individual and composite major outcomes up to five years in either men or women. In men with CAS, old age was a risk factor of a 5-year major adverse cardiac event (MACE), and moderate stenosis was a risk factor of both 5-year MACE and 5-year recurrent angina. In women with CAS, mild stenosis was a risk factor of 5-year MACE, while myocardial bridge was a risk factor of 5-year recurrent angina. Conclusions In this study, there were sex differences in the angiographic and clinical parameters during the acetylcholine provocation test, incidence of CAS, risk factors of CAS, 5-year MACE, and recurrent angina. Old age, dyslipidemia, and MB were independent risk factors of CAS in both sexes. However, major clinical outcomes up to five years in CAS patients were not different according to sex.
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Abstract
PURPOSE OF REVIEW Obstructive coronary artery disease is a major cause of ischemia in both men and women; however, women are more likely to present with ischemia in the setting of no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA), conditions that are associated with adverse cardiovascular prognosis despite absence of coronary stenosis. In this review, we focus on mechanisms of coronary ischemia that should be considered in the differential diagnosis when routine anatomic clinical investigation leads to the finding of non-obstructive coronary artery disease on coronary angiography in the setting of acute myocardial infarction. RECENT FINDINGS There are multiple mechanisms that contribute to MINOCA, including atherosclerotic plaque disruption, coronary artery spasm, coronary microvascular dysfunction (CMD), coronary embolism and/or thrombosis, and spontaneous coronary artery dissection. Non-coronary causes such as myocarditis or supply-demand mismatch should also be considered on the differential when there is an unexplained troponin elevation. Use of advanced imaging and diagnostic techniques to determine the underlying etiology of MINOCA is feasible and helpful, as this has the potential to guide management and secondary prevention. Failure to identify the underlying cause(s) may result in inappropriate treatment and inaccurate counseling to patients. MINOCA predominates in young women and is associated with a guarded prognosis. The diagnosis of MINOCA should prompt further investigation to determine the underlying cause of troponin elevation. Patients with INOCA and MINOCA are heterogeneous, and response to treatments can be variable. Large randomized controlled trials to determine longer-term optimal medical therapy for management of these conditions are under investigation.
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Affiliation(s)
- Jingwen Huang
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sonali Kumar
- Department of Medicine, Emory Cardiovascular Disease Fellowship Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Olga Toleva
- Andreas Gruentzig Cardiovascular Center, Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Puja K Mehta
- Division of Cardiology, Emory Women's Heart Center, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Rd, Suite 505, GA, 30322, Atlanta, USA.
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Sinha A, Rahman H, Perera D. Vasospastic Angina: A Contemporary Review of its Pathophysiology, Diagnosis and Management. Heart Int 2022; 16:99-104. [PMID: 36741101 PMCID: PMC9872780 DOI: 10.17925/hi.2022.16.2.99] [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: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 12/25/2022] Open
Abstract
Nearly 40% of patients presenting to the catheter laboratory with angina have non-obstructed coronary arteries (ANOCA), an umbrella term that encompasses distinct pathophysiological entities, such as coronary artery spasm. Coronary artery spasm leads to sudden reversible coronary flow attenuation, which clinically manifests as vasospastic angina (VSA). VSA is associated with poor quality of life and an increased risk of major adverse cardiac events. However, the pathophysiological mechanisms underlying this phenomenon are incompletely understood, which has resulted in limited therapeutic options for patients afflicted with this condition. The past decade has seen a surge in new research being conducted in the field of ANOCA and VSA. This review article provides a comprehensive summary of the underlying pathophysiological mechanisms of VSA and the current therapeutic options. We also appraise the current diagnostic approach in patients with suspected VSA.
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Affiliation(s)
- Aish Sinha
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Haseeb Rahman
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Divaka Perera
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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Endothelial Autophagy in Coronary Microvascular Dysfunction and Cardiovascular Disease. Cells 2022; 11:cells11132081. [PMID: 35805165 PMCID: PMC9265562 DOI: 10.3390/cells11132081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 02/06/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) refers to a subset of structural and/or functional disorders of coronary microcirculation that lead to impaired coronary blood flow and eventually myocardial ischemia. Amid the growing knowledge of the pathophysiological mechanisms and the development of advanced tools for assessment, CMD has emerged as a prevalent cause of a broad spectrum of cardiovascular diseases (CVDs), including obstructive and nonobstructive coronary artery disease, diabetic cardiomyopathy, and heart failure with preserved ejection fraction. Of note, the endothelium exerts vital functions in regulating coronary microvascular and cardiac function. Importantly, insufficient or uncontrolled activation of endothelial autophagy facilitates the pathogenesis of CMD in diverse CVDs. Here, we review the progress in understanding the pathophysiological mechanisms of autophagy in coronary endothelial cells and discuss their potential role in CMD and CVDs.
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Bil J, Pietraszek N, Gil RJ, Gromadziński L, Onichimowski D, Jalali R, Kern A. Complete Blood Count-Derived Indices as Prognostic Factors of 5-Year Outcomes in Patients With Confirmed Coronary Microvascular Spasm. Front Cardiovasc Med 2022; 9:933374. [PMID: 35845050 PMCID: PMC9279657 DOI: 10.3389/fcvm.2022.933374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/15/2022] [Indexed: 12/08/2022] Open
Abstract
Background Coronary microcirculatory dysfunction is a meaningful factor in the development of ischemic heart disease. We investigated the relationship between coronary microvascular spasm and complete blood count indices. Methods Between 2010 and 2013, we performed acetylcholine test (AChT) in subjects with suspicion of angina evoked by epicardial coronary spasm or coronary microvascular spasm according to COVADIS criteria. We administered acetylcholine in increasing doses of 25, 50, and 75 μg into the right coronary artery and 25, 50, and 100 μg into the left coronary artery. Patients were followed up for 60 months. Results In total, 211 patients (60.5 ± 7.8 years, 67.8% women) were included in the study. The AChT revealed angina due to epicardial coronary spasm in 99 patients (46.9%) and coronary microvascular spasm in 72 (34.1%). White blood cell (WBC), red blood cell distribution width (RDW), platelets (PLT), mean platelet volume (MPV), and platelet distribution width (PDW) values were significantly higher in patients with coronary microvascular spasm than in patients from the other two groups, i.e., epicardial coronary spasm and negative AChT. PDW showed the highest sensitivity (65%) and specificity (72%) at the cutoff value of 15.32% [area under the curve, 0.723; 95% confidence interval (CI) 0.64-0.83; P < 0.001]. Independent risk factors for coronary microvascular spasm diagnosis using AChT were as follows: female sex (OR, 1.199), PDW (OR, 2.891), and RDW (OR, 1.567). Conclusion PDW and RDW are significantly associated with the diagnosis of coronary microvascular spasm in patients undergoing AChT as well as with poor prognosis in such patients at 5 years.
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Affiliation(s)
- Jacek Bil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Natalia Pietraszek
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Robert J. Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Leszek Gromadziński
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Dariusz Onichimowski
- Department of Anesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
- Clinical Department of Anesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
| | - Rakesh Jalali
- Emergency Medicine Department, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Clinical Emergency Department, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
| | - Adam Kern
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Department of Cardiology, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
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Qilin L, Yanbin Z, Huaizhi L, Tao Z, Miao Y, Yi X, Dayong D, Yang L, Yuntian L. Effect of Statins on Clinical Outcomes in Patients With Coronary Artery Spasm: A Meta-Analysis. Clin Ther 2022; 44:971-981. [PMID: 35715362 DOI: 10.1016/j.clinthera.2022.05.007] [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: 10/05/2021] [Revised: 04/14/2022] [Accepted: 05/15/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this meta-analysis was to assess the effect of statins on major adverse cardiovascular events (MACE) related to coronary artery spasm (CAS) and to evaluate the effectiveness of statins in patients with CAS. METHODS A systematic search of electronic databases, including Google Scholar, the Cochrane Central Register of Controlled Trials, and PubMed, was conducted. These studies were all published in English, and the databases were searched from inception to July 2021. All articles were evaluated independently by 2 researchers on the basis of inclusion and exclusion criteria. In the research, data about the incidence of major adverse cardiovascular events in CAS patients undergoing statin therapy was included and divided into different subgroups. A random effects model was conducted to synthesize the data. FINDINGS Five cohort studies were included in the analysis. These results indicated that statins failed to reduce the incidence of stroke in patients with CAS in general. However, subgroup analysis revealed that statins were more effective in improving outcomes for CAS patients without severe coronary stenosis compared with those with severe coronary stenosis. IMPLICATIONS Statins may have a potential benefit in patients with CAS who do not have coronary stenosis. To investigate these findings further, future prospective, randomized controlled research will be required.
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Affiliation(s)
- Liu Qilin
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Zhang Yanbin
- Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Lu Huaizhi
- Shangqiu People's Hospital, henan, China
| | - Zhang Tao
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Yang Miao
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Xue Yi
- PLA 305 Hospital, Beijing, China
| | | | - Liu Yang
- PLA 305 Hospital, Beijing, China
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Severe Coronary Artery Vasospasm after Mitral Valve Replacement in a Diabetic Patient with Previous Stent Implantation: A Case Report. J Crit Care Med (Targu Mures) 2022; 8:131-135. [PMID: 35950156 PMCID: PMC9097639 DOI: 10.2478/jccm-2022-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/05/2022] [Indexed: 12/05/2022] Open
Abstract
Postoperative coronary vasospasm is a well-known cause of angina that may lead to myocardial infarction if not treated promptly. We report a case of a 70-year-old female with severe mitral regurgitation submitted to mitral valve replacement, and a history of diabetes mellitus type II, stroke, idiopathic thrombocytopenic purpura on steroid therapy, and previous percutaneous coronary intervention (PCI) for severe obstruction of the circumflex coronary artery, 4 months prior to surgery. Immediately after intensive care unit admission, the patient developed pulseless electrical activity which required extracorporeal membrane oxygenation for hemodynamic support. The coronary angiography showed diffuse occlusive coronary artery vasospasm, ameliorated after intra-coronary administration of nitroglycerin. The following postoperative evolution was marked by cardiogenic shock and multiple organ dysfunction syndrome. Subsequent echocardiographic findings showed an increase in left ventricular function with an EF of 40%, and extracorporeal membrane oxygenation (ECMO) support was weaned after seven days. However, after a few hours, the patient progressively deteriorated, with cardiac arrest and no response to resuscitation maneuvers. Hemodynamic instability following the surgical procedure in a patient with previous PCI associated with an autoimmune disease and diabetes mellitus should raise the suspicion of a coronary artery vasospasm.
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Epicardial and microvascular coronary artery spasm in biopsy-proven viral myocarditis. Int J Cardiol 2022; 360:1-4. [DOI: 10.1016/j.ijcard.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/16/2022] [Accepted: 05/04/2022] [Indexed: 11/05/2022]
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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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