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Jiang L, Yan WF, Zhang L, Xu HY, Guo YK, Li ZL, Liu KL, Zeng LM, Li Y, Yang ZG. Early left ventricular microvascular dysfunction in diabetic pigs: a longitudinal quantitative myocardial perfusion CMR study. Cardiovasc Diabetol 2024; 23:9. [PMID: 38184602 PMCID: PMC10771679 DOI: 10.1186/s12933-023-02106-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Microvascular pathology is one of the main characteristics of diabetic cardiomyopathy; however, the early longitudinal course of diabetic microvascular dysfunction remains uncertain. This study aimed to investigate the early dynamic changes in left ventricular (LV) microvascular function in diabetic pig model using the cardiac magnetic resonance (CMR)-derived quantitative perfusion technique. METHODS Twelve pigs with streptozotocin-induced diabetes mellitus (DM) were included in this study, and longitudinal CMR scanning was performed before and 2, 6, 10, and 16 months after diabetic modeling. CMR-derived semiquantitative parameters (upslope, maximal signal intensity, perfusion index, and myocardial perfusion reserve index [MPRI]) and fully quantitative perfusion parameters (myocardial blood flow [MBF] and myocardial perfusion reserve [MPR]) were analyzed to evaluate longitudinal changes in LV myocardial microvascular function. Pearson correlation was used to analyze the relationship between LV structure and function and myocardial perfusion function. RESULTS With the progression of DM duration, the upslope at rest showed a gradually increasing trend (P = 0.029); however, the upslope at stress and MBF did not change significantly (P > 0.05). Regarding perfusion reserve function, both MPRI and MPR showed a decreasing trend with the progression of disease duration (MPRI, P = 0.001; MPR, P = 0.042), with high consistency (r = 0.551, P < 0.001). Furthermore, LV MPR is moderately associated with LV longitudinal strain (r = - 0.353, P = 0.022), LV remodeling index (r = - 0.312, P = 0.033), fasting blood glucose (r = - 0.313, P = 0.043), and HbA1c (r = - 0.309, P = 0.046). Microscopically, pathological results showed that collagen volume fraction increased gradually, whereas no significant decrease in microvascular density was observed with the progression of DM duration. CONCLUSIONS Myocardial microvascular reserve function decreased gradually in the early stage of DM, which is related to both structural (but not reduced microvascular density) and functional abnormalities of microvessels, and is associated with increased blood glucose, reduced LV deformation, and myocardial remodeling.
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Affiliation(s)
- Li Jiang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Wei-Feng Yan
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Lu Zhang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Zhen-Lin Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ke-Ling Liu
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ling-Ming Zeng
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Silva TQAC, Pezel T, Jerosch-Herold M, Coelho-Filho OR. The Role and Advantages of Cardiac Magnetic Resonance in the Diagnosis of Myocardial Ischemia. J Thorac Imaging 2023; 38:235-246. [PMID: 36917509 DOI: 10.1097/rti.0000000000000701] [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: 03/15/2023]
Abstract
Ischemic heart disease continues to be the leading cause of death and disability worldwide. For the diagnosis of ischemic heart disease, some form of cardiac stress test involving exercise or pharmacological stimulation continues to play an important role, despite advances within modalities like computer tomography for the noninvasive detection and characterization of epicardial coronary lesions. Among noninvasive stress imaging tests, cardiac magnetic resonance (CMR) combines several capabilities that are highly relevant for the diagnosis of ischemic heart disease: assessment of wall motion abnormalities, myocardial perfusion imaging, and depiction of replacement and interstitial fibrosis markers by late gadolinium enhancement techniques and T1 mapping. On top of these qualities, CMR is also well tolerated and safe in most clinical scenarios, including in the presence of cardiovascular implantable devices, while in the presence of renal disease, gadolinium-based contrast should only be used according to guidelines. CMR also offers outstanding viability assessment and prognostication of cardiovascular events. The last 2019 European Society of Cardiology guidelines for chronic coronary syndromes has positioned stress CMR as a class I noninvasive imaging technique for the diagnosis of coronary artery disease in symptomatic patients. In the present review, we present the current state-of-the-art assessment of myocardial ischemia by stress perfusion CMR, highlighting its advantages and current shortcomings. We discuss the safety, clinical, and cost-effectiveness aspects of gadolinium-based CMR-perfusion imaging for ischemic heart disease assessment.
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Affiliation(s)
- Thiago Quinaglia A C Silva
- Discipline of Cardiology, Faculty of Medical Science-State University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Théo Pezel
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Cardiology, University of Paris, CHU Lariboisière, Inserm, UMRS 942, Paris, France
| | - Michael Jerosch-Herold
- Noninvasive Cardiovascular Imaging Program and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Otávio R Coelho-Filho
- Discipline of Cardiology, Faculty of Medical Science-State University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
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Groenhoff L, De Zan G, Costantini P, Siani A, Ostillio E, Carriero S, Muscogiuri G, Bergamaschi L, Patti G, Pizzi C, Sironi S, Pavon AG, Carriero A, Guglielmo M. The Non-Invasive Diagnosis of Chronic Coronary Syndrome: A Focus on Stress Computed Tomography Perfusion and Stress Cardiac Magnetic Resonance. J Clin Med 2023; 12:jcm12113793. [PMID: 37297986 DOI: 10.3390/jcm12113793] [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: 04/25/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Coronary artery disease is still a major cause of death and morbidity worldwide. In the setting of chronic coronary disease, demonstration of inducible ischemia is mandatory to address treatment. Consequently, scientific and technological efforts were made in response to the request for non-invasive diagnostic tools with better sensitivity and specificity. To date, clinicians have at their disposal a wide range of stress-imaging techniques. Among others, stress cardiac magnetic resonance (S-CMR) and computed tomography perfusion (CTP) techniques both demonstrated their diagnostic efficacy and prognostic value in clinical trials when compared to other non-invasive ischemia-assessing techniques and invasive fractional flow reserve measurement techniques. Standardized protocols for both S-CMR and CTP usually imply the administration of vasodilator agents to induce hyperemia and contrast agents to depict perfusion defects. However, both methods have their own limitations, meaning that optimizing their performance still requires a patient-tailored approach. This review focuses on the characteristics, drawbacks, and future perspectives of these two techniques.
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Affiliation(s)
- Léon Groenhoff
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Giulia De Zan
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Pietro Costantini
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Agnese Siani
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Eleonora Ostillio
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Serena Carriero
- Postgraduate School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Giuseppe Muscogiuri
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
| | - Luca Bergamaschi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Sandro Sironi
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Anna Giulia Pavon
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | | | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, 2545 AA The Hague, The Netherlands
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Kwan JM, Arbune A, Henry ML, Hu R, Wei W, Nguyen V, Lee S, Lopez-Mattei J, Guha A, Huber S, Bader AS, Meadows J, Sinusas A, Mojibian H, Peters D, Lustberg M, Hull S, Baldassarre LA. Quantitative cardiovascular magnetic resonance findings and clinical risk factors predict cardiovascular outcomes in breast cancer patients. PLoS One 2023; 18:e0286364. [PMID: 37252927 PMCID: PMC10228774 DOI: 10.1371/journal.pone.0286364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/15/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) global longitudinal strain and circumferential strain abnormalities have been associated with left ventricular ejection fraction (LVEF) reduction and cardiotoxicity from oncologic therapy. However, few studies have evaluated the associations of strain and cardiovascular outcomes. OBJECTIVES To assess CMR circumferential and global longitudinal strain (GLS) correlations with cardiovascular outcomes including myocardial infarction, systolic dysfunction, diastolic dysfunction, arrhythmias and valvular disease in breast cancer patients treated with and without anthracyclines and/or trastuzumab therapy. METHODS Breast cancer patients with a CMR from 2013-2017 at Yale New Haven Hospital were included. Patient co-morbidities, medications, and cardiovascular outcomes were obtained from chart review. Biostatistical analyses, including Pearson correlations, competing risk regression model, and competing risk survival curves comparing the two groups were analyzed. RESULTS 116 breast cancer with CMRs were included in our analysis to assess differences between Anthracycline/Trastuzumab (AT) (62) treated versus non anthracycline/trastuzumab (NAT) (54) treated patients in terms of imaging characteristics and outcomes. More AT patients 17 (27.4%) developed systolic heart failure compared to the NAT group 6 (10.9%), p = 0.025. Statin use was associated with a significant reduction in future arrhythmias (HR 0.416; 95% CI 0.229-0.755, p = 0.004). In a sub-group of 13 patients that underwent stress CMR, we did not find evidence of microvascular dysfunction by sub-endocardial/sub-epicardial myocardial perfusion index ratio after adjusting for ischemic heart disease. CONCLUSIONS In our study, CMR detected signs of subclinical cardiotoxicity such as strain abnormalities despite normal LV function and abnormal circumferential strain was associated with adverse cardiovascular outcomes such as valvular disease and systolic heart failure. Thus, CMR is an important tool during and after cancer treatment to identity and prognosticate cancer treatment-related cardiotoxicity.
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Affiliation(s)
- Jennifer M. Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Amit Arbune
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Mariana L. Henry
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Rose Hu
- Department of Biostatistics, New Haven CT Yale School of Public Health, New Haven, CT, United States of America
| | - Wei Wei
- Department of Biostatistics, New Haven CT Yale School of Public Health, New Haven, CT, United States of America
| | | | - Seohyuk Lee
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Allegheny General Hospital, Pittsburg, PA, United States of America
| | | | - Avirup Guha
- Medical College of Georgia, Augusta, Georgia, United States of America
| | - Steffen Huber
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
| | - Anna S. Bader
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
| | - Judith Meadows
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Albert Sinusas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
| | - Hamid Mojibian
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
| | - Dana Peters
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
| | - Maryam Lustberg
- Cardiology, Yale School of Medicine, New Haven, CT, United States of America
| | - Sarah Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Lauren A. Baldassarre
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Department of Radiology, Yale School of Medicine, Section of Medical Oncology Yale School of Medicine, New Haven, CT, United States of America
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5
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Lin CY, Sung HY, Chen YJ, Yeh HI, Hou CJY, Tsai CT, Hung CL. Personalized Management for Heart Failure with Preserved Ejection Fraction. J Pers Med 2023; 13:jpm13050746. [PMID: 37240916 DOI: 10.3390/jpm13050746] [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: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome with multiple underlying mechanisms and comorbidities that leads to a variety of clinical phenotypes. The identification and characterization of these phenotypes are essential for better understanding the precise pathophysiology of HFpEF, identifying appropriate treatment strategies, and improving patient outcomes. Despite accumulating data showing the potentiality of artificial intelligence (AI)-based phenotyping using clinical, biomarker, and imaging information from multiple dimensions in HFpEF management, contemporary guidelines and consensus do not incorporate these in daily practice. In the future, further studies are required to authenticate and substantiate these findings in order to establish a more standardized approach for clinical implementation.
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Affiliation(s)
- Chang-Yi Lin
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Road, Taipei 10449, Taiwan
| | - Heng-You Sung
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Road, Taipei 10449, Taiwan
| | - Ying-Ju Chen
- Telemedicine Center, MacKay Memorial Hospital, Taipei 10449, Taiwan
| | - Hung-I Yeh
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Road, Taipei 10449, Taiwan
- Departments of Internal Medicine, Mackay Medical College, New Taipei City 25245, Taiwan
| | - Charles Jia-Yin Hou
- Departments of Internal Medicine, Mackay Medical College, New Taipei City 25245, Taiwan
| | - Cheng-Ting Tsai
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Road, Taipei 10449, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City 25245, Taiwan
| | - Chung-Lieh Hung
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Road, Taipei 10449, Taiwan
- Institute of Biomedical Sciences, Mackay Medical College, New Taipei City 25245, Taiwan
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Zhu H, Wang H, Zhu X, Chen Q, Fang X, Xu X, Ping Y, Gao B, Tong G, Ding Y, Chen T, Huang J. The Importance of Integrated Regulation Mechanism of Coronary Microvascular Function for Maintaining the Stability of Coronary Microcirculation: An Easily Overlooked Perspective. Adv Ther 2023; 40:76-101. [PMID: 36279093 DOI: 10.1007/s12325-022-02343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 01/25/2023]
Abstract
Coronary microvascular dysfunction (CMD) refers to a group of disorders affecting the structure and function of coronary microcirculation and is associated with an increased risk of major adverse cardiovascular events. At present, great progress has been made in the diagnosis of CMD, but there is no specific treatment for it because of the complexity of CMD pathogenesis. Vascular dysfunction is one of the important causes of CMD, but previous reviews mostly considered microvascular dysfunction as a whole abnormality so the obtained conclusions are skewed. The coronary microvascular function is co-regulated by multiple mechanisms, and the mechanisms by which microvessels of different luminal diameters are regulated vary. The main purpose of this review is to revisit the mechanisms by which coronary microvessels at different diameters regulate coronary microcirculation through integrated sequential activation and briefly discuss the pathogenesis, diagnosis, and treatment progress of CMD from this perspective.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xinyu Zhu
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Qilan Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaojiang Fang
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Yan Ping
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Beibei Gao
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Guoxin Tong
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Yu Ding
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China.
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7
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Tang CX, Zhou Z, Zhang JY, Xu L, Lv B, Jiang Zhang L. Cardiovascular Imaging in China: Yesterday, Today, and Tomorrow. J Thorac Imaging 2022; 37:355-365. [PMID: 36162066 DOI: 10.1097/rti.0000000000000678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The high prevalence and mortality of cardiovascular diseases in China's large population has increased the use of cardiovascular imaging for the assessment of conditions in recent years. In this study, we review the past 20 years of cardiovascular imaging in China, the increasingly important role played by cardiovascular computed tomography in coronary artery disease and pulmonary embolism assessment, magnetic resonance imaging's use for cardiomyopathy assessment, the development and application of artificial intelligence in cardiovascular imaging, and the future of Chinese cardiovascular imaging.
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Affiliation(s)
- Chun Xiang Tang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province
| | - Zhen Zhou
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University
| | - Jia Yin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University
| | - Bin Lv
- Department of Radiology, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences
- State Key Laboratory and National Center for Cardiovascular Diseases, Beijing
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province
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8
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Zhai C, Fan H, Zhu Y, Chen Y, Shen L. Coronary functional assessment in non-obstructive coronary artery disease: Present situation and future direction. Front Cardiovasc Med 2022; 9:934279. [PMID: 36082113 PMCID: PMC9445206 DOI: 10.3389/fcvm.2022.934279] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Non-obstructive coronary artery disease (CAD), which is defined as coronary stenosis <50%, has been increasingly recognized as an emerging entity in clinical practice. Vasomotion abnormality and coronary microvascular dysfunction are two major mechanisms contributing to the occur of angina with non-obstructive CAD. Although routine coronary functional assessment is limited due to several disadvantages, functional evaluation can help to understand the pathophysiological mechanism and/or to exclude specific etiologies. In this review, we summarized the potential mechanisms involved in ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA), the two major form of non-obstructive CAD. Additionally, we reviewed currently available functional assessment indices and their use in non-obstructive CAD. Furthermore, we speculated that novel technique combined anatomic and physiologic parameters might provide more individualized therapeutic choice for patients with non-obstructive CAD.
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Affiliation(s)
- Changlin Zhai
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Hongyan Fan
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yujuan Zhu
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yunqing Chen
- Department of Infectious Diseases, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Liang Shen
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Liang Shen
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9
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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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Huang Q, Wang SS, Luo RH. Correlation and mechanism between cardiac magnetic resonance imaging and oral streptococcus count in patients with primary microvascular angina pectoris. Medicine (Baltimore) 2022; 101:e29060. [PMID: 35357350 DOI: 10.1097/md.0000000000029060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although primary microvascular angina (PMVA) can be diagnosed clinically, the etiology and pathophysiology of PMVA remain unclear. The effects of conventional clinical medications (aspirin, statins, and nitrates) are unsatisfactory, and PMVA can lead to serious cardiovascular events. The present study was designed to analyze the correlation between the load perfusion cardiovascular magnetic resonance imaging (CMR) results and the Streptococcus sanguinis(S sanguinis) count and the correlations between the S sanguinis count in oral cavity subgingival plaque and changes in the plasma levels of platelet alpha-granule membrane glycoprotein 140 (GMP-140), fibrinopeptide A (FPA), von Willebrand factor (vWF), and homocysteine (Hcy) in patients with PMVA after increased anti-infective treatment of the oral cavity. This study also discusses the pathogenesis of PMVA from this perspective. The differences in the S sanguinis count in oral cavity subgingival plaque and oral health status between healthy people and PMVA patients will be compared, and the correlation between the oral cavity health status and disease in PMVA patients will be analyzed. METHODS The present randomized controlled trial with a parallel control group will be conducted in 68 PMVA patients diagnosed by the in-patient cardiology department. The selected patients will be randomly divided into 2 groups, one receiving routine drug treatment and the other a combination of anti-infective treatments. The normal control group will comprise 30 healthy people with no infectious oral cavity disease matched by age and sex. We will conduct CMR, and the presence of S sanguinis in subgingival plaques will be used to determine the bacterial count in PMVA patients. Blood samples will also be collected to determine the levels of GMP-140, FPA, vWF, and Hcy. S sanguinis in the subgingival plaque of PMVA patients will be further analyzed after increasing the oral cavity anti-infective treatment; the resulting changes and their correlations with changes in GMP-140, FPA, vWF, and Hcy levels will be assessed. Additionally, the differences in the S sanguinis count and the oral cavity health status of oral cavity dental plaque between healthy people and PMVA patients will be determined, and the correlation between the oral cavity conditions and PMVA will be analyzed. The relationship between the perfusion CMR results and the oral cavity S sanguinis count of PMVA patients, and the potential pathogenesis, will be explored. We will use the SPSS19.0 statistical software package to analyze the data. The measurements will be expressed as means±standard deviation. Student t test will be used for intergroup comparisons, a relative number description will be used for the count data, and the chi-square test will be used for intergroup comparisons. Multivariate logistic regression will be performed to identify associations. A P value < .05 will be considered significant. DISCUSSION In this study, the correlation between the perfusion CMR results and the S sanguinis count in oral cavity subgingival plaque of PMVA patients will be analyzed. Changes in the levels of GMP-140, FPA, vWF, and Hcy of PMVA patients after receiving increased oral cavity anti-infective treatment will be explored, and the difference in the S sanguinis count in oral cavity subgingival plaque and the oral cavity health status between healthy people and PMVA patients will be compared. ATRIAL REGISTRATION Chinese Clinical Trial Registry, (http://www.chictr.org.cn/showprojen.aspx?proj=45091).
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Affiliation(s)
- Qi Huang
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine (HangZhou Red Cross Hospital), Hangzhou, 208 Huancheng East Road, Zhejiang, China
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11
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Sharir T, Brodkin B. Can myocardial perfusion imaging predict outcome in patients with angina and ischemia but no obstructive coronary artery disease (INOCA)? J Nucl Cardiol 2021; 28:3038-3043. [PMID: 33000404 DOI: 10.1007/s12350-020-02338-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Center, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel.
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel.
| | - Boris Brodkin
- Department of Nuclear Cardiology, Assuta Medical Center, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel
- Department of Cardiology, Barzilai Medical Center, Ashkelon, Israel
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12
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Preda A, Liberale L, Montecucco F. Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome. Heart Fail Rev 2021; 27:1883-1897. [PMID: 34796433 DOI: 10.1007/s10741-021-10195-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 12/23/2022]
Abstract
Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.
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Affiliation(s)
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132, Genoa, Italy.,Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland.,IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132, Genoa, Italy. .,IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy.
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13
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King O, Sunyovszki I, Terracciano CM. Vascularisation of pluripotent stem cell-derived myocardium: biomechanical insights for physiological relevance in cardiac tissue engineering. Pflugers Arch 2021; 473:1117-1136. [PMID: 33855631 PMCID: PMC8245389 DOI: 10.1007/s00424-021-02557-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022]
Abstract
The myocardium is a diverse environment, requiring coordination between a variety of specialised cell types. Biochemical crosstalk between cardiomyocytes (CM) and microvascular endothelial cells (MVEC) is essential to maintain contractility and healthy tissue homeostasis. Yet, as myocytes beat, heterocellular communication occurs also through constantly fluctuating biomechanical stimuli, namely (1) compressive and tensile forces generated directly by the beating myocardium, and (2) pulsatile shear stress caused by intra-microvascular flow. Despite endothelial cells (EC) being highly mechanosensitive, the role of biomechanical stimuli from beating CM as a regulatory mode of myocardial-microvascular crosstalk is relatively unexplored. Given that cardiac biomechanics are dramatically altered during disease, and disruption of myocardial-microvascular communication is a known driver of pathological remodelling, understanding the biomechanical context necessary for healthy myocardial-microvascular interaction is of high importance. The current gap in understanding can largely be attributed to technical limitations associated with reproducing dynamic physiological biomechanics in multicellular in vitro platforms, coupled with limited in vitro viability of primary cardiac tissue. However, differentiation of CM from human pluripotent stem cells (hPSC) has provided an unlimited source of human myocytes suitable for designing in vitro models. This technology is now converging with the diverse field of tissue engineering, which utilises in vitro techniques designed to enhance physiological relevance, such as biomimetic extracellular matrix (ECM) as 3D scaffolds, microfluidic perfusion of vascularised networks, and complex multicellular architectures generated via 3D bioprinting. These strategies are now allowing researchers to design in vitro platforms which emulate the cell composition, architectures, and biomechanics specific to the myocardial-microvascular microenvironment. Inclusion of physiological multicellularity and biomechanics may also induce a more mature phenotype in stem cell-derived CM, further enhancing their value. This review aims to highlight the importance of biomechanical stimuli as determinants of CM-EC crosstalk in cardiac health and disease, and to explore emerging tissue engineering and hPSC technologies which can recapitulate physiological dynamics to enhance the value of in vitro cardiac experimentation.
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Affiliation(s)
- Oisín King
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK.
| | - Ilona Sunyovszki
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK
| | - Cesare M Terracciano
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK
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14
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Huang Q, Wang WT, Wang SS, Pei DA, Sui XQ. Cardiovascular magnetic resonance image analysis and mechanism study for the changes after treatments for primary microvascular angina pectoris. Medicine (Baltimore) 2021; 100:e26038. [PMID: 34032727 PMCID: PMC8154500 DOI: 10.1097/md.0000000000026038] [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: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Most cases of primary microvascular angina pectoris (PMVA) are diagnosed clinically, but the etiology and pathological mechanisms are unknown. The effect of routine clinical medications is minimal, and PMVA can progress to serious cardiovascular events. To improve the diagnosis and effective treatment of this disease, this study was designed to diagnose PMVA via cardiovascular magnetic resonance (CMR) and the coronary angiography thrombolysis in myocardial infarction (TIMI) blood flow grade, as well as to analyze vascular endothelial function to elucidate the pathogenesis of PMVA and compare the effects of routine clinical medications.The present randomized controlled trial including a parallel control group will be conducted on 63 PMVA patients in our cardiovascular department. The patients will be selected and randomly divided into the control, diltiazem, and nicorandil groups. The control group will be administered routine drug treatments (aspirin, atorvastatin, betaloc ZOK, perindopril, and isosorbidemononitrate sustained-release tablets). The diltiazem group will be additionally treated with 90 mg qd diltiazem sustained-release capsules. The nicorandil group was additionally given 5 mg tid nicorandil tablets. Coronary angiography will be performed before treatment, the severity and frequency of chest pain will be evaluated before and after 9 months of treatment, and homocysteine and von Willebrand factor levels will be measured. Electrocardiography, echocardiography, dynamic electrocardiography, a treadmill exercise test, and CMR will be performed. Sex, age, body mass index, complications, smoking, and family history will also be recorded. The SPSS19.0 statistical software package will be used to analyze the data. The measurements will be expressed as the mean ± standard deviation. Measurement data will be compared between the groups using Student's t-test. A relative number description will be used for the counting data, and the chi-squaretest will be used to compare the groups. A multivariate logistic regression analysis will be performed A P-value < .05 will be considered significant.The direct indices (CMR and coronary angiographic TIMI blood flow grade) may improve after adding diltiazem or nicorandil during routine drug treatments (such as aspirin, statins, and nitrates) in PMVA patients, and indirect indices (homocysteine and von Willebrand factor levels) may be reduced. TRIAL REGISTRATION Chinese Clinical Trial Registry (http://www.chictr.org.cn/showprojen.aspx?proj=41894), No. CHiCTR1900025319, Registered on August 23, 2019; pre initiation.
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Sirajuddin A, Mirmomen SM, Kligerman SJ, Groves DW, Burke AP, Kureshi F, White CS, Arai AE. Ischemic Heart Disease: Noninvasive Imaging Techniques and Findings. Radiographics 2021; 41:990-1021. [PMID: 34019437 PMCID: PMC8262179 DOI: 10.1148/rg.2021200125] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Ischemic heart disease is a leading cause of death worldwide and comprises a large proportion of annual health care expenditure. Management of ischemic heart disease is now best guided by the physiologic significance of coronary artery stenosis. Invasive coronary angiography is the standard for diagnosing coronary artery stenosis. However, it is expensive and has risks including vascular access site complications and contrast material–induced nephropathy. Invasive coronary angiography requires fractional flow reserve (FFR) measurement to determine the physiologic significance of a coronary artery stenosis. Multiple noninvasive cardiac imaging modalities can also anatomically delineate or functionally assess for significant coronary artery stenosis, as well as detect the presence of myocardial infarction (MI). While coronary CT angiography can help assess the degree of anatomic stenosis, its inability to assess the physiologic significance of lesions limits its specificity. Physiologic significance of coronary artery stenosis can be determined by cardiac MR vasodilator or dobutamine stress imaging, CT stress perfusion imaging, FFR CT, PET myocardial perfusion imaging (MPI), SPECT MPI, and stress echocardiography. Clinically unrecognized MI, another clear indicator of physiologically significant coronary artery disease, is relatively common and is best evaluated with cardiac MRI. The authors illustrate the spectrum of imaging findings of ischemic heart disease (coronary artery disease, myocardial ischemia, and MI); highlight the advantages and disadvantages of the various noninvasive imaging methods used to assess ischemic heart disease, as illustrated by recent clinical trials; and summarize current indications and contraindications for noninvasive imaging techniques for detection of ischemic heart disease. Online supplemental material is available for this article. Published under a CC BY 4.0 license.
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Affiliation(s)
- Arlene Sirajuddin
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - S Mojdeh Mirmomen
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Seth J Kligerman
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Daniel W Groves
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Allen P Burke
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Faraz Kureshi
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Charles S White
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Andrew E Arai
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
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Katunaric B, Cohen KE, Beyer AM, Gutterman DD, Freed JK. Sweat the small stuff: The human microvasculature and heart disease. Microcirculation 2021; 28:e12658. [PMID: 32939881 PMCID: PMC7960576 DOI: 10.1111/micc.12658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/13/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
Abstract
Traditionally thought of primarily as the predominant regulator of myocardial perfusion, it is becoming more accepted that the human coronary microvasculature also exerts a more direct influence on the surrounding myocardium. Coronary microvascular dysfunction (CMD) not only precedes large artery atherosclerosis, but is associated with other cardiovascular diseases such as heart failure with preserved ejection fraction and hypertrophic cardiomyopathy. It is also highly predictive of cardiovascular events in patients with or without atherosclerotic cardiovascular disease. This review focuses on this recent paradigm shift and delves into the clinical consequences of CMD. Concepts of how resistance arterioles contribute to disease will be discussed, highlighting how the microvasculature may serve as a potential target for novel therapies and interventions. Finally, both invasive and non-invasive methods with which to assess the coronary microvasculature both for diagnostic and risk stratification purposes will be reviewed.
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Affiliation(s)
- Boran Katunaric
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katie E. Cohen
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andreas M. Beyer
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David D. Gutterman
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K. Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
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Sinha A, Rahman H, Perera D. Coronary microvascular disease: current concepts of pathophysiology, diagnosis and management. Cardiovasc Endocrinol Metab 2021; 10:22-30. [PMID: 33634252 PMCID: PMC7901821 DOI: 10.1097/xce.0000000000000223] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/23/2020] [Indexed: 12/28/2022]
Abstract
Coronary microvascular disease (CMD) is present in 30% of patients with angina and is associated with increased morbidity and mortality. We now have an improved understanding of the pathophysiology of CMD and the invasive and noninvasive tests that can be used to make the diagnosis. Recent studies have shown that management of CMD guided by physiological testing yields better results than empirical treatment. Despite major advances in diagnosing and stratifying this condition, therapeutic strategies remain limited and poorly defined. This review article discusses recent advances in understanding the pathophysiology of CMD, the modalities that are available to diagnose it clinically, current management options and a look at what is in store for the future.
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Affiliation(s)
- Aish Sinha
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Haseeb Rahman
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Divaka Perera
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
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18
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Horton WB, Barrett EJ. Microvascular Dysfunction in Diabetes Mellitus and Cardiometabolic Disease. Endocr Rev 2021; 42:29-55. [PMID: 33125468 PMCID: PMC7846151 DOI: 10.1210/endrev/bnaa025] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Indexed: 02/07/2023]
Abstract
This review takes an inclusive approach to microvascular dysfunction in diabetes mellitus and cardiometabolic disease. In virtually every organ, dynamic interactions between the microvasculature and resident tissue elements normally modulate vascular and tissue function in a homeostatic fashion. This regulation is disordered by diabetes mellitus, by hypertension, by obesity, and by dyslipidemia individually (or combined in cardiometabolic disease), with dysfunction serving as an early marker of change. In particular, we suggest that the familiar retinal, renal, and neural complications of diabetes mellitus are late-stage manifestations of microvascular injury that begins years earlier and is often abetted by other cardiometabolic disease elements (eg, hypertension, obesity, dyslipidemia). We focus on evidence that microvascular dysfunction precedes anatomic microvascular disease in these organs as well as in heart, muscle, and brain. We suggest that early on, diabetes mellitus and/or cardiometabolic disease can each cause reversible microvascular injury with accompanying dysfunction, which in time may or may not become irreversible and anatomically identifiable disease (eg, vascular basement membrane thickening, capillary rarefaction, pericyte loss, etc.). Consequences can include the familiar vision loss, renal insufficiency, and neuropathy, but also heart failure, sarcopenia, cognitive impairment, and escalating metabolic dysfunction. Our understanding of normal microvascular function and early dysfunction is rapidly evolving, aided by innovative genetic and imaging tools. This is leading, in tissues like the retina, to testing novel preventive interventions at early, reversible stages of microvascular injury. Great hope lies in the possibility that some of these interventions may develop into effective therapies.
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Affiliation(s)
- William B Horton
- Division of Endocrinology and Metabolism, Department of Medicine
| | - Eugene J Barrett
- Division of Endocrinology and Metabolism, Department of Medicine.,Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, Virginia
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19
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Zhang Y, Wang X, Liu R, Li Q, Tian W, Lei H, Shi C. The effectiveness and safety of nicorandil in the treatment of patients with microvascular angina: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23888. [PMID: 33466132 PMCID: PMC7808505 DOI: 10.1097/md.0000000000023888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microvascular angina has become a clinical and frequent cardiovascular disease in recent years, which is complicated and there is no clear treatment. Today, Western medicine still deals with microvascular angina with standardized treatment based on the stable angina. Firstly, it is to control the risk factors of atherosclerosis, and the second is to reduce the oxygen consumption of the patient's heart muscle. In the previous randomized controlled clinical trials, it has shown that nicorandil can improve the symptoms of angina for the treatment of microvascular angina, but there is a lack of high-quality randomized controlled trials on the clinical effectiveness and safety of nicorandil in the treatment of microvascular angina, and the lack of evaluation of its effectiveness and safety. Therefore, this paper aims to understand whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug through the method of systematic evaluation. METHODS Retrieval of relevant network electronic databases by computer: SinoMed, CNKI, WanFang Data, VIP, PubMed, EMbase and The Cochrane Library, the retrieval time is from the establishment of each database to December 2017, to collect randomized controlled studies of nicorandil in the treatment of microvascular angina. At the same time, it is supplemented by manual search of the included literature references, as far as possible to increase the included literature imformation. Two researchers independently browse the topics and abstracts, and select, find, read the full text of the relevant literature, and screen the literature according to the criteria for inclusion and exclusion established in advance, then extract the data, and cross-check, and resolve the differences through multi-person discussion. Data analysis of collected information is performed by using RevMan 5.3 software. RESULTS The data of the included literature are statistically analyzed by meta-analysis, and the key outcome indicators are used to determine whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug. CONCLUSION Through the method of evidence-based medicine, this study finds the existing problems and defects in the current research, which will provide high-quality evidence-based medical evidence for nicorandil's treatment of microvascular angina, and it help the clinical treatment and further research. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/DSQG9.
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Affiliation(s)
- Ye Zhang
- Nursing Teaching and Research Section of Medical Department, Hetao College, Yunzhong Street, Shuanghe Town, Linhe District, Bayannur
| | - Xiaojuan Wang
- Parasitology Teaching and Research Section of School of Basic Medical Sciences, Inner Mongolia Medical University, Jinshan Development Zone
| | - Ruijuan Liu
- Nursing Teaching and Research Section of Medical Department, Hetao College, Yunzhong Street, Shuanghe Town, Linhe District, Bayannur
| | - Qingsheng Li
- Department of Pharmacy, the Affiliated Hospital of Inner Mongolia Medical University, NO.1 Tongdao North Road, Huimin District, Hohhot 010050
| | - Wei Tian
- Department of Pharmacy, Bayannur Hospital, NO.98 Wulanbuhe Road, Linhe District, Bayannur
| | - Hong Lei
- Department of Pharmacy, Inner Mongolia People's Hospital, NO.20 Zhaowuda Road, Saihan District, Hohhot
| | - Conghong Shi
- Department of Cardiovascular Medicine, the Fourth Hospital of Baotou, NO.29 Aogeng Road, Qingshan District, Baotou, Inner Mongolia Autonomous Region, PR of China
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20
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Groepenhoff F, Klaassen RGM, Valstar GB, Bots SH, Onland-Moret NC, Den Ruijter HM, Leiner T, Eikendal ALM. Evaluation of non-invasive imaging parameters in coronary microvascular disease: a systematic review. BMC Med Imaging 2021; 21:5. [PMID: 33407208 PMCID: PMC7789672 DOI: 10.1186/s12880-020-00535-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/08/2020] [Indexed: 05/08/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is an important underlying cause of angina pectoris. Currently, no diagnostic tool is available to directly visualize the coronary microvasculature. Invasive microvascular reactivity testing is the diagnostic standard for CMD, but several non-invasive imaging techniques are being evaluated. However, evidence on reported non-invasive parameters and cut-off values is limited. Thus, we aimed to provide an overview of reported non-invasive parameters and corresponding cut-off values for CMD. Methods Pubmed and EMBASE databases were systematically searched for studies enrolling patients with angina pectoris without obstructed coronary arteries, investigating at least one non-invasive imaging technique to quantify CMD. Methodological quality assessment of included studies was performed using QUADAS-2. Results Thirty-seven studies were included. Ten cardiac magnetic resonance studies reported MPRI and nine positron emission tomography (PET) and transthoracic echocardiography (TTE) studies reported CFR. Mean MPRI ranged from 1.47 ± 0.36 to 2.01 ± 0.41 in patients and from 1.50 ± 0.47 to 2.68 ± 0.49 in controls without CMD. Reported mean CFR in PET and TTE ranged from 1.39 ± 0.31 to 2.85 ± 1.35 and 1.69 ± 0.40 to 2.40 ± 0.40 for patients, and 2.68 ± 0.83 to 4.32 ± 1.78 and 2.65 ± 0.65 to 3.31 ± 1.10 for controls, respectively. Conclusions This systematic review summarized current evidence on reported parameters and cut-off values to diagnose CMD for various non-invasive imaging modalities. In current clinical practice, CMD is generally diagnosed with a CFR less than 2.0. However, due to heterogeneity in methodology and reporting of outcome measures, outcomes could not be compared and no definite reference values could be provided.
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Affiliation(s)
- F Groepenhoff
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R G M Klaassen
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - G B Valstar
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - S H Bots
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - N C Onland-Moret
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H M Den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - T Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A L M Eikendal
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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21
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Mangion K, Morrow A, Bagot C, Bayes H, Blyth KG, Church C, Corcoran D, Delles C, Gillespie L, Grieve D, Ho A, Kean S, Lang NN, Lennie V, Lowe DJ, Kellman P, Macfarlane PW, McConnachie A, Roditi G, Sykes R, Touyz RM, Sattar N, Wereski R, Wright S, Berry C. The Chief Scientist Office Cardiovascular and Pulmonary Imaging in SARS Coronavirus disease-19 (CISCO-19) study. Cardiovasc Res 2020; 116:2185-2196. [PMID: 32702087 PMCID: PMC7454350 DOI: 10.1093/cvr/cvaa209] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND COVID-19 is typically a primary respiratory illness with multisystem involvement. The prevalence and clinical significance of cardiovascular and multisystem involvement in COVID-19 remain unclear. METHODS This is a prospective, observational, multicentre, longitudinal, cohort study with minimal selection criteria and a near-consecutive approach to screening. Patients who have received hospital care for COVID-19 will be enrolled within 28 days of discharge. Myocardial injury will be diagnosed according to the peak troponin I in relation to the upper reference limit (URL, 99th centile) (Abbott Architect troponin I assay; sex-specific URL, male: >34 ng/L; female: >16 ng/L). Multisystem, multimodality imaging will be undertaken during the convalescent phase at 28 days post-discharge (Visit 2). Imaging of the heart, lung, and kidneys will include multiparametric, stress perfusion, cardiovascular magnetic resonance imaging, and computed tomography coronary angiography. Health and well-being will be assessed in the longer term. The primary outcome is the proportion of patients with a diagnosis of myocardial inflammation. CONCLUSION CISCO-19 will provide detailed insights into cardiovascular and multisystem involvement of COVID-19. Our study will inform the rationale and design of novel therapeutic and management strategies for affected patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04403607.
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Affiliation(s)
- Kenneth Mangion
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Andrew Morrow
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Catherine Bagot
- Department of Haemostasis and Thrombosis, Royal Infirmary, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Hannah Bayes
- Department of Respiratory Medicine, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Kevin G Blyth
- Department of Respiratory Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Colin Church
- Department of Respiratory Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Christian Delles
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lynsey Gillespie
- Project Management Unit, Glasgow Clinical Research Facility, Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Douglas Grieve
- Department of Respiratory Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Antonia Ho
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Sharon Kean
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Ninian N Lang
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Vera Lennie
- Department of Cardiology, University Hospital Ayr, Ayrshire and Arran Health Board, Ayr, UK
| | - David J Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD, USA
| | - Peter W Macfarlane
- Electrocardiography Core Laboratory, Institute of Health and Wellbeing, University of Glasgow, UK
| | - Alex McConnachie
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Giles Roditi
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Radiology, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Robert Sykes
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Royal Infirmary, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Rhian M Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ryan Wereski
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
- Department of Cardiology, University Hospital Ayr, Ayrshire and Arran Health Board, Ayr, UK
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sylvia Wright
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Respiratory Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
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22
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Zhou W, Lee JCY, Leung ST, Lai A, Lee TF, Chiang JB, Cheng YW, Chan HL, Yiu KH, Goh VKM, Pennell DJ, Ng MY. Long-Term Prognosis of Patients With Coronary Microvascular Disease Using Stress Perfusion Cardiac Magnetic Resonance. JACC Cardiovasc Imaging 2020; 14:602-611. [PMID: 33248966 DOI: 10.1016/j.jcmg.2020.09.034] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/20/2020] [Accepted: 09/03/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study investigated the prognosis of coronary microvascular disease (CMD) as determined by stress perfusion cardiac magnetic resonance (CMR) in patients with ischemic symptoms but without significant coronary artery disease (CAD). BACKGROUND Patients with CMD have poorer prognosis with various cardiac diseases. The myocardial perfusion reserve index (MPRI) derived from noninvasive stress perfusion CMR has been established to diagnose microvascular angina with a threshold MPRI <1.4. The prognosis of CMD as determined by MPRI is unknown. METHODS Chest pain patients without epicardial CAD or myocardial disease from January 2009 to December 2017 were retrospectively included from 3 imaging centers in Hong Kong (HK). Stress perfusion CMR examinations were performed using either adenosine or adenosine triphosphate. Adequate stress was assessed by achieving splenic switch-off sign. Measurement of MPRI was performed in all stress perfusion CMR scans. Patients were followed for major adverse cardiovascular events defined as all-cause death, acute coronary syndrome (ACS), epicardial CAD development, heart failure hospitalization and non-fatal stroke. RESULTS A total of 218 patients were studied (mean age 59 ± 12 years; 49.5% male) and the average MPRI of that cohort was 1.56 ± 0.33. Females and a history of hyperlipidemia were predictors of lower MPRI. Major adverse cardiovascular events (MACE) occurred in 15.6% of patients during a median follow-up of 5.5 years (interquartile range: 4.6 to 6.8 years). The optimal cutoff value of MPRI in predicting MACE was found with a threshold MPRI ≤1.47. Patients with MPRI ≤1.47 had three-fold increased risk of MACE compared with those with MPRI >1.47 (hazard ratio [HR]: 3.14; 95% confidence interval [CI]: 1.58 to 6.25; p = 0.001). Multivariate Cox regression after adjusting for age and hypertension demonstrated that MPRI was an independent predictor of MACE (HR: 0.10; 95% CI: 0.03 to 0.34; p < 0.001). CONCLUSIONS Stress perfusion CMR-derived MPRI is an independent imaging marker that predicts MACE in patients with ischemic symptom and no overt CAD over the medium term.
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Affiliation(s)
- Wenli Zhou
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong
| | | | - Siu Ting Leung
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Alta Lai
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Tang-Fei Lee
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | | | - Yuet Wong Cheng
- Division of Cardiology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Hiu-Lam Chan
- Division of Cardiology, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Kai-Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Victor King-Man Goh
- Hong Kong Sanatorium and Hospital, Hong Kong; School of Public Health, The Chinese University of Hong Kong, Hong Kong
| | - Dudley John Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong; Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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23
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Sinha A, Rahman H, Perera D. Ischaemia without obstructive coronary artery disease: the pathophysiology of microvascular dysfunction. Curr Opin Cardiol 2020; 35:720-725. [PMID: 32852345 DOI: 10.1097/hco.0000000000000788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Nearly one-third of patients presenting with angina have unobstructed epicardial coronary arteries and evidence of coronary microvascular disease. Up until recently, the pathophysiology of coronary microvascular disease has been poorly understood, resulting in limited effective therapeutic options in these patients. As a result, patients with coronary microvascular disease continue to suffer from a poor quality of life and adverse cardiovascular outcomes. RECENT FINDINGS Recent mechanistic studies have improved our understanding of the pathophysiology underlying coronary microvascular dysfunction; these studies have implicated the nitric oxide and endothelin pathways as the main drivers. The aim of this article is to review our current understanding of the pathophysiology of ischaemia in patients with coronary microvascular disease. SUMMARY Patients with angina who have coronary microvascular disease, but no obstructive coronary artery disease, are unable to augment their coronary blood flow in response to physiological stress, thereby predisposing them to myocardial ischaemia as a result of supply:demand mismatch in the myocardium. In addition to abnormalities of vascular resistance, perturbations in cardiac-coronary coupling also contribute to ischaemia in these patients. Although impaired flow reserve is the diagnostic hallmark, mechanistic studies have demonstrated that the underlying pathophysiology is heterogeneous. At present, two main endotypes have been identified, which can be readily differentiated on the basis of minimal microvascular resistance. A better understanding of the pathophysiology and mechanisms driving ischaemia in coronary microvascular dysfunction may stimulate the development of individualised therapies that may lead to an improvement in patients' quality of life and prognosis.
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Affiliation(s)
- Aish Sinha
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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24
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Bechsgaard DF, Hove JD, Michelsen MM, Mygind ND, Pena A, Hansen PR, Hansen HS, Kastrup J, Høst N, Gustafsson I, Prescott E. Myocardial CT perfusion compared with transthoracic Doppler echocardiography in evaluation of the coronary microvascular function: An iPOWER substudy. Clin Physiol Funct Imaging 2020; 41:85-94. [PMID: 33030280 DOI: 10.1111/cpf.12669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 08/20/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A significant number of women with angina and no obstructive coronary artery disease (CAD; <50% stenosis) have coronary microvascular dysfunction (CMD) which carries an adverse cardiovascular prognosis. Coronary microvascular function can be evaluated by transthoracic Doppler echocardiography (TTDE) as a coronary flow velocity reserve (CFVR) and by static CT myocardial perfusion (CTP) as a myocardial perfusion reserve (MPR). Whether these methods are correlated is not known. We assessed the correlation between CFVR and MPR and investigated whether women with angina, CMD and no obstructive CAD have reduced MPR compared with asymptomatic women. METHODS Static CTP with adenosine-induced vasodilation and TTDE of the left anterior descending artery with dipyridamole-induced vasodilation were successfully performed and analysed in 99 women with stable angina and no obstructive CAD and 33 asymptomatic women with no obstructive CAD. CMD was defined as CFVR < 2. RESULTS Correlation between rate-pressure product corrected MPR and CFVR was weak but significant (r = .23; p = .007). MPR was highest among asymptomatic women with normal CFVR (median [interquartile range; IQR] 158 [145-181] %). Symptomatic women with normal CFVR had reduced MPR (148 [134-162] %; age-adjusted p < .001); however, the lowest MPR was found in symptomatic women with CMD (140 [129-164] %; age-adjusted p < .001), independent of cardiovascular risk factors and haemodynamic parameters (p = .017). CONCLUSION Women with angina, CMD and no obstructive CAD had markedly diminished MPR compared with asymptomatic women. Correlation between CFVR and MPR was weak, suggesting that CTP and TTDE are not interchangeable for detection of CMD.
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Affiliation(s)
- Daria F Bechsgaard
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Hove
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark.,Center for Functional and Diagnostic Imaging, Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Naja D Mygind
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Adam Pena
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter R Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Henrik S Hansen
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
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25
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Sechtem U, Brown D, Godo S, Lanza GA, Shimokawa H, Sidik N. Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease). Cardiovasc Res 2020; 116:771-786. [PMID: 31958128 DOI: 10.1093/cvr/cvaa005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus, Auerbachstr. 110, D-70376 Stuttgart, Germany
| | - David Brown
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute, Roma, Italy
| | - Hiro Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Novalia Sidik
- University of Glasgow, Golden Jubilee National Hospital, Glasgow, UK
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26
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Waheed N, Elias-Smale S, Malas W, Maas AH, Sedlak TL, Tremmel J, Mehta PK. Sex differences in non-obstructive coronary artery disease. Cardiovasc Res 2020; 116:829-840. [PMID: 31958135 DOI: 10.1093/cvr/cvaa001] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/03/2019] [Accepted: 01/13/2020] [Indexed: 12/31/2022] Open
Abstract
Ischaemic heart disease is a leading cause of morbidity and mortality in both women and men. Compared with men, symptomatic women who are suspected of having myocardial ischaemia are more likely to have no obstructive coronary artery disease (CAD) on coronary angiography. Coronary vasomotor disorders and coronary microvascular dysfunction (CMD) have been increasingly recognized as important contributors to angina and adverse outcomes in patients with no obstructive CAD. CMD from functional and structural abnormalities in the microvasculature is associated with adverse cardiac events and mortality in both sexes. Women may be particularly susceptible to vasomotor disorders and CMD due to unique factors such as inflammation, mental stress, autonomic, and neuroendocrine dysfunction, which predispose to endothelial dysfunction and CMD. CMD can be detected with coronary reactivity testing and non-invasive imaging modalities; however, it remains underdiagnosed. This review focuses on sex differences in presentation, pathophysiologic risk factors, diagnostic testing, and prognosis of CMD.
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Affiliation(s)
- Nida Waheed
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Waddah Malas
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
| | - Angela H Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tara L Sedlak
- Leslie Diamond Women's Heart Center, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Puja K Mehta
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
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27
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Gallone G, Baldetti L, Tzanis G, Gramegna M, Latib A, Colombo A, Henry TD, Giannini F. Refractory Angina: From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovasc Interv 2020; 13:1-19. [PMID: 31918927 DOI: 10.1016/j.jcin.2019.08.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
Abstract
Despite optimal combination of guideline-directed anti-ischemic therapies and myocardial revascularization, a substantial proportion of patients with stable coronary artery disease continues to experience disabling symptoms and is often referred as "no-option." The appraisal of the pathways linking ischemia to symptom perception indicates a complex model of heart-brain interactions in the generation of the subjective anginal experience and inspired novel approaches that may be clinically effective in alleviating the angina burden of this population. Conversely, the prevailing ischemia-centered view of angina, with the focus on traditional myocardial revascularization as the sole option to address ischemia on top of medical therapy, hinders the experimental characterization and broad-scale clinical implementation of strongly needed therapeutic options. The interventionist, often the first physician to establish the diagnosis of refractory angina pectoris (RAP) following coronary angiography, should be aware of the numerous emerging technologies with the potential to improve quality of life in the growing population of RAP patients. This review describes the current landscape and the future perspectives on nonpharmacological treatment technologies for patients with RAP, with a view on the underlying physiopathological rationale and current clinical evidence.
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Affiliation(s)
- Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, Città della Scienza e della Salute Hospital, University of Turin, Turin, Italy
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Georgios Tzanis
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Bronx, New York. https://twitter.com/azeemlatib
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio; University of Florida, Gainesville, Florida
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy.
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28
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Crea F, Bairey Merz CN, Beltrame JF, Berry C, Camici PG, Kaski JC, Ong P, Pepine CJ, Sechtem U, Shimokawa H. Mechanisms and diagnostic evaluation of persistent or recurrent angina following percutaneous coronary revascularization. Eur Heart J 2020; 40:2455-2462. [PMID: 30608528 DOI: 10.1093/eurheartj/ehy857] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/09/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023] Open
Abstract
Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20-40% of patients during short-medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Gemelli - IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Roma, Italy
| | - Cathleen Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd, Los Angeles, CA, USA
| | - John F Beltrame
- Discipline of Medicine, Ward 5B, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, Adelaide, South Australia, Australia
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, University Place, Glasgow, UK
| | - Paolo G Camici
- Department of Cardiology, Vita Salute University and San Raffaele Hospital, Via Olgettina 60, Milano, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Departmant of Medicine, College of Medicine, University of Florida, 1600 SW Archer Rd, Box 100288, Gainesville, FL, USA
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Japan
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29
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Coronary Microvascular Dysfunction and the Role of Noninvasive Cardiovascular Imaging. Diagnostics (Basel) 2020; 10:diagnostics10090679. [PMID: 32916881 PMCID: PMC7555249 DOI: 10.3390/diagnostics10090679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with coronary microvascular dysfunction (CMD) have significantly higher rates of cardiovascular events, including hospitalization for heart failure, sudden cardiac death, and myocardial infarction (MI). In CMD, several pathophysiological changes lead to functional and structural abnormalities in the coronary microvasculature, which disrupt the ability of the vessels to vasodilate and augment myocardial blood flow in response to increased myocardial oxygen demand, causing ischemia and angina. With the advent of more advanced non-invasive cardiac imaging techniques, the coronary microvasculature has been subjected to more intense study in the past two decades-this has led to further insights into the diagnosis, pathophysiology, treatment, prognosis and follow-up of CMD. This review will highlight and compare the salient features of the currently available non-invasive imaging modalities used in these patients, and discuss the clinical utility of these techniques in the workup and management of these patients.
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30
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Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
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31
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Peper J, Suchá D, Swaans M, Leiner T. Functional cardiac CT-Going beyond Anatomical Evaluation of Coronary Artery Disease with Cine CT, CT-FFR, CT Perfusion and Machine Learning. Br J Radiol 2020; 93:20200349. [PMID: 32783626 DOI: 10.1259/bjr.20200349] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The aim of this review is to provide an overview of different functional cardiac CT techniques which can be used to supplement assessment of the coronary arteries to establish the significance of coronary artery stenoses. We focus on cine-CT, CT-FFR, CT-myocardial perfusion and how developments in machine learning can supplement these techniques.
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Affiliation(s)
- Joyce Peper
- Department of Cardiology, St. Antonius Hospital Koekoekslaan 1, Nieuwegein, the Netherlands.,Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Dominika Suchá
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Martin Swaans
- Department of Cardiology, St. Antonius Hospital Koekoekslaan 1, Nieuwegein, the Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
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32
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Konst RE, Meeder JG, Wittekoek ME, Maas AHEM, Appelman Y, Piek JJ, van de Hoef TP, Damman P, Elias-Smale SE. Ischaemia with no obstructive coronary arteries. Neth Heart J 2020; 28:66-72. [PMID: 32780334 PMCID: PMC7419395 DOI: 10.1007/s12471-020-01451-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.
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Affiliation(s)
- R E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | | | - A H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Y Appelman
- Department of Cardiology, Amsterdam UMC, Location VUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T P van de Hoef
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.
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33
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Saraste A, Knuuti J. ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes : Recommendations for cardiovascular imaging. Herz 2020; 45:409-420. [PMID: 32430520 PMCID: PMC7391397 DOI: 10.1007/s00059-020-04935-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.
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Affiliation(s)
- Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamllynkatu 4-8, 20520, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamllynkatu 4-8, 20520, Turku, Finland.
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34
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Mejía-Rentería H, Lee JM, van der Hoeven NW, Gonzalo N, Jiménez-Quevedo P, Nombela-Franco L, Núñez-Gil IJ, Salinas P, Del Trigo M, Cerrato E, van Royen N, Knaapen P, Koo BK, Macaya C, Fernández-Ortiz A, Escaned J. Coronary Microcirculation Downstream Non-Infarct-Related Arteries in the Subacute Phase of Myocardial Infarction: Implications for Physiology-Guided Revascularization. J Am Heart Assoc 2020; 8:e011534. [PMID: 31014181 PMCID: PMC6512122 DOI: 10.1161/jaha.118.011534] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Concerns exist about reliability of pressure‐wire‐guided coronary revascularization of non‐infarct‐related arteries (non‐IRA). We investigated whether physiological assessment of non‐IRA during the subacute phase of myocardial infarction might be flawed by microcirculatory dysfunction. Methods and Results We analyzed non‐IRA that underwent fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance assessment. Microcirculation and hyperemic response were evaluated in 49 acute myocardial infarction patients (59 non‐IRA) and compared with a matched control group of 46 stable angina (SA) patients (59 vessels). Time between acute myocardial infarction to physiological interrogation was 5.9±2.4 days. Fractional flow reserve was similar in both groups (0.79±0.11 in non‐IRA versus 0.80±0.13 in SA vessels, P=0.527). Lower coronary flow reserve values were found in non‐IRA compared with SA vessels (1.77 [1.25–2.76] versus 2.44 [1.63–4.00], P=0.018), primarily driven by an increased baseline flow in non‐IRA (rest mean transit time 0.58 [0.32–0.83] versus 0.65 s [0.39–1.20], P=0.045), whereas the hyperemic flow was similar (hyperemic mean transit time 0.26 [0.20–0.42] versus 0.26 s [0.18–0.35], P=0.873). No differences were found regarding index of microcirculatory resistance (15.6 [10.4–21.8] in non‐IRA versus 16.7 [11.6–23.6] U in SA vessels, P=0.559). During adenosine infusion, the hyperemic response was similar in both groups (non‐IRA versus SA vessels) in terms of the resistive reserve ratio (3.1±2.1 versus 3.7±2.2, P=0.118). Conclusions In the subacute phase of myocardial infarction, non‐IRA show an increased baseline flow that may cause abnormal coronary flow reserve despite preserved hyperemic flow. In non‐IRA, microcirculatory resistance and adenosine‐induced hyperemic response are similar to those found in SA patients. From a physiological perspective, these findings support the use of fractional flow reserve to interrogate non‐IRA during the subacute phase of myocardial infarction. See Editorial Koh and Samady
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Affiliation(s)
- Hernán Mejía-Rentería
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Joo Myung Lee
- 2 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | | | - Nieves Gonzalo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pilar Jiménez-Quevedo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Luis Nombela-Franco
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Iván J Núñez-Gil
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pablo Salinas
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - María Del Trigo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Enrico Cerrato
- 4 Interventional Cardiology San Luigi Gonzaga University Hospital Orbassano and Rivoli Infermi Hospital Turin Italy
| | - Niels van Royen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Paul Knaapen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Bon-Kwon Koo
- 5 Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea.,6 Institute on Aging Seoul National University Seoul Korea
| | - Carlos Macaya
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | | | - Javier Escaned
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
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35
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Thomas MA, Hazany S, Ellingson BM, Hu P, Nguyen KL. Pathophysiology, classification, and MRI parallels in microvascular disease of the heart and brain. Microcirculation 2020; 27:e12648. [PMID: 32640064 DOI: 10.1111/micc.12648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/12/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Diagnostic imaging technology in vascular disease has long focused on large vessels and the pathologic processes that impact them. With improved diagnostic techniques, investigators are now able to uncover many underlying mechanisms and prognostic factors for microvascular disease. In the heart and brain, these pathologic entities include coronary microvascular disease and cerebral small vessel disease, both of which have significant impact on patients, causing angina, myocardial infarction, heart failure, stroke, and dementia. In the current paper, we will discuss parallels in pathophysiology, classification, and diagnostic modalities, with a focus on the role of magnetic resonance imaging in microvascular disease of the heart and brain. Novel approaches for streamlined imaging of the cardiac and central nervous systems including the use of intravascular contrast agents such as ferumoxytol are presented, and unmet research gaps in diagnostics are summarized.
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Affiliation(s)
- Michael A Thomas
- Division of Cardiology, David Geffen School of Medicine at, UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Saman Hazany
- Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Benjamin M Ellingson
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at, UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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36
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Maznyczka AM, Oldroyd KG, McCartney P, McEntegart M, Berry C. The Potential Use of the Index of Microcirculatory Resistance to Guide Stratification of Patients for Adjunctive Therapy in Acute Myocardial Infarction. JACC Cardiovasc Interv 2020; 12:951-966. [PMID: 31122353 DOI: 10.1016/j.jcin.2019.01.246] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/20/2018] [Accepted: 01/03/2019] [Indexed: 12/31/2022]
Abstract
The goal of reperfusion therapies in ST-segment elevation myocardial infarction has evolved to include effective reperfusion of the microcirculation subtended by the culprit epicardial coronary artery. The index of microcirculatory resistance is measured using a pressure- and temperature-sensing coronary guidewire and quantifies microvascular dysfunction. The index of microcirculatory resistance is an independent predictor of microvascular obstruction, infarct size, and adverse clinical outcomes. It has the advantage of being immediately measurable in the catheterization laboratory, before the results of blood biomarkers or noninvasive imaging become available. This provides an opportunity for additional intervention that may alter outcomes. In this review, the authors provide a critical appraisal of the published research on the emerging role of the index of microcirculatory resistance as a tool to guide the stratification of patients for adjunctive therapeutic strategies in acute ST-segment elevation myocardial infarction.
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Affiliation(s)
- Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Peter McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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37
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Mathew RC, Bourque JM, Salerno M, Kramer CM. Cardiovascular Imaging Techniques to Assess Microvascular Dysfunction. JACC Cardiovasc Imaging 2020; 13:1577-1590. [PMID: 31607665 PMCID: PMC7148179 DOI: 10.1016/j.jcmg.2019.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/02/2019] [Accepted: 09/03/2019] [Indexed: 02/08/2023]
Abstract
The understanding of microvascular dysfunction without evidence of epicardial coronary artery disease pales in comparison with that of obstructive epicardial coronary artery disease. A primary limitation in the past had been the lack of development of noninvasive methods of detecting and quantifying microvascular dysfunction. This limitation has particularly affected the ability to study the pathophysiology, morbidity, and treatment of this disease. More recently, almost all of the noninvasive cardiac imaging modalities have been used to quantify blood flow and advance understanding of microvascular dysfunction.
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Affiliation(s)
- Roshin C Mathew
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia
| | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Michael Salerno
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia; Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher M Kramer
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia.
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38
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Fearon WF. A link between resting flow, coronary flow reserve and adverse outcomes. Int J Cardiol 2020; 309:25-26. [PMID: 32192749 DOI: 10.1016/j.ijcard.2020.03.018] [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] [Received: 03/01/2020] [Accepted: 03/06/2020] [Indexed: 11/17/2022]
Affiliation(s)
- William F Fearon
- Stanford University and, the Stanford Cardiovascular Institute, Stanford, CA, USA.
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39
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Tian J, Zhang L, Yang X, Zuo H, Zhao X, Yong J, He Y, Song X. The effect of Shexiang Tongxin Dropping Pills on coronary microvascular dysfunction (CMVD) among those with a mental disorder and non-obstructive coronary artery disease based on stress cardiac magnetic resonance images: A study protocol. Medicine (Baltimore) 2020; 99:e20099. [PMID: 32481277 PMCID: PMC7249860 DOI: 10.1097/md.0000000000020099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Coronary microvascular dysfunction (CMVD), highly prevalent among patients with a mental disorder (anxiety or depression), is closely related to adverse cardiac events, including hospitalization, sudden cardiac death, and myocardial infarction. Shexiang Tongxin Dropping Pills (STDP), a traditional Chinese medicine, exerts endothelial protective function by anti-inflammation, anti-oxidative stress, and promoting blood circulation. STDP protects against CMVD in previous fundamental studies. The present trial is aiming at evaluating the effect of STDP on CMVD among depressed or anxious patients with non-obstructive coronary artery disease (NOCAD). METHODS AND ANALYSIS Seventy-two depressed or anxious patients diagnosed with NOCAD combined with CMVD utilizing coronary artery angiography and stress cardiac magnetic resonance (CMR) will be recruited in the present study. These patients will be randomized into two groups, namely, Nicorandil group (Nicorandil combined with routine medicine), and STDP groups (STDP combined with routine medicine). The change of CMVD status by assessing absolute myocardial blood flow and myocardial reperfusion using stress CMR 3-month after discharge is defined as the primary endpoint. Major adverse cardiac events (MACEs), quality of life (QOL), and metal disorder improvement are defined as the secondary endpoints. Seattle angina questionnaire (SAQ) which is used to assess angina pectoris and QOL will be recorded at 1-, 3-, 6-, 9-, 12-month of follow-up. Seven-item Generalized Anxiety Disorder Scale (GAD-7) and 9-item depression module from the Patient Health Questionnaire (PHQ9) which utilized to evaluate anxiety and depression, respectively, will be recorded at 1-, 3-, 6-, 9-, 12-month of follow-up. This study will first evaluate the efficacy of STDP on CMVD among patients with a mental disorder and NOCAD, and discuss the potential mechanisms, providing therapeutic evidence for the STDP for these patients.
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Affiliation(s)
| | | | | | - Huijuan Zuo
- Department of Community Health Research, Beijing Anzhen Hospital, Capital Medical University
| | | | | | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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41
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Namani R, Lanir Y, Lee LC, Kassab GS. Overview of mathematical modeling of myocardial blood flow regulation. Am J Physiol Heart Circ Physiol 2020; 318:H966-H975. [PMID: 32142361 DOI: 10.1152/ajpheart.00563.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The oxygen consumption by the heart and its extraction from the coronary arterial blood are the highest among all organs. Any increase in oxygen demand due to a change in heart metabolic activity requires an increase in coronary blood flow. This functional requirement of adjustment of coronary blood flow is mediated by coronary flow regulation to meet the oxygen demand without any discomfort, even under strenuous exercise conditions. The goal of this article is to provide an overview of the theoretical and computational models of coronary flow regulation and to reveal insights into the functioning of a complex physiological system that affects the perfusion requirements of the myocardium. Models for three major control mechanisms of myogenic, flow, and metabolic control are presented. These explain how the flow regulation mechanisms operating over multiple spatial scales from the precapillaries to the large coronary arteries yield the myocardial perfusion characteristics of flow reserve, autoregulation, flow dispersion, and self-similarity. The review not only introduces concepts of coronary blood flow regulation but also presents state-of-the-art advances and their potential to impact the assessment of coronary microvascular dysfunction (CMD), cardiac-coronary coupling in metabolic diseases, and therapies for angina and heart failure. Experimentalists and modelers not trained in these models will have exposure through this review such that the nonintuitive and highly nonlinear behavior of coronary physiology can be understood from a different perspective. This survey highlights knowledge gaps, key challenges, future research directions, and novel paradigms in the modeling of coronary flow regulation.
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Affiliation(s)
- Ravi Namani
- Department of Mechanical Engineering, Michigan State University, East Lansing, Michigan
| | - Yoram Lanir
- Faculty of Biomedical Engineering, Technion, Israel Institute of Technology, Haifa, Israel
| | - Lik Chuan Lee
- Department of Mechanical Engineering, Michigan State University, East Lansing, Michigan
| | - Ghassan S Kassab
- The California Medical Innovations Institute Incorporated, San Diego, California
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42
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Ng MY, Zhou W, Vardhanabhuti V, Lee CH, Yu EYT, Wan EYF, Chan K, Yan AT, Ip TP, Yiu KH, Wintersperger BJ. Cardiac magnetic resonance for asymptomatic patients with type 2 diabetes and cardiovascular high risk (CATCH): a pilot study. Cardiovasc Diabetol 2020; 19:42. [PMID: 32234045 PMCID: PMC7110673 DOI: 10.1186/s12933-020-01019-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022] Open
Abstract
Background Stress cardiovascular magnetic resonance (CMR) to screen for silent myocardial ischaemia in asymptomatic high risk patients with type 2 diabetes mellitus (DM) has never been performed, and its effectiveness is unknown. Our aim was to determine the feasibility of a screening programme using stress CMR by obtaining preliminary data on the prevalence of silent ischaemia caused by obstructive coronary artery disease (CAD) and quantify myocardial perfusion in asymptomatic high risk patients with type 2 diabetes. Methods In this prospective cohort study, we recruited 63 asymptomatic DM patients (mean age 66 years ± 4.4 years; 77.8% male); with Framingham risk score ≥ 20% from 3 sites from June 2017 to August 2018. Normal volunteers were recruited to determine normal global myocardial perfusion reserve index (MPRI). Adenosine stress CMR and global MPRI was performed and measured in all subjects. Positive stress CMR cases were referred for catheter coronary angiography (CCA) with/without fractional flow reserve (FFR) measurements. Positive CCA was defined as an FFR ≤ 0.8 or coronary narrowing ≥ 70%. Patients were followed up for major adverse cardiovascular events. Prevalence is presented as patient numbers and percentage. Mann–Whitney U test was used to compare global MPRI between patients and normal volunteers. Results 13 patients had positive stress CMR with positive CCA (20.6% of patient population), while 9 patients with positive stress CMR examinations had a negative CCA. 5 patients (7.9%) had infarcts detected of which 2 patients had no stress perfusion defects. 12 patients had coronary artery stents inserted, whilst 1 patient declined stent placement. DM patients had lower global MPRI than normal volunteers (n = 7) (1.43 ± 0.27 vs 1.83 ± 0.31 respectively; p < 0.01). After a median follow-up of 653 days, there was no death, heart failure, acute coronary syndrome hospitalisation or stroke. Conclusion 20.6% of asymptomatic DM patients (with Framingham risk ≥ 20%) had silent obstructive CAD. Furthermore, asymptomatic patients have reduced global MPRI than normal volunteers. Trial Registration: ClinicalTrials.gov Registration Number: NCT03263728 on 28th August 2017; https://clinicaltrials.gov/ct2/show/NCT03263728.
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Affiliation(s)
- Ming-Yen Ng
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China. .,Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Wenli Zhou
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China
| | - Varut Vardhanabhuti
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China
| | - Chi-Ho Lee
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Kit Chan
- Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Andrew T Yan
- Departments of Medicine and Medical Imaging, St. Michael's Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Tai-Pang Ip
- Department of Medicine, Tung Wah Hospital, Hong Kong, China
| | - Kai-Hang Yiu
- Department of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Bernd J Wintersperger
- Department of Medical Imaging, University of Toronto, Toronto, Canada.,Department of Medical Imaging, University Health Network, Toronto, Canada
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43
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Baggiano A, Guglielmo M, Muscogiuri G, Guaricci AI, Del Torto A, Pontone G. (Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance. Eur Heart J Suppl 2020; 22:E116-E120. [PMID: 32523454 PMCID: PMC7270897 DOI: 10.1093/eurheartj/suaa075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.
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Affiliation(s)
- Andrea Baggiano
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marco Guglielmo
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | | | - Andrea Igoren Guaricci
- Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital "Policlinico" of Bari, Bari, Italy
| | - Alberico Del Torto
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy.,Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital "Policlinico" of Bari, Bari, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
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44
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Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116:841-855. [DOI: 10.1093/cvr/cvz339] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, Australia
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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45
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van de Wouw J, Sorop O, van Drie RWA, van Duin RWB, Nguyen ITN, Joles JA, Verhaar MC, Merkus D, Duncker DJ. Perturbations in myocardial perfusion and oxygen balance in swine with multiple risk factors: a novel model of ischemia and no obstructive coronary artery disease. Basic Res Cardiol 2020; 115:21. [PMID: 32100119 PMCID: PMC7042191 DOI: 10.1007/s00395-020-0778-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Comorbidities of ischemic heart disease, including diabetes mellitus (DM), hypercholesterolemia (HC) and chronic kidney disease (CKD), are associated with coronary microvascular dysfunction (CMD). Increasing evidence suggests that CMD may contribute to myocardial ‘Ischemia and No Obstructive Coronary Artery disease’ (INOCA). In the present study, we tested the hypothesis that CMD results in perturbations in myocardial perfusion and oxygen delivery using a novel swine model with multiple comorbidities. DM (streptozotocin), HC (high-fat diet) and CKD (renal embolization) were induced in 10 female swine (DM + HC + CKD), while 12 healthy female swine on a normal diet served as controls (Normal). After 5 months, at a time when coronary atherosclerosis was still negligible, myocardial perfusion, metabolism, and function were studied at rest and during treadmill exercise. DM + HC + CKD animals showed hyperglycemia, hypercholesterolemia, and impaired kidney function. During exercise, DM + HC + CKD swine demonstrated perturbations in myocardial blood flow and oxygen delivery, necessitating a higher myocardial oxygen extraction—achieved despite reduced capillary density—resulting in lower coronary venous oxygen levels. Moreover, myocardial efficiency was lower, requiring higher oxygen consumption for a given level of myocardial work. These perturbations in myocardial oxygen balance were associated with lower myocardial lactate consumption, stroke volume, and LVdP/dtmax, suggestive of myocardial ischemia and dysfunction. Further analyses showed a reduction in adenosine-recruitable coronary flow reserve, but this was exclusively the result of an increase in basal coronary blood flow, while maximal coronary flow per gram of myocardium was maintained; the latter was consistent with the unchanged arteriolar wall/lumen ratio, arteriolar density and peri-arteriolar collagen content. However, isolated small arteries displayed selective blunting of endothelium-dependent vasodilation in response to bradykinin in DM + HC + CKD swine, suggesting that changes in coronary microvascular function rather than in structure contributed to the perturbations in myocardial oxygen delivery. In conclusion, common comorbidities in swine result in CMD, in the absence of appreciable atherosclerosis, which is severe enough to produce perturbations in myocardial oxygen balance, particularly during exercise, resembling key features of INOCA.
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Affiliation(s)
- Jens van de Wouw
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ruben W A van Drie
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Isabel T N Nguyen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.,Walter Brendel Center of Experimental Medicine (WBex), LMU Munich, 81377, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance (MHA), 81377, Munich, Germany
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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46
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Kanno Y, Hoshino M, Hamaya R, Sugiyama T, Kanaji Y, Usui E, Yamaguchi M, Hada M, Ohya H, Sumino Y, Hirano H, Yuki H, Horie T, Murai T, Lee T, Yonetsu T, Kakuta T. Functional classification discordance in intermediate coronary stenoses between fractional flow reserve and angiography-based quantitative flow ratio. Open Heart 2020; 7:e001179. [PMID: 32076563 PMCID: PMC6999689 DOI: 10.1136/openhrt-2019-001179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/19/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022] Open
Abstract
Background Measurement of the contrast-flow quantitative flow ratio (cQFR) is a novel method for rapid computational estimation of fractional flow reserve (FFR). Discordance between FFR and cQFR has not been completely characterised. Methods We performed a post-hoc analysis of 504 vessels with angiographically intermediate stenosis in 504 patients who underwent measurement of FFR, coronary flow reserve (CFR), the index of microcirculatory resistance (IMR) and Duke jeopardy score. Results In total, 396 (78.6%) and 108 (21.4%) lesions showed concordant and discordant FFR and cQFR functional classifications, respectively. Among lesions with a reduced FFR (FFR+), those with a preserved cQFR (cQFR-) showed significantly lower IMR, shorter mean transit time (Tmn), shorter lesion length (all, p<0.01) and similar CFR and Duke jeopardy scores compared with lesions showing a reduced cQFR (cQFR+). Furthermore, lesions with FFR+ and cQFR- had significantly lower IMR and shorter Tmn compared with lesions showing a preserved FFR (FFR-) and cQFR+. Of note, in cQFR+ lesions, higher IMR lesions were associated with decreased diagnostic accuracy (high-IMR; 63.0% and low-IMR; 75.8%, p<0.01). In contrast, in cQFR- lesions, lower IMR lesions was associated with decreased diagnostic accuracy (high-IMR group; 96.8% and low-IMR group; 80.0%, p<0.01). Notably, in total, 31 territories (6.2%; 'jump out' group) had an FFR above the upper limit of the grey zone (>0.80) and a cQFR below the lower limit (≤0.75). In contrast, five territories (1.0%; 'jump in' group) exhibited opposite results (FFR of ≤0.75 and cQFR of >0.80). The 'jump out' territories showed significantly higher IMR values than 'jump in' territories (p<0.01). Conclusions FFR- with cQFR+ is associated with increased microvascular resistance, and FFR+ with cQFR- showed preservation of microvascular function with high coronary flow. Microvascular function affected diagnostic performance of cQFR in relation to functional stenosis significance.
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Affiliation(s)
- Yoshinori Kanno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Rikuta Hamaya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Eisuke Usui
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masao Yamaguchi
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Hiroaki Ohya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Yohei Sumino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Hidenori Hirano
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Haruhito Yuki
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tomoki Horie
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tetsumin Lee
- Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taishi Yonetsu
- Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
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Abstract
PURPOSE OF REVIEW Our review discusses the management of post percutaneous coronary intervention angina (PPCIA) which negatively impacts 20-40% of patients and imposes a high burden on the healthcare system. RECENT FINDINGS Mechanisms of PPCIA include microvascular dysfunction, distal coronary vasospasm or disease, microembolization, myocardial bridge, coronary artery disease (CAD) progression, and rarely stent thrombosis or in-stent restenosis. Nitrates, beta blockers (BB), calcium channel blockers, and ranolazine are the common medical management options. Only BB showed 1-year mortality benefit following myocardial infarction. Stress echocardiography and cardiac magnetic resonance are the best to detect CAD vs. microvascular dysfunction. Invasively, vasoprovocative testing and fractional flow reserve provide useful prognostic information. If the ischemia burden is ≤10%, conservative management should be considered based upon the individual patient scenario. The optimal management of PPCIA remains unclear and further research is necessary. Multiple treatment options exist, which should be implemented in an individualized fashion.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Subrata Kar
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3652] [Impact Index Per Article: 913.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Everaars H, van Diemen PA, Bom MJ, Schumacher SP, de Winter RW, van de Ven PM, Raijmakers PG, Lammertsma AA, Hofman MBM, van der Geest RJ, Götte MJ, van Rossum AC, Nijveldt R, Danad I, Driessen RS, Knaapen P. Comparison between quantitative cardiac magnetic resonance perfusion imaging and [ 15O]H 2O positron emission tomography. Eur J Nucl Med Mol Imaging 2019; 47:1688-1697. [PMID: 31822958 PMCID: PMC7248026 DOI: 10.1007/s00259-019-04641-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Purpose To compare cardiac magnetic resonance imaging (CMR) with [15O]H2O positron emission tomography (PET) for quantification of absolute myocardial blood flow (MBF) and myocardial flow reserve (MFR) in patients with coronary artery disease (CAD). Methods Fifty-nine patients with stable CAD underwent CMR and [15O]H2O PET. The CMR imaging protocol included late gadolinium enhancement to rule out presence of scar tissue and perfusion imaging using a dual sequence, single bolus technique. Absolute MBF was determined for the three main vascular territories at rest and during vasodilator stress. Results CMR measurements of regional stress MBF and MFR showed only moderate correlation to those obtained using PET (r = 0.39; P < 0.001 for stress MBF and r = 0.36; P < 0.001 for MFR). Bland-Altman analysis revealed a significant bias of 0.2 ± 1.0 mL/min/g for stress MBF and − 0.5 ± 1.2 for MFR. CMR-derived stress MBF and MFR demonstrated area under the curves of respectively 0.72 (95% CI: 0.65 to 0.79) and 0.76 (95% CI: 0.69 to 0.83) and had optimal cutoff values of 2.35 mL/min/g and 2.25 for detecting abnormal myocardial perfusion, defined as [15O]H2O PET-derived stress MBF ≤ 2.3 mL/min/g and MFR ≤ 2.5. Using these cutoff values, CMR and PET were concordant in 137 (77%) vascular territories for stress MBF and 135 (80%) vascular territories for MFR. Conclusion CMR measurements of stress MBF and MFR showed modest agreement to those obtained with [15O]H2O PET. Nevertheless, stress MBF and MFR were concordant between CMR and [15O]H2O PET in 77% and 80% of vascular territories, respectively.
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Affiliation(s)
- Henk Everaars
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Adriaan A Lammertsma
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Mark B M Hofman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Rob J van der Geest
- Department of Radiology, Leiden University Medical Centers, Leiden, the Netherlands
| | - Marco J Götte
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands.
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50
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Rahman H, Ryan M, Lumley M, Modi B, McConkey H, Ellis H, Scannell C, Clapp B, Marber M, Webb A, Chiribiri A, Perera D. Coronary Microvascular Dysfunction Is Associated With Myocardial Ischemia and Abnormal Coronary Perfusion During Exercise. Circulation 2019; 140:1805-1816. [PMID: 31707835 PMCID: PMC6882540 DOI: 10.1161/circulationaha.119.041595] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 10/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (MVD) is defined by impaired flow augmentation in response to a pharmacological vasodilator in the presence of nonobstructive coronary artery disease. It is unknown whether diminished coronary vasodilator response correlates with abnormal exercise physiology or inducible myocardial ischemia. METHODS Patients with angina and nonobstructive coronary artery disease had simultaneous coronary pressure and flow velocity measured using a dual sensor-tipped guidewire during rest, supine bicycle exercise, and adenosine-mediated hyperemia. Microvascular resistance (MR) was calculated as coronary pressure divided by flow velocity. Wave intensity analysis quantified the proportion of accelerating wave energy (perfusion efficiency). Global myocardial blood flow and subendocardial:subepicardial perfusion ratio were quantified using 3-Tesla cardiac magnetic resonance imaging during hyperemia and rest; inducible ischemia was defined as hyperemic subendocardial:subepicardial perfusion ratio <1.0. Patients were classified as having MVD if coronary flow reserve <2.5 and controls if coronary flow reserve ≥2.5, with researchers blinded to the classification. RESULTS Eighty-five patients were enrolled (78% female, 57±10 years), 45 (53%) were classified as having MVD. Of the MVD group, 82% had inducible ischemia compared with 22% of controls (P<0.001); global myocardial perfusion reserve was 2.01±0.41 and 2.68±0.49 (P<0.001). In controls, coronary perfusion efficiency improved from rest to exercise and was unchanged during hyperemia (59±11% vs 65±14% vs 57±18%; P=0.02 and P=0.14). In contrast, perfusion efficiency decreased during both forms of stress in MVD (61±12 vs 44±10 vs 42±11%; both P<0.001). Among patients with a coronary flow reserve <2.5, 62% had functional MVD, with normal minimal MR (hyperemic MR<2.5 mmHg/cm/s), and 38% had structural MVD with elevated hyperemic MR. Resting MR was lower in those with functional MVD (4.2±1.0 mmHg/cm/s) than in those with structural MVD (6.9±1.7 mmHg/cm/s) or controls (7.3±2.2 mmHg/cm/s; both P<0.001). During exercise, the structural group had a higher systolic blood pressure (188±25 mmHg) than did those with functional MVD (161±27 mmHg; P=0.004) and controls (156±30 mmHg; P<0.001). Functional and structural MVD had similar stress myocardial perfusion and exercise perfusion efficiency values. CONCLUSION In patients with angina and nonobstructive coronary artery disease, diminished coronary flow reserve characterizes a cohort with inducible ischemia and a maladaptive physiological response to exercise. We have identified 2 endotypes of MVD with distinctive systemic vascular responses to exercise; whether endotypes have a different prognosis or require different treatments merits further investigation.
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Affiliation(s)
- Haseeb Rahman
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Ryan
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Lumley
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Bhavik Modi
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Hannah McConkey
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Howard Ellis
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Cian Scannell
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Brian Clapp
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Michael Marber
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Andrew Webb
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Amedeo Chiribiri
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Divaka Perera
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
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