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Patel NH, Dave EK, Fatade YA, De Cecco CN, Ko YA, Chen Y, Sharma A, Rashid F, Vatsa N, Samady H, Toleva O, Quyyumi A, Mehta PK, Stillman AE. Epicardial adipose tissue attenuation on computed tomography in women with coronary microvascular dysfunction: A pilot, hypothesis generating study. Atherosclerosis 2024; 395:118520. [PMID: 38944545 DOI: 10.1016/j.atherosclerosis.2024.118520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Patients with myocardial ischemia without obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) and associated increased risk of cardiovascular (CV) events and anginal hospitalizations. Epicardial adipose tissue (EAT) covers much of the myocardium and coronary arteries and when dysfunctional, secretes proinflammatory cytokines and is associated with CV events. While oxidative stress and systemic inflammation are associated with CMD, the relationship between EAT and CMD in women is not well known. METHODS Women diagnosed with CMD (n = 21) who underwent coronary computed tomography with coronary artery calcium (CAC) scoring were compared to a reference group (RG) of women referred for CAC screening for preventive risk assessment (n = 181). EAT attenuation (Hounsfield units (HU)) was measured adjacent to the proximal right coronary artery, along with subcutaneous adipose tissue (SCAT). Two-sample t-tests with unequal variances were utilized. RESULTS Mean age of the CMD group was 56 ± 8 years and body mass index (BMI) was 31.6 ± 6.8 kg/m2. CV risk factors in the CMD group were prevalent: 67 % hypertension, 44 % hyperlipidemia, and 33 % diabetes. Both CMD and RG had similar CAC score (25.86 ± 59.54 vs. 24.17 ± 104.6; p = 0.21. In the CMD group, 67 % had a CAC of 0. Minimal atherosclerosis (CAD-RADS 1) was present in 76 % of women with CMD. The CMD group had lower EAT attenuation than RG (-103.3 ± 6.33 HU vs. -97.9 ± 8.3 HU, p = 0.009, respectively). There were no differences in SCAT attenuation. Hypertension, smoking history, age, BMI, and CAC score did not correlate with EAT in either of the groups. CONCLUSIONS Women with CMD have decreased EAT attenuation compared to RG women. EAT-mediated inflammation and changes in vascular tone may be a mechanistic contributor to abnormal microvascular reactivity. Clinical trials testing therapeutic strategies to decrease EAT may be warranted in the management of CMD.
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Affiliation(s)
- Nidhi H Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, USA
| | - Esha K Dave
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | - Yetunde A Fatade
- J. Willis Hurst Internal Medicine Residency Program, Emory University, USA
| | - Carlo N De Cecco
- Department of Radiology, Emory University School of Medicine, USA
| | - Yi-An Ko
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Yunyun Chen
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Ashish Sharma
- Division of Hospital Medicine, Emory University School of Medicine, USA
| | - Fauzia Rashid
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | - Nishant Vatsa
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | | | | | - Arshed Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Puja K Mehta
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA; Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA.
| | - Arthur E Stillman
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA; Department of Radiology, Emory University School of Medicine, USA
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Rheum Dis Clin North Am 2024; 50:519-533. [PMID: 38942582 DOI: 10.1016/j.rdc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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3
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Paiva LMV, Vieira MJ, Simões M, Ferreira MJ, Gonçalves L. Unstable Angina Risk Stratification Using High-Sensitivity Cardiac Troponin and Coronary Angiography. Am J Cardiol 2024; 221:1-8. [PMID: 38580042 DOI: 10.1016/j.amjcard.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/09/2024] [Accepted: 03/30/2024] [Indexed: 04/07/2024]
Abstract
Patients formerly diagnosed with unstable angina (UA) are being reclassified as non-ST-elevation myocardial infarction with the widespread adoption of high-sensitivity troponin (hsTn) assays, leading to significant changes in the incidence and prognosis of UA. This study aimed to evaluate the value of hsTn and the presence of significant obstructive coronary artery disease (CAD) in the risk stratification of patients with UA. We conducted a retrospective, single-center study of 742 patients hospitalized for UA between 2016 and 2021. The primary end point of this study was all-cause mortality. The secondary outcome (major adverse cardiac events [MACEs]) was defined as a composite of nonfatal myocardial infarction (MI), hospitalization for heart failure (hHF), and repeated coronary angiography because of recurring UA (rUA) after the index event. The outcomes were assessed within 1 month, 1 year, and up to 5 years of follow-up. The average follow-up duration was 45 ± 24 months, and 37.2% (n = 276) of patients completed a 5-year follow-up. No in-hospital death was observed, and 6.9% of patients died during follow-up, which was more commonly a late event (>12 months). The composite secondary end point (MI+hHF+rUA) was observed in 16.7% of the patients. There were 3.2% nonfatal MI, 2.3% hHF, and 11.6% rUA during follow-up. We developed a risk model (UA mortality risk) using variables with the highest discriminatory power: age, hsTn, and ST-segment deviation. Our model performed well against the Global Registry of Acute Coronary Events and Thrombolysis in Myocardial Infarction risk scores in predicting death during follow-up. Obstructive CAD on coronary angiography was the only independent predictor of MACEs during follow-up. In conclusion, a contemporary cohort of patients with UA presented with favorable prognosis, particularly, within the first year after the index event. Nonsignificant increases in hsTn levels add to the risk stratification of patients with UA, and the presence of obstructive CAD was the only independent predictor of MACEs, highlighting the potential importance of assessing coronary anatomy.
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Affiliation(s)
- Luis Manuel Vilardouro Paiva
- Medical Faculty, Coimbra University, Portugal; Cardiology Department, Coimbra University Hospital Centre, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra University, Portugal.
| | | | - Mariana Simões
- Cardiology Department, Coimbra University Hospital Centre, Portugal
| | - Maria João Ferreira
- Medical Faculty, Coimbra University, Portugal; Cardiology Department, Coimbra University Hospital Centre, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, Coimbra University, Portugal
| | - Lino Gonçalves
- Medical Faculty, Coimbra University, Portugal; Cardiology Department, Coimbra University Hospital Centre, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra University, Portugal
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4
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Ágoston A, Dorj A, Üveges Á, Tar B, Szabó GT, Barta J, Szűk T, Kest M, Méhész R, Komócsi A, Czuriga D, Csippa B, Piróth Z, Barbato E, Kőszegi Z. The pressure-derived microvascular resistance reserve and its correlation to Doppler MRR measurement-a proof of concept study. Front Cardiovasc Med 2024; 11:1322161. [PMID: 38887446 PMCID: PMC11180812 DOI: 10.3389/fcvm.2024.1322161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Background Microvascular resistance reserve (MRR) is a recently introduced specific index of coronary microcirculation. MRR calculation can utilize parameters deriving from coronary flow reserve (CFR) assessment, provided that intracoronary pressure data are also available. The previously proposed pressure-bounded CFR (CFRpb) defines the possible CFR interval on the basis of resting and hyperemic pressure gradients in the epicardial vessel, however, its correlation to the Doppler wire measurement was reported to be rather poor without the correction for hydrostatic pressure. Purpose We aimed to determine the pressure-bounded coronary MRR interval with hydrostatic pressure correction according to the previously established equations of CFRpb adapted for the MRR concept. Furthermore, we also aimed to design a prediction model using the actual MRR value within the pressure-bounded interval and validate the results against the gold-standard Doppler wire technique. Methods Hydrostatic pressure between the tip of the catheter and the sensor of the pressure wire was calculated by height difference measurement from a lateral angiographic view. In the derivation cohort the pressure-bounded MRR interval (between MRRpbmin and MRRpbmax) was determined solely from hydrostatic pressure-corrected intracoronary pressure data. The actual MRR was calculated by simple hemodynamic equations incorporating the anatomical data of the three-dimensionally reconstructed coronary artery (MRRp-3D). These results were analyzed by regression analyses to find relations between the MRRpb bounds and the actual MRRp-3D. Results In the derivation cohort of 23 measurements, linear regression analysis showed a tight relation between MRRpbmax and MRRp-3D (r 2 = 0.74, p < 0.0001). Using this relation (MRRp-3D = 1.04 + 0.51 × MRRpbmax), the linear prediction of the MRR was tested in the validation cohort of 19 measurements against the gold standard Doppler wire technique. A significant correlation was found between the linearly predicted and the measured values (r = 0.54, p = 0.01). If the area stenosis (AS%) was included to a quadratic prediction model, the correlation was improved (r = 0.63, p = 0.004). Conclusions The MRR can be predicted reliably to assess microvascular function by our simple model. After the correction for hydrostatic pressure error, the pressure data during routine FFR measurement provides a simultaneous physiological assessment of the macro- and microvasculature.
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Affiliation(s)
- András Ágoston
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - Azzaya Dorj
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Áron Üveges
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - Balázs Tar
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - Gábor Tamás Szabó
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Barta
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tibor Szűk
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Michael Kest
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - Réka Méhész
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | | | - Dániel Czuriga
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Benjámin Csippa
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, Budapest, Hungary
| | - Zsolt Piróth
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Zsolt Kőszegi
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Department of Cardiology, Szabolcs—Szatmár—Bereg Country Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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5
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Yan J, Huang B, Tonko J, Toulemonde M, Hansen-Shearer J, Tan Q, Riemer K, Ntagiantas K, Chowdhury RA, Lambiase PD, Senior R, Tang MX. Transthoracic ultrasound localization microscopy of myocardial vasculature in patients. Nat Biomed Eng 2024; 8:689-700. [PMID: 38710839 PMCID: PMC11250254 DOI: 10.1038/s41551-024-01206-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/30/2024] [Indexed: 05/08/2024]
Abstract
Myocardial microvasculature and haemodynamics are indicative of potential microvascular diseases for patients with symptoms of coronary heart disease in the absence of obstructive coronary arteries. However, imaging microvascular structure and flow within the myocardium is challenging owing to the small size of the vessels and the constant movement of the patient's heart. Here we show the feasibility of transthoracic ultrasound localization microscopy for imaging myocardial microvasculature and haemodynamics in explanted pig hearts and in patients in vivo. Through a customized data-acquisition and processing pipeline with a cardiac phased-array probe, we leveraged motion correction and tracking to reconstruct the dynamics of microcirculation. For four patients, two of whom had impaired myocardial function, we obtained super-resolution images of myocardial vascular structure and flow using data acquired within a breath hold. Myocardial ultrasound localization microscopy may facilitate the understanding of myocardial microcirculation and the management of patients with cardiac microvascular diseases.
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Affiliation(s)
- Jipeng Yan
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | - Biao Huang
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | - Johanna Tonko
- Institute of Cardiovascular Science, University College London, London, UK
| | - Matthieu Toulemonde
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | - Joseph Hansen-Shearer
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | - Qingyuan Tan
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | - Kai Riemer
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK
| | | | - Rasheda A Chowdhury
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, UK
| | - Roxy Senior
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Northwick Park Hospital, Harrow, UK
| | - Meng-Xing Tang
- Ultrasound Lab for Imaging and Sensing, Department of Bioengineering, Imperial College London, London, UK.
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6
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Freund O, Shetrit A, Bar-Shai A, Zornitzki L, Frydman S, Banai A, Shamir RA, Ben-Shoshan J, Arbel Y, Banai S, Konigstein M. Smoking and Respiratory Diseases in Patients with Coronary Microvascular Dysfunction. Am J Med 2024; 137:538-544.e1. [PMID: 38485108 DOI: 10.1016/j.amjmed.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/18/2024] [Accepted: 02/18/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Coronary microvascular disease (CMD) is common in patients with and without obstructive coronary artery disease, and is associated with adverse clinical outcomes. Respiratory-related variables are associated with pulmonary and systemic microvascular dysfunction, while evidence about their relationship with CMD is limited. We aim to evaluate respiratory-related variables as risk factors of CMD. METHODS This is an observational, single-center study enrolling consecutive patients undergoing invasive evaluation of coronary microvascular function in the catheterization laboratory. Patients with evidence of obstructive coronary artery disease or with missing data were excluded. Associations between respiratory-related variables and indices of CMD were assessed using univariate and multivariate regression models. RESULTS Overall, 266 patients (mean age 67 ± 11 years, 59% females) were included in the current analysis. Of those, 155 (58%) had evidence of CMD. Among the respiratory variables, independent predictors of CMD were current smoking (adjusted odds ratio [AOR] 2.5; 95% confidence interval [CI], 1.2-5; P = .01) and obstructive sleep apnea (AOR 5.7; 95% CI, 1.2-26; P = .03), while chronic obstructive pulmonary disease was not. Among ever-smokers, higher smoking pack-years was an independent risk factor for CMD (median 35 vs 25 pack-years, AOR 1.09; 95% CI, 1.04-1.13; P < .01), and was associated with higher rates of pathologic index of microcirculatory resistance and resistive reserve ratio. CONCLUSION In patients undergoing invasive coronary microvascular evaluation, current smoking and obstructive sleep apnea are independently associated with CMD. Among smokers, higher pack-years is a strong predictor for CMD. Our findings should raise awareness for prevention and possible treatment options.
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Affiliation(s)
- Ophir Freund
- Institute of Pulmonary Medicine, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel; Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Aviel Shetrit
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Amir Bar-Shai
- Institute of Pulmonary Medicine, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Lior Zornitzki
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Shir Frydman
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Ariel Banai
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Reut Amar Shamir
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Jeremy Ben-Shoshan
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Yaron Arbel
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Shmuel Banai
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Sourasky Medical Center, and Tel Aviv University School of Medicine, Israel.
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AlShaikh S, Rohm CL, Sutton NR, Burgess SN, Alasnag M. INOCA: Ischemia in non-obstructive coronary arteries. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100391. [PMID: 38680648 PMCID: PMC11043816 DOI: 10.1016/j.ahjo.2024.100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
This article provides a summary of the clinical spectrum of no obstructive coronary arteries. We describe the pathologies, invasive and noninvasive assessment, and management strategies.
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Affiliation(s)
- Shereen AlShaikh
- Adult Cardiology Department, Mohammed bin Khalifa Cardiac Centre, Riffa, Bahrain
| | - Charlene L. Rohm
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nadia R. Sutton
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
| | - Sonya N. Burgess
- Cardiology Department, University of Sydney and Nepean Hospital, Sydney, Australia
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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8
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Zhang W, Liu L, Yin G, Mohammed AQ, Xiang L, Lv X, Shi T, Galip J, Wang C, Mohammed AA, Mareai RM, Yu F, Abdu FA, Che W. Triglyceride-glucose index is associated with myocardial ischemia and poor prognosis in patients with ischemia and no obstructive coronary artery disease. Cardiovasc Diabetol 2024; 23:187. [PMID: 38822373 PMCID: PMC11140859 DOI: 10.1186/s12933-024-02230-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/09/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Ischemia and no obstructive coronary artery disease (INOCA) is increasingly recognized and associated with poor outcomes. The triglyceride-glucose (TyG) index is a reliable alternative measure of insulin resistance significantly linked to cardiovascular disease and adverse prognosis. We investigated the association between the TyG index and myocardial ischemia and the prognosis in INOCA patients. METHODS INOCA patients who underwent both coronary angiography and myocardial perfusion imaging (MPI) were included consecutively. All participants were divided into three groups according to TyG tertiles (T1, T2, and T3). Abnormal MPI for myocardial ischemia in individual coronary territories was defined as summed stress score (SSS) ≥ 4 and summed difference score (SDS) ≥ 2. SSS refers to the sum of all defects in the stress images, and SDS is the difference of the sum of all defects between the rest images and stress images. All patients were followed up for major adverse cardiac events (MACE). RESULTS Among 332 INOCA patients, 113 (34.0%) had abnormal MPI. Patients with higher TyG index had a higher rate of abnormal MPI (25.5% vs. 32.4% vs. 44.1%; p = 0.012). Multivariate logistic analysis showed that a high TyG index was significantly correlated with abnormal MPI in INOCA patients (OR, 1.901; 95% CI, 1.045-3.458; P = 0.035). During the median 35 months of follow-up, 83 (25%) MACE were recorded, and a higher incidence of MACE was observed in the T3 group (T3 vs. T2 vs. T1: 36.9% vs. 21.6% vs. 16.4%, respectively; p = 0.001). In multivariate Cox regression analysis, the T3 group was significantly associated with the risk of MACE compared to the T1 group (HR, 2.338; 95% CI 1.253-4.364, P = 0.008). CONCLUSION This study indicates for the first time that the TyG index is significantly associated with myocardial ischemia and poor prognosis among INOCA patients.
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Affiliation(s)
- Wen Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Lanqing Xiang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Tingting Shi
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Jassur Galip
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Chunyue Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Fei Yu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China.
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China.
- Department of Cardiology, Shanghai Tenth People's Hospital Chongming branch, Shanghai, China.
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9
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Moody JB, Poitrasson-Rivière A, Renaud JM, Hagio T, Alahdab F, Al-Mallah MH, Vanderver MD, Ficaro EP, Murthy VL. Self-supervised deep representation learning of a foundation transformer model enabling efficient ECG-based assessment of cardiac and coronary function with limited labels. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.10.25.23297552. [PMID: 37961713 PMCID: PMC10635192 DOI: 10.1101/2023.10.25.23297552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background: Although deep learning methods have shown great promise for identification of structural and functional cardiac abnormalities using electrocardiographic data, these methods are data hungry, posing a challenge for critically important tasks where ground truth labels are relatively scarce. Impaired coronary microvascular and vasomotor function is difficult to identify with standard clinical methods of cardiovascular testing such as coronary angiography and noninvasive single photon emission tomography (SPECT) myocardial perfusion imaging (MPI). Gold standard data from positron emission tomography (PET) are gaining emphasis in clinical guidelines but are expensive and only available in relatively limited centers. We hypothesized that signals embedded within resting and stress electrocardiograms (ECGs) identify individuals with microvascular and vasomotor dysfunction. Methods: We developed and pretrained a self-supervised foundation vision transformer model using a large database of unlabeled ECG waveforms (N=800,035). We then fine-tuned the foundation model for two clinical tasks: the difficult problem of identifying patients with impaired myocardial flow reserve (AI-MFR), and the relatively easier problem of detecting impaired LVEF (AI-LVEF). A second ECG database was labeled with task-specific annotations derived from quantitative PET MPI (N=4167). Diagnostic accuracy of AI predictions was tested in a holdout set of patients undergoing PET MPI (N=1031). Prognostic evaluation was performed in the PET holdout cohort, as well as independent cohorts of patients undergoing pharmacologic or exercise stress SPECT MPI (N=6635). Results: The diagnostic accuracy of AI-MFR with SSL pretraining increased significantly compared to de novo supervised training (AUROC, sensitivity, specificity: 0.758, 70.1%, 69.4% vs. 0.632, 66.1%, 57.3%, p < 0.0001). SSL pretraining also produced a smaller increase in AI-LVEF accuracy (AUROC, sensitivity, specificity: 0.946, 89.4%, 85.9% vs. 0.918, 87.6%, 82.5%, p < 0.02). Abnormal AI-MFR was found to be significantly associated with mortality risk in all three test cohorts (Hazard Ratio (HR) 2.61 [95% CI 1.83, 3.71], p < 0.0001, PET cohort; HR 2.30 [2.03, 2.61], p < 0.0001, pharmacologic stress SPECT cohort; HR 3.76 [2.36, 5.99], p < 0.0001, exercise stress SPECT cohort). Conclusion: SSL pretraining of a vision transformer foundation model enabled identification of signals predictive of impaired MFR, a hallmark of microvascular and vasomotor dysfunction, and impaired LV function in resting and stress ECG waveforms. These signals are powerful predictors of prognosis in patients undergoing routine noninvasive stress testing and could enable more efficient diagnosis and management of these common conditions.
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Linna-Kuosmanen S, Schmauch E, Galani K, Ojanen J, Boix CA, Örd T, Toropainen A, Singha PK, Moreau PR, Harju K, Blazeski A, Segerstolpe Å, Lahtinen V, Hou L, Kang K, Meibalan E, Agudelo LZ, Kokki H, Halonen J, Jalkanen J, Gunn J, MacRae CA, Hollmén M, Hartikainen JEK, Kaikkonen MU, García-Cardeña G, Tavi P, Kiviniemi T, Kellis M. Transcriptomic and spatial dissection of human ex vivo right atrial tissue reveals proinflammatory microvascular changes in ischemic heart disease. Cell Rep Med 2024; 5:101556. [PMID: 38776872 PMCID: PMC11148807 DOI: 10.1016/j.xcrm.2024.101556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 11/27/2023] [Accepted: 04/16/2024] [Indexed: 05/25/2024]
Abstract
Cardiovascular disease plays a central role in the electrical and structural remodeling of the right atrium, predisposing to arrhythmias, heart failure, and sudden death. Here, we dissect with single-nuclei RNA sequencing (snRNA-seq) and spatial transcriptomics the gene expression changes in the human ex vivo right atrial tissue and pericardial fluid in ischemic heart disease, myocardial infarction, and ischemic and non-ischemic heart failure using asymptomatic patients with valvular disease who undergo preventive surgery as the control group. We reveal substantial differences in disease-associated gene expression in all cell types, collectively suggesting inflammatory microvascular dysfunction and changes in the right atrial tissue composition as the valvular and vascular diseases progress into heart failure. The data collectively suggest that investigation of human cardiovascular disease should expand to all functionally important parts of the heart, which may help us to identify mechanisms promoting more severe types of the disease.
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Affiliation(s)
- Suvi Linna-Kuosmanen
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland.
| | - Eloi Schmauch
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Kyriakitsa Galani
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Johannes Ojanen
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Carles A Boix
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Tiit Örd
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Anu Toropainen
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Prosanta K Singha
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Pierre R Moreau
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Kristiina Harju
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Adriana Blazeski
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Åsa Segerstolpe
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Veikko Lahtinen
- Heart Center, Turku University Hospital, 20521 Turku, Finland; MediCity Research Laboratories and InFLAMES Flagship, University of Turku, 20500 Turku, Finland
| | - Lei Hou
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Kai Kang
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Elamaran Meibalan
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Leandro Z Agudelo
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland
| | - Jari Halonen
- School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; Heart Center, Kuopio University Hospital, 70200 Kuopio, Finland
| | - Juho Jalkanen
- MediCity Research Laboratories and InFLAMES Flagship, University of Turku, 20500 Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital, 20521 Turku, Finland; Department of Medicine, University of Turku, 20500 Turku, Finland
| | - Calum A MacRae
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; Cardiovascular Medicine and Network Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Maija Hollmén
- MediCity Research Laboratories and InFLAMES Flagship, University of Turku, 20500 Turku, Finland
| | - Juha E K Hartikainen
- School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; Heart Center, Kuopio University Hospital, 70200 Kuopio, Finland
| | - Minna U Kaikkonen
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Guillermo García-Cardeña
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Pasi Tavi
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, 20521 Turku, Finland; Department of Medicine, University of Turku, 20500 Turku, Finland; Cardiovascular Medicine and Network Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Manolis Kellis
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.
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11
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Akhiyat N, Ozcan I, Gulati R, Prasad A, Tchkonia T, Kirkland JL, Lewis B, Lerman LO, Lerman A. Patients With Coronary Microvascular Dysfunction Have Less Circulating α-Klotho. J Am Heart Assoc 2024; 13:e031972. [PMID: 38639380 PMCID: PMC11179916 DOI: 10.1161/jaha.123.031972] [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: 07/27/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) represents an early functional characteristic of coronary vascular aging. Klotho (α-klotho) is a circulating protein inversely linked to physiological aging. We examined low klotho as a potential marker for vascular aging in patients with CMD and no coronary artery disease. METHODS AND RESULTS Patients undergoing nonurgent angiogram for chest pain who had no coronary artery disease underwent invasive coronary microvascular and endothelial function testing. CMD was defined by ≤50% increase in coronary blood flow (percentage change in coronary blood flow) in response to intracoronary acetylcholine or coronary flow reserve ≤2. Fresh arterial whole blood was used to analyze circulating endothelial progenitor cells with flow cytometry. Stored arterial plasma was used for klotho analysis by ELISA. Participants with CMD (n=62) were compared with those without CMD (n=36). Those with CMD were age 55±10 years (versus 51±11 years; P=0.07) and 73% women (versus 81%; P=0.38). Traditional risk factors for coronary artery disease were similar between groups. Patients with CMD had less klotho (0.88±1.50 versus 1.75±2.38 ng/mL; P=0.03), and the odds of low klotho in CMD were significant in a logistic regression model after adjusting for traditional cardiovascular risk factors (odds ratio [OR], 0.80 [95% CI, 0.636-0.996]; P=0.05). Higher klotho was associated with higher numbers of endothelial progenitor cells with vascular regenerative potential (CD34+ and CD34+CD133+KDR+). Among a subgroup of patients with atherosclerotic cardiovascular disease risk <5% (n=58), CMD remained associated with lower klotho (OR, 0.80 [95% CI, 0.636-0.996]; P=0.047). CONCLUSIONS Klotho may be a biomarker for CMD and may be a therapeutic target for groups of patients without significant traditional cardiovascular risk.
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Affiliation(s)
- Nadia Akhiyat
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Ilke Ozcan
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Rajiv Gulati
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Abhiram Prasad
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Tamara Tchkonia
- Department of Physiology and Biomedical EngineeringMayo ClinicRochesterMNUSA
| | - James L. Kirkland
- Department of Physiology and Biomedical EngineeringMayo ClinicRochesterMNUSA
- Division of General Internal Medicine, Department of MedicineMayo ClinicRochesterMNUSA
| | - Bradley Lewis
- Division of Clinical Trials and BiostatisticsMayo ClinicRochesterMNUSA
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Department of MedicineMayo ClinicRochesterMNUSA
| | - Amir Lerman
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
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12
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Zhu C, Miao L, Wei K, Shi D, Gao J. Coronary microvascular dysfunction. Microvasc Res 2024; 153:104652. [PMID: 38211894 DOI: 10.1016/j.mvr.2024.104652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
Coronary microvascular dysfunction (CMD) is a key mechanism underlying ischemic heart disease (IHD), yet its diagnosis and treatment remain challenging. This article presents a comprehensive overview of CMD research, covering its pathogenesis, diagnostic criteria, assessment techniques, risk factors, and therapeutic strategies. Additionally, it highlights the prospects for future CMD research. The article aims at advocating early and effective intervention for CMD and improving the prognosis of IHD.
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Affiliation(s)
- Chunlin Zhu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kangkang Wei
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Jie Gao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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13
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Zornitzki L, Shetrit A, Freund O, Frydman S, Banai A, Amar Shamir R, Ben-Shoshan J, Arbel Y, Banai S, Konigstein M. Traditional Cardiovascular Risk Factors and Coronary Microvascular Dysfunction in Women and Men: A Single-Center Study. Cardiology 2024:1-8. [PMID: 38679011 DOI: 10.1159/000539102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Coronary microvascular dysfunction (CMD) is common in patients with and without obstructive epicardial coronary artery disease (CAD). Risk factors for the development of CMD have not been fully elucidated, and data regarding sex-associated differences in traditional cardiovascular risk factors for obstructive CAD in patients with CMD are lacking. METHODS In this single-center, prospective registry, we enrolled patients with nonobstructive CAD undergoing clinically indicated invasive assessment of coronary microvascular function between November 2019 and March 2023. Associations between coronary microvascular dysfunction, traditional cardiovascular risk factors, and sex were assessed using univariate and multivariate regression models. RESULTS Overall, 245 patients with nonobstructive CAD were included in the analysis (62.9% female; median age 68 (interquartile range: 59, 75). Microvascular dysfunction was diagnosed in 141 patients (57.5%). The prevalence of microvascular dysfunction was similar in women and men (59.0% vs. 57.0%; p = 0.77). No association was found between traditional risk factors for coronary atherosclerosis and CMD regardless of whether CMD was structural or functional. In women, but not in men, older age and the presence of previous ischemic heart disease were associated with lower coronary flow reserve (β = -0.29; p < 0.01 and β = -0.15; p = 0.05, respectively) and lower resistive reserve ratio (β = -0.28; p < 0.01 and β = -0.17; p = 0.04, respectively). CONCLUSION For the entire population, no association was found between coronary microvascular dysfunction and traditional risk factors for coronary atherosclerosis. In women only, older age and previous ischemic heart disease were associated with coronary microvascular dysfunction. Larger studies are needed to elucidate risk factors for CMD.
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Affiliation(s)
- Lior Zornitzki
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Aviel Shetrit
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Ophir Freund
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Shir Frydman
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Ariel Banai
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Reut Amar Shamir
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Jeremy Ben-Shoshan
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Yaron Arbel
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Shmuel Banai
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with Tel Aviv University School of Medicine, Tel Aviv, Israel
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14
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Toftgård J, Hedskog H, Rune L, Svedenhag J, Riva G. Association of postsystolic shortening on stress echocardiography and significant coronary artery stenosis: A single-centre retrospective cohort study. Clin Physiol Funct Imaging 2024. [PMID: 38659382 DOI: 10.1111/cpf.12883] [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: 09/25/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Postsystolic shortening (PSS) is one of the proposed quantitative measures to predict myocardial ischaemia in the stress echocardiographic (SE) evaluation. It is previously known that hypo-/akinesia (HA) correlates well with coronary stenosis. However, some patients undergoing SE only present with PSS, and their risk of significant coronary stenosis is less clear. This study aimed to evaluate the association between PSS and significant coronary stenosis compared with HA. METHODS This was a retrospective cohort study at the hospital of S:t Görans, Stockholm, Sweden. All patients who underwent SE to investigate inducible ischaemia between 1 January 2018 and 15 October 2021 were eligible for inclusion. Exclusion criteria were normal SE and inconclusive test. Pathological SE were divided into two groups, patients with HA and those with PSS. Outcome was significant coronary artery stenosis visualized by invasive coronary angiography. RESULTS The final study population consisted of 108 patients (73 PSS, 35 HA). The presence of HA was associated with a higher risk of significant stenosis compared to those with PSS (63% vs. 23%, p < 0.001). This relationship was observed among males (p < 0.001), but not among females (p = 0.133). Nonsignificant stenosis trended to be more common among patients with PSS (21% vs. 6%, p = 0.053) CONCLUSIONS: The finding of PSS without HA was associated with a lower risk of significant coronary stenosis than HA. However, patients with PSS still often had nonsignificant coronary stenosis and PSS in the evaluation for nonobstructive coronary artery disease (CAD) should be further investigated.
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Affiliation(s)
- Joel Toftgård
- Department of Clinical Physiology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - Henrik Hedskog
- Department of Clinical Physiology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - Lars Rune
- Department of Clinical Physiology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - Jan Svedenhag
- Department of Clinical Physiology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - Gabriel Riva
- Department of Cardiology, Capio S:t Göran Hospital, Stockholm, Sweden
- Department of Clinical Science and Education, KI SÖS, Stockholm, Sweden
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15
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Seto AH, Tehrani DM. How much does CMD cost before it is diagnosed? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00168-4. [PMID: 38641439 DOI: 10.1016/j.carrev.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Arnold H Seto
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, United States of America; VA Long Beach Healthcare System, Long Beach, CA, United States of America; University of California, Irvine, Orange, CA, United States of America.
| | - David M Tehrani
- Stanford Health Care Tri-Valley, Pleasanton, CA, United States of America
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Rinaldi R, Colucci M, Torre I, Ausiello D, Bonanni A, Basile M, Salzillo C, Sanna T, Liuzzo G, Leone AM, Burzotta F, Trani C, Lanza GA, Niccoli G, Crea F, Montone RA. Predicting the response to acetylcholine in ischemia or infarction with non-obstructive coronary arteries: The ABCD score. Atherosclerosis 2024; 391:117503. [PMID: 38447435 DOI: 10.1016/j.atherosclerosis.2024.117503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/19/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response. METHODS We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort). RESULTS 551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652-0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626-0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test. CONCLUSIONS The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.
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Affiliation(s)
- Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Michele Colucci
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Ilaria Torre
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Davide Ausiello
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alice Bonanni
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mattia Basile
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Carmine Salzillo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano A Lanza
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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17
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Angeli F, Ricci F, Moscucci F, Sciomer S, Bucciarelli V, Bianco F, Mattioli AV, Pizzi C, Gallina S. Sex- and gender-related disparities in chest pain syndromes: the feminine mystique of chest pain. Curr Probl Cardiol 2024; 49:102457. [PMID: 38342350 DOI: 10.1016/j.cpcardiol.2024.102457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/13/2024]
Abstract
Chest pain syndromes encompass a wide range of different clinical conditions, being coronary artery disease one of the most important and feared aetiology. Sex and gender disparities have been reported in pathophysiology, clinical presentations, diagnostic work-up and outcomes of patients admitted for chest pain. Biological differences in sexual hormones and neurological pain procession pathways have been proposed as contributors to disparities between men and women; however, gender-related disparities in socio-economic and psychological status have emerged as additional factors involved in these conditions. A better understanding of gender- and sex-related disparities will lead to improved clinical care and management of chest pain syndromes in both men and women. In this comprehensive review, we describe the existing knowledge regarding sex and gender-based differences in management and outcomes of chest pain syndromes in order to stimulate and promote the development of a more sex- and gender-oriented approach to these conditions.
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Affiliation(s)
- Francesco Angeli
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda, Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences- DIMEC, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Federica Moscucci
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, Viale del Policlinico n. 155, 00161 Rome, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, 'Sapienza', Rome University, Viale dell'Università, 37, 00185, Rome, Italy
| | - Valentina Bucciarelli
- Cardiovascular Sciences Department-Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Francesco Bianco
- Cardiovascular Sciences Department-Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Anna Vittoria Mattioli
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda, Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences- DIMEC, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy.
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
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18
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Gowda SN, Garapati SS, Kurrelmeyer K. Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle. Methodist Debakey Cardiovasc J 2024; 20:81-93. [PMID: 38495657 PMCID: PMC10941714 DOI: 10.14797/mdcvj.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.
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Affiliation(s)
- Smitha Narayana Gowda
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Sai sita Garapati
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Karla Kurrelmeyer
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
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19
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Kanaji Y, Ahmad A, Sara JDS, Ozcan I, Akhiyat N, Prasad A, Raphael CE, Kakuta T, Lerman LO, Lerman A. Coronary Vasomotor Dysfunction Is Associated With Cardiovascular Events in Patients With Nonobstructive Coronary Artery Disease. JACC Cardiovasc Interv 2024; 17:474-487. [PMID: 38418053 DOI: 10.1016/j.jcin.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Coronary vasomotor dysfunction (CVDys) can be comprehensively classified on the basis of anatomy and functional mechanisms. OBJECTIVES The aim of this study was to evaluate the association between different CVDys phenotypes and outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA). METHODS Patients with ANOCA who underwent coronary reactivity testing using an intracoronary Doppler guidewire to assess microvascular and epicardial coronary endothelium-dependent and endothelium-independent function were enrolled. Endothelium-dependent microvascular and epicardial coronary dysfunction were defined as a <50% change in coronary blood flow in response to intracoronary acetylcholine (Ach) infusion and a <-20% change in coronary artery diameter in response to Ach. Endothelium-independent microvascular and epicardial coronary dysfunction were defined as coronary flow reserve < 2.5 during adenosine-induced hyperemia and change in cross-sectional area in response to intracoronary nitroglycerin administration < 20%. Major adverse cardiac and cerebrovascular events (cardiovascular death, nonfatal MI, heart failure, stroke, and late revascularization) served as clinical outcomes. RESULTS Among the 1,196 patients with ANOCA, the prevalence of CVDys was 24.5% and 51.8% among those with endothelium-independent and endothelium-dependent microvascular dysfunction, respectively, and 47.4% and 25.4% among those with endothelium-independent and endothelium-dependent epicardial coronary dysfunction, respectively. During 6.3 years (Q1-Q3: 2.5-12.9 years) of follow-up, patients with endothelium-dependent microvascular dysfunction, endothelium-dependent epicardial coronary dysfunction, or endothelium-independent microvascular dysfunction showed significantly higher event rates compared with those without (19.5% vs 12.0% [P < 0.001], 19.7% vs 14.6% [P = 0.038] and 22.2% vs 13.8% [P = 0.001], respectively). Coronary flow reserve (HR: 0.757; 95% CI: 0.604-0.957) and percentage change in coronary blood flow in response to Ach infusion (HR: 0.998; 95% CI: 0.996-0.999) remained significant predictors of major adverse cardiac and cerebrovascular event after adjustment for conventional risk factors. CONCLUSIONS CVDys phenotype is differentially associated with worse outcomes, and endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information in patients with ANOCA.
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Affiliation(s)
- Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadia Akhiyat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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20
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Stein AP, Harder J, Holmes HR, Merz CNB, Pepine CJ, Keeley EC. Single Nucleotide Polymorphisms in Coronary Microvascular Dysfunction. J Am Heart Assoc 2024; 13:e032137. [PMID: 38348798 PMCID: PMC11010085 DOI: 10.1161/jaha.123.032137] [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: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Abstract
Coronary microvascular dysfunction is an underdiagnosed pathologic process that is associated with adverse clinical outcomes. There are data to suggest that coronary microvascular dysfunction, in some cases, may be genetically determined. We present an updated review of single nucleotide polymorphisms in coronary microvascular dysfunction.
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Affiliation(s)
| | | | | | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart CenterSmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Carl J. Pepine
- Department of MedicineUniversity of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineUniversity of FloridaGainesvilleFLUSA
| | - Ellen C. Keeley
- Department of MedicineUniversity of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineUniversity of FloridaGainesvilleFLUSA
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21
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Qiu Z, Wang Y, Liu Y, Zhou Z, Wang Z. Diagnostic value of angiography-derived index of microcirculatory resistance (AMR) for coronary microcirculatory dysfunction (CMD) and its prognostic significance in patients with chronic coronary syndromes in the smoking population. Medicine (Baltimore) 2024; 103:e37022. [PMID: 38335436 PMCID: PMC10860928 DOI: 10.1097/md.0000000000037022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/24/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024] Open
Abstract
This study aims to analyze the prognostic significance of angiographic microvascular resistance (AMR) derived from functional coronary angiography in diagnosing coronary microvascular dysfunction (CMD) among patients with chronic coronary syndrome (CCS), particularly focusing on the prognostic significance of CMD in smokers. Additionally, this study assesses the prognostic significance of the diagnostic accuracy of the AMR index for CMD in CCS patients within the smoking population. Seventy-five CCS patients were studied for IMR measurement between June 2018 and December 2020, classified into CMD and non-CMD groups. Pearson correlation analyzed AMR and IMR relationship, while ROC curves determined AMR's predictive value for CMD with optimal cutoff value. An additional 223 CCS patients were included for AMR measurements. The study's primary endpoint was MACE occurrence, followed up through telephone calls. COX one-way analysis and Kaplan-Meier analysis evaluated the association between AMR and MACE risk. In the study, 52% of patients were diagnosed with CMD, and the AUC under the AMR curve for predicted IMR ≥ 25 was 0.90 (95% CI: 0.79-0.95). The CMD group had a higher proportion of female patients, smokers, and those with hypertension and diabetes mellitus compared to the non-CMD group (all P < .05). The CMD group exhibited higher AMR values than the non-CMD group (3.20 ± 0.5 vs 1.95 ± 0.45, P < .01), with a significant correlation between AMR and IMR (R2 = 0.81, P < .001). The ROC curve illustrated AMR's effectiveness in diagnosing CMD in CCS patients, using IMR as the gold standard, with the optimal cutoff value of AMR = 2.6mmHgs/cm (sensitivity: 90.5%, specificity: 81.5%). Patients with AMR ≥ 2.6mmHgs/cm had a higher risk of MACE events (HR = 6.00; 95% CI: 1.59-22.67). AMR in patients with CCS was significantly correlated with IMR and demonstrated good diagnostic accuracy. AMR ≥ 2.6 mm Hg*s/cm was associated with an increased risk of MACE occurrence and served as a valuable prognostic factor. In patients with CCS, AMR has a high diagnostic performance, In patients with CCS who smoke, impaired coronary microvascular function as assessed by AMR is significant and is an independent predictor of MACE.
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Affiliation(s)
- Zhongjue Qiu
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yong Wang
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
- Center for Post-Doctoral Studies, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yang Liu
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhou Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen Wang
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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22
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Bland A, Chuah E, Meere W, Ford TJ. Targeted Therapies for Microvascular Disease. Cardiol Clin 2024; 42:137-145. [PMID: 37949535 DOI: 10.1016/j.ccl.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.
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Affiliation(s)
- Adam Bland
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - William Meere
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia; University of Glasgow, ICAMS, G12 8QQ Glasgow, UK.
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23
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Patel N, Greene N, Guynn N, Sharma A, Toleva O, Mehta PK. Ischemia but no obstructive coronary artery disease: more than meets the eye. Climacteric 2024; 27:22-31. [PMID: 38224068 DOI: 10.1080/13697137.2023.2281933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024]
Abstract
Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.
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Affiliation(s)
- N Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - N Greene
- Emory University School of Medicine, Atlanta, GA, USA
| | - N Guynn
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - A Sharma
- Department of Internal Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - O Toleva
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - P K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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24
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Théberge ET, Vikulova DN, Pimstone SN, Brunham LR, Humphries KH, Sedlak TL. The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes. CJC Open 2024; 6:279-291. [PMID: 38487074 PMCID: PMC10935675 DOI: 10.1016/j.cjco.2023.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/26/2023] [Indexed: 03/17/2024] Open
Abstract
Background Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women. Methods This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD. Results A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD. Conclusions The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.
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Affiliation(s)
| | - Diana N. Vikulova
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Simon N. Pimstone
- University of British Columbia, Vancouver, British Columbia, Canada
- University of British Columbia Hospital, Vancouver, British Columbia, Canada
| | - Liam R. Brunham
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | | | - Tara L. Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
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25
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Cardiol Clin 2024; 42:125-135. [PMID: 37949533 PMCID: PMC11090694 DOI: 10.1016/j.ccl.2023.07.003] [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] [Indexed: 11/12/2023]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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26
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Crosier R, Lopez Laporte MA, Unni RR, Coutinho T. Female-Specific Considerations in Aortic Health and Disease. CJC Open 2024; 6:391-406. [PMID: 38487044 PMCID: PMC10935703 DOI: 10.1016/j.cjco.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/06/2023] [Indexed: 03/17/2024] Open
Abstract
The aorta plays a central role in the modulation of blood flow to supply end organs and to optimize the workload of the left ventricle. The constant interaction of the arterial wall with protective and deleterious circulating factors, and the cumulative exposure to ventriculoarterial pulsatile load, with its associated intimal-medial changes, are important players in the complex process of vascular aging. Vascular aging is also modulated by biomolecular processes such as oxidative stress, genomic instability, and cellular senescence. Concomitantly with well-established cardiometabolic and sex-specific risk factors and environmental stressors, arterial stiffness is associated with cardiovascular disease, which remains the leading cause of morbidity and mortality in women worldwide. Sexual dimorphisms in aortic health and disease are increasingly recognized and explain-at least in part-some of the observable sex differences in cardiovascular disease, which will be explored in this review. Specifically, we will discuss how biological sex affects arterial health and vascular aging and the implications this has for development of certain cardiovascular diseases uniquely or predominantly affecting women. We will then expand on sex differences in thoracic and abdominal aortic aneurysms, with special considerations for aortopathies in pregnancy.
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Affiliation(s)
- Rebecca Crosier
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Rudy R. Unni
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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27
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Parvand M, Ghadiri S, Théberge E, Comber L, Mullen KA, Bhalla NP, Johnson D, McKinley G, Sedlak TL. Sex, Gender, and Women's Heart Health: How Women's Heart Programs Address the Knowledge Gap. CJC Open 2024; 6:442-453. [PMID: 38487062 PMCID: PMC10935996 DOI: 10.1016/j.cjco.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/15/2023] [Indexed: 03/17/2024] Open
Abstract
This article aims to bridge existing knowledge gaps that impact clinical cardiovascular care and outcomes for women in Canada. The authors discuss various aspects of women's heart health, emphasizing the efficacy of multidisciplinary care in promoting women's well-being. The article also identifies the impact of national women's heart health campaigns and the value of peer support in improving outcomes. The article addresses the particular risks that women face, such as pregnancy-related complications and hormone replacement therapy, all of which are associated with cardiovascular events, and highlights the differences in ischemic symptoms between men and women. Despite improvements in acute event outcomes, challenges persist in accessing timely ambulatory care, particularly for women. Canada has responded to these challenges by introducing Women Heart Programs, which offer tailored programs, support groups, and specialized testing. However, these programs remain few in number and are found only in urban settings. Overall, this review identifies sex and gender factors related to women's heart health, underscoring the importance of specialized programs and multidisciplinary care in improving women's cardiovascular health.
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Affiliation(s)
- Mahraz Parvand
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Siavash Ghadiri
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Emilie Théberge
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Lisa Comber
- Ottawa Heart Institute Research Corporation (OHIRC), Ottawa, Ontario, Canada
| | - Kerri-Anne Mullen
- Ottawa Heart Institute Research Corporation (OHIRC), Ottawa, Ontario, Canada
| | | | - Denise Johnson
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gayl McKinley
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara L. Sedlak
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
- British Columbia Women's Hospital, Vancouver, British Columbia, Canada
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28
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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29
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Xi P, Xie Y, Huang F, Liu Y, Xu J. Influence of Trichosanthes pericarpium extract on improving microcirculation and outcomes of patients with acute myocardial infarction after percutaneous coronary intervention. Front Cardiovasc Med 2024; 10:1126573. [PMID: 38239872 PMCID: PMC10794635 DOI: 10.3389/fcvm.2023.1126573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 12/11/2023] [Indexed: 01/22/2024] Open
Abstract
Background Microcirculatory dysfunction is an independent risk factor for a poor prognosis after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Trichosanthes pericarpium is a well-known Chinese traditional herb described with the effect of activating blood circulation to dissipate blood stasis and improve blood circulation. However, its effects on microcirculation in patients with AMI after primary PCI remain unknown. This study aimed to investigate the effect of Trichosanthes pericarpium extract (TPE) on improving microcirculation and outcomes in patients with AMI after PCI. Methods This study included 155 patients with a history of emergency PCI treatment. In this cohort, 31 patients received a course of TPE, defined as intravenous TPE infusion (12 ml TPE dissolved in 250 ml 5% Glucose Injection) once daily for 7 days on the background of standard treatment after PCI; 124 who did not receive TPE were regarded as the control group and received standard treatment after PCI. The corrected thrombolysis in myocardial infarction frame count (CTFC) and index of microcirculatory resistance (IMR) were used to evaluate myocardial microcirculation. Cardiac function was measured by echocardiography during hospitalization and follow-up. Major adverse cardiac events (MACEs) were recorded for prognostic analysis. Results At the 6-month follow-up, AMI patients who received TPE after primary PCI had significantly lower levels of CTCF (24.27 ± 2.40 vs. 21.88 ± 1.92, P < 0.001) and IMR (20.02 ± 2.20 vs. 17.80 ± 2.11, P < 0.001) than patients in the control group. Left ventricular ejection fraction and left ventricular internal dimension at systolic at 6-month follow-up in the TPE group significantly improved than in the control group (56.6 ± 4.5 vs. 62.1 ± 3.5, P < 0.001; 32.5 ± 1.5 vs. 30.2 ± 1.8, P < 0.001). Kaplan-Meier curve analysis indicated that patients with AMI who received TPE had significantly lower rates of MACEs than the control group at 6-month follow-up (P = 0.042). Conclusion In the context of standard treatment, Trichosanthes pericarpium further improved coronary microcirculation, increased cardiac function, and reduced short-term MACEs rate. Our data suggest that TPE could be used in combination therapy for patients with AMI after primary PCI.
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Affiliation(s)
| | | | | | - Yang Liu
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiahong Xu
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Bland A, Chuah E, Meere W, Ford TJ. Targeted Therapies for Microvascular Disease. Heart Fail Clin 2024; 20:91-99. [PMID: 37953025 DOI: 10.1016/j.hfc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.
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Affiliation(s)
- Adam Bland
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - William Meere
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia; University of Glasgow, ICAMS, G12 8QQ Glasgow, UK.
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Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, Senior R, Shapiro MD, Pellikka PA, Lyubarova R, Alfakih K, Abdul-Nour K, Anthopolos R, Xu Y, Kunichoff DM, Fleg JL, Spertus JA, Hochman J, Maron D, Picard MH, Reynolds HR. Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA Study. J Am Soc Echocardiogr 2024; 37:89-99. [PMID: 37722490 PMCID: PMC10842002 DOI: 10.1016/j.echo.2023.09.006] [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: 03/09/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS Left ventricular GLS was calculated offline on resting SE images at enrollment (n = 144) and 1-year follow-up (n = 120) in the CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial screen failures with no obstructive CAD on computed tomography [CT] angiography) study, which enrolled participants with moderate or severe ischemia by local SE interpretation (≥3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) on coronary computed tomography angiography. RESULTS Global longitudinal strain values were normal in 83.3% at enrollment and 94.2% at follow-up. Global longitudinal strain values were not associated with a positive SE at enrollment (GLS = -21.5% positive SE vs GLS = -19.9% negative SE, P = .443) or follow-up (GLS = -23.2% positive SE vs GLS = -23.1% negative SE, P = .859). Significant change in GLS was not associated with positive SE in follow-up (P = .401). Regional strain was not associated with colocalizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β = 0.41; 95% CI, 0.16, 0.67; P = .002). CONCLUSIONS In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity, or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
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Affiliation(s)
- Esther F Davis
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Victorian Heart Institute and Victorian Heart Hospital, Victoria, Australia
| | - Daniela R Crousillat
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, Florida; Department of Obstetrics and Gynecology, Tampa General-Heart and Vascular Institute, University of South Florida, Tampa, Florida
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Michael D Shapiro
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Rebecca Anthopolos
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Yifan Xu
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Dennis M Kunichoff
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Jerome L Fleg
- National Institute of Health-National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Judith Hochman
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - David Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael H Picard
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York.
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Kim SR, Kim MN, Cho DH, Kim HD, Bae SA, Kim HL, Kim MA, Hong KS, Shim WJ, Park SM. Sex differences of sequential changes in coronary blood flow and microvascular function in patients with suspected angina. Clin Res Cardiol 2023:10.1007/s00392-023-02358-2. [PMID: 38112743 DOI: 10.1007/s00392-023-02358-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
AIMS This study evaluated the sex differences of sequential changes in coronary blood flows and microvascular function in patients with suspected angina but with no obstructed coronary arteries. METHODS A total of 202 consecutive patients who experienced chest pain but had no significant coronary artery stenosis and who underwent adenosine stress echocardiography were included in the study. Coronary blood flow (CBF) velocities were measured at 1, 2, and 3 min after adenosine infusion. RESULTS The mean age was 61 years, and 138 (68%) were women. Approximately 40% of patients had coronary microvascular dysfunction (CMD, coronary flow velocity reserve < 2.3), with women exhibiting higher CMD prevalence. The left ventricular (LV) mass index was similar between men and women, while women exhibited higher baseline rate pressure products (RPP). At baseline, coronary blood flow velocities were similar between the sexes. However, CBF velocities in women gradually increased during the examination; and in men, the increase was abrupt and steep during the early stages of examination (p = 0.015 for interaction between time and sex), even with similar RPP in stress. Coronary flow velocity reserve was steadily lower in women compared to men (1 min, 2.09 ± 0.86 vs 2.44 ± 0.87; 2 min, 2.39 ± 0.72 vs 2.63 ± 0.85; 3 min, 2.45 ± 0.70 vs 2.68 ± 0.73). CONCLUSIONS In patients with suspected angina but with no obstructed coronary arteries, CMD was especially prevalent among women. Women exhibited higher oxygen consumption, while exhibiting slower and gradual increases in CBF velocities. Conversely, men exhibited faster and steeper increases in CBF velocities even with similar RPP in stress.
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Affiliation(s)
- So Ree Kim
- Division of Cardiology, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Mi-Na Kim
- Division of Cardiology, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Hee-Dong Kim
- Division of Cardiology, Soonchunhyang University Hospital, 31, Suncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, Republic of Korea
| | - Sung A Bae
- Division of Cardiology, Yongin Severance Hospital, 363, Dongbaekjukjeon-daero, Giheung-gu, Yongin-si, Gyeonggi-do, Republic of Korea
| | - Hack-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - Myung-A Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - Kyung-Soon Hong
- Division of Cardiology, Hallym University Chuncheon Sacred Heart Hospital, 77, Sakju-ro, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Wan Joo Shim
- Division of Cardiology, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Seong-Mi Park
- Division of Cardiology, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea.
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Koo BK, Hwang D, Park S, Kuramitsu S, Yonetsu T, Kim CH, Zhang J, Yang S, Doh JH, Jeong YH, Choi KH, Lee JM, Ahn JM, Matsuo H, Shin ES, Hu X, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2. JACC. ASIA 2023; 3:825-842. [PMID: 38155788 PMCID: PMC10751650 DOI: 10.1016/j.jacasi.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Shoichi Kuramitsu
- Department of Cardiovascular Medicine, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chee Hae Kim
- Department of Internal Medicine and Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Jensen SM, Prescott EIB, Abdulla J. The prognostic value of coronary flow reserve in patients with non-obstructive coronary artery disease and microvascular dysfunction: a systematic review and meta-analysis with focus on imaging modality and sex difference. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2545-2556. [PMID: 37716916 DOI: 10.1007/s10554-023-02948-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/30/2023] [Indexed: 09/18/2023]
Abstract
To clarify prognosis of patients with non-obstructive coronary artery disease (NOCAD) and coronary microvascular disease (CMD) assessed as low coronary flow reserve (CFR) according to imaging modalities and sex difference. Comprehensive systematic literature review and meta-analyses were conducted. Risk of death and major adverse cardiac events (MACE) were pooled and compared in patients with abnormally low versus normal CFR using cut-off limits 2.0-2.5. Random effects model used for estimation of odds ratios (OR) and hazard ratios (HR) with 95% confidence interval (CI). Nineteen eligible observational studies provided data for death and MACE, publication bias was insignificant, p = 0.62. Risk of death and MACE were significantly higher in patients with low (n = 4.612, 29%) than normal CFR (n = 11.367, 71%): using transthoracal echocardiography (TTE) (OR 4.25 (95% CI 2.94, 6.15) p < 0.001) and (OR 6.98 (95% CI 2.56, 19.01) p < 0.001), positron emission tomography (PET) (OR 2.51 (CI 95%: 1.40, 4..49) p = 0.002) and (OR 2.87 (95% CI 2.16, 3.81) p < 0.001), and invasive intracoronary assessment (OR 2.23 (95% CI 1.15, 4.34) p < 0.018), and (OR 4.61 (95% CI 2.51, 8.48) p < 0.001), respectively. Pooled adjusted HR for death and MACE were (HR 2.45(95% CI 1.37, 3.53) p < 0.001) and (HR 2.08 (95% CI 1.54, 2.63) p < 0.001) respectively. Studies comparing men and women with abnormally low CFR demonstrated similar worse prognosis in both sexes. Low CFR is associated with poorer prognosis in patients with NOCAD regardless of sex. TTE may overestimate risk of death and MACE, while PET seems to be more appropriate. Future studies are needed to consolidate the current evidence.
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Affiliation(s)
- Signe Miang Jensen
- Department of Medicine, Section of Cardiology, Glostrup University Hospital of Copenhagen, Valdemar Hansens vej 1, 2600, Glostrup, Denmark
| | - Eva Irene Bossano Prescott
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Jawdat Abdulla
- Department of Medicine, Section of Cardiology, Glostrup University Hospital of Copenhagen, Valdemar Hansens vej 1, 2600, Glostrup, Denmark.
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Mohammed AQ, Abdu FA, Liu L, Yin G, Mareai RM, Mohammed AA, Xu Y, Che W. Coronary microvascular dysfunction and myocardial infarction with non-obstructive coronary arteries: Where do we stand? Eur J Intern Med 2023; 117:8-20. [PMID: 37482469 DOI: 10.1016/j.ejim.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/15/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
In the past decade, scientific and clinical research has provided a translational perspective on myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). MINOCA is characterized by clinical documentation of an acute MI but angiography shows no significant coronary artery obstruction (stenosis <50%). The prevalence of MINOCA is estimated to range from approximately 6 to 10% among MI patients, and those with this condition have a poor prognosis, experiencing high rates of mortality, rehospitalization, and socioeconomic burden. MINOCA represents a major unmet need in cardiovascular medicine, with uncertain clinical management. It is a complex condition that can be caused by various factors, including atherosclerosis, plaque rupture, coronary vasospasm, and microvascular dysfunction. Effective management of MINOCA depends on identifying the underlying mechanism of the infarction, thus a systematic diagnostic approach is recommended. Contemporary data shows that a significant number of patients exhibit structural and functional abnormalities in coronary microcirculation, which is referred to as coronary microvascular dysfunction (CMD). CMD plays a crucial role in patients with signs and symptoms of myocardial ischemia and non-obstructive coronary artery stenosis, including MINOCA. Furthermore, conducting a thorough evaluation of coronary function can have significant prognostic and therapeutic implications, since personalized patient management strategies based on this assessment have been shown to improve symptoms and prognosis. Therefore, an accurate and timely diagnosis of CMD is essential for effective patient management, which can be achieved through various invasive and non-invasive methods. This review will discuss the pathophysiological understanding, current diagnostic techniques, and management strategies of patients with MINOCA and CMD.
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Affiliation(s)
- Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China.
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Tobin R, Patel N, Tobb K, Weber B, Mehta PK, Isiadinso I. Atherosclerosis in Systemic Lupus Erythematosus. Curr Atheroscler Rep 2023; 25:819-827. [PMID: 37768411 DOI: 10.1007/s11883-023-01149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE OF THE REVIEW Systemic lupus erythematosus (SLE) patients are at increased risk of cardiovascular disease (CVD) compared to the general population, despite most patients being young females, who are not classically considered to be at high risk for cardiovascular disease using traditional risk assessment tools. The purpose of this review is to discuss the pathophysiology of atherosclerosis in SLE and raise awareness of the relationship between SLE and CVD. RECENT FINDINGS The increased risk of CVD in SLE patients is multifactorial, due to proatherogenic lipid profiles, immune dysregulation and inflammation, side effects of lupus treatment, and microvascular dysfunction. Conventional CV risk models often underperform in the identification of SLE patients at high risk of atherosclerosis. The use of non-invasive imaging serves as a strategy to identify patients with evidence of subclinical CVD and in the evaluation of symptomatic patients. Identification of subclinical atherosclerosis allows for aggressive management of CV risk factors. SLE patients experience an increased risk of atherosclerotic CVD, which is not solely explained by traditional CV risk factors. It is imperative that clinicians are aware of this association to implement prompt detection and treatment of atherosclerotic CVD in SLE patients.
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Affiliation(s)
- Rachel Tobin
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Nidhi Patel
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kardie Tobb
- Cone Health Medical Group, Greensboro, NC, USA
| | - Brittany Weber
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Puja K Mehta
- Division of Cardiology, Department of Medicine, Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, USA
| | - Ijeoma Isiadinso
- Division of Cardiology, Department of Medicine, Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, USA
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37
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Wang Z, Yang F, He Z, Liang C. Light-induced circadian rhythm disorder leads to microvascular dysfunction via up-regulating NETs. Microvasc Res 2023; 150:104592. [PMID: 37567437 DOI: 10.1016/j.mvr.2023.104592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/13/2023]
Abstract
Circadian rhythm is a physical, mental, and behavioral pattern over the course of 24-hour cycle, and its disturbance is associated with increased risk of cardiovascular diseases. Microvascular dysfunction serves as an important cause of cardiovascular disease, but the relationship between rhythm disturbances and microcirculation remains elusive. Herein, we constructed the mice model of circadian rhythm disturbance and investigated the alterations of microvascular conditions. It was revealed that coronary microcirculatory function and cardiac diastolic function were significantly reduced, along with endothelium-dependent diastolic function of microvessels remarkably impaired in the rhythm-disordered group of mice compared to the control group. Notably, rhythm disturbance led to a significant upregulation of neutrophil extracellular traps (NETs) levels in mice, which cause endothelial dysfunction by inhibiting microvascular endothelial cell activity and migration capacity as well as inducing apoptosis. Additionally, intraperitoneal injection of Cl-amidine suppressed the production of NETs, which further improved coronary microcirculatory function and endothelium-dependent diastolic function. In conclusion, this study demonstrated that circadian rhythm disorders could induce the development of coronary microvascular dysfunction (CMD) through the up-regulation of NETs, providing a potential therapeutic direction for the treatment of CMD.
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Affiliation(s)
- Zhanhui Wang
- Department of Cardiology, Second Affiliated Hospital of Naval Medical University, Shanghai, China; Department of Health Care Section, 971th Hospital of PLA, Qingdao, China
| | - Fupeng Yang
- Department of Cardiology, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhiqing He
- Department of Cardiology, Second Affiliated Hospital of Naval Medical University, Shanghai, China.
| | - Chun Liang
- Department of Cardiology, Second Affiliated Hospital of Naval Medical University, Shanghai, China.
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Bradley CP, Orchard V, McKinley G, Heggie R, Wu O, Good R, Watkins S, Lindsay M, Eteiba H, McGowan J, McGeoch R, Corcoran D, Kellman P, McConnachie A, Berry C. The coronary microvascular angina cardiovascular magnetic resonance imaging trial: Rationale and design. Am Heart J 2023; 265:213-224. [PMID: 37657593 DOI: 10.1016/j.ahj.2023.08.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/23/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction may cause myocardial ischemia with no obstructive coronary artery disease (INOCA). If functional testing is not performed INOCA may pass undetected. Stress perfusion cardiovascular MRI (CMR) quantifies myocardial blood flow (MBF) but the clinical utility of stress CMR in the management of patients with suspected angina with no obstructive coronary arteries (ANOCA) is uncertain. OBJECTIVES First, to undertake a diagnostic study using stress CMR in patients with ANOCA following invasive coronary angiography and, second, in a nested, double-blind, randomized, controlled trial to assess the effect of disclosure on the final diagnosis and health status in the longer term. DESIGN All-comers referred for clinically indicated coronary angiography for the investigation of suspected coronary artery disease will be screened in 3 regional centers in the United Kingdom. Following invasive coronary angiography, patients with ANOCA who provide informed consent will undergo noninvasive endotyping using stress CMR within 3 months of the angiogram. DIAGNOSTIC STUDY Stress perfusion CMR imaging to assess the prevalence of coronary microvascular dysfunction and clinically significant incidental findings in patients with ANOCA. The primary outcome is the between-group difference in the reclassification rate of the initial diagnosis based on invasive angiography versus the final diagnosis after CMR imaging. RANDOMIZED, CONTROLLED TRIAL Participants will be randomized to inclusion (intervention group) or exclusion (control group) of myocardial blood flow to inform the final diagnosis. The primary outcome of the clinical trial is the mean within-subject change in the Seattle Angina Questionnaire summary score (SAQSS) at 6 months. Secondary outcome assessments include the EUROQOL EQ-5D-5L questionnaire, the Brief Illness Perception Questionnaire (Brief-IPQ), the Treatment Satisfaction Questionnaire (TSQM-9), the Patient Health Questionnaire-4 (PHQ-4), the Duke Activity Status Index (DASI), the International Physical Activity Questionnaire- Short Form (IPAQ-SF), the Montreal Cognitive Assessment (MOCA) and the 8-item Productivity Cost Questionnaire (iPCQ). Health and economic outcomes will be assessed using electronic healthcare records. VALUE To clarify if routine stress perfusion CMR imaging reclassifies the final diagnosis in patients with ANOCA and whether this strategy improves symptoms, health-related quality of life and health economic outcomes. CLINICALTRIALS GOV: NCT04805814.
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Affiliation(s)
- Conor P Bradley
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK; Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - Vanessa Orchard
- Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - Gemma McKinley
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Robert Heggie
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Richard Good
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK; Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - Stuart Watkins
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK; Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - Mitchell Lindsay
- Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - Hany Eteiba
- Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK
| | - James McGowan
- Department of Cardiology, University Hospital Ayr, Ayr, UK
| | - Ross McGeoch
- Department of Cardiology, University Hospital Hairmyres, East Kilbride, Scotland, UK
| | - David Corcoran
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Colin Berry
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK; Department of Cardiology, NHS Golden Jubilee Hospital, Clydebank, Scotland, UK.
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39
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Allbritton-King JD, García-Cardeña G. Endothelial cell dysfunction in cardiac disease: driver or consequence? Front Cell Dev Biol 2023; 11:1278166. [PMID: 37965580 PMCID: PMC10642230 DOI: 10.3389/fcell.2023.1278166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
The vascular endothelium is a multifunctional cellular system which directly influences blood components and cells within the vessel wall in a given tissue. Importantly, this cellular interface undergoes critical phenotypic changes in response to various biochemical and hemodynamic stimuli, driving several developmental and pathophysiological processes. Multiple studies have indicated a central role of the endothelium in the initiation, progression, and clinical outcomes of cardiac disease. In this review we synthesize the current understanding of endothelial function and dysfunction as mediators of the cardiomyocyte phenotype in the setting of distinct cardiac pathologies; outline existing in vivo and in vitro models where key features of endothelial cell dysfunction can be recapitulated; and discuss future directions for development of endothelium-targeted therapeutics for cardiac diseases with limited existing treatment options.
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Affiliation(s)
- Jules D. Allbritton-King
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Guillermo García-Cardeña
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
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40
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Bradley CP, Berry C. Microvascular arterial disease of the brain and the heart: a shared pathogenesis. QJM 2023; 116:829-834. [PMID: 37467080 PMCID: PMC10593384 DOI: 10.1093/qjmed/hcad158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/22/2023] [Indexed: 07/21/2023] Open
Abstract
Microvascular arterial disease in the heart manifest as coronary microvascular dysfunction. This condition causes microvascular angina and is associated increased morbidity and mortality. Microvascular arterial disease in the brain is referred to as cerebrovascular small vessel disease. This is responsible for 45% of dementias and 25% of ischaemic strokes. The heart and brain share similar vascular anatomy and common pathogenic risk factors are associated with the development of both coronary microvascular dysfunction and cerebrovascular small vessel disease. Microvascular disease in the heart and brain also appear to share common multisystem pathophysiological mechanisms. Further studies on diagnostic approaches, epidemiology and development of disease-modifying therapy seem warranted.
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Affiliation(s)
- C P Bradley
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- NHS Golden Jubilee Hospital, Clydebank, UK
| | - C Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- NHS Golden Jubilee Hospital, Clydebank, UK
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Srinivasa S, Walpert AR, Thomas TS, Huck DM, Jerosch-Herold M, Islam S, Lu MT, Burdo TH, deFilippi CR, Dunderdale CN, Feldpausch M, Iyengar S, Shen G, Baak S, Torriani M, Robbins GK, Lee H, Kwong R, DiCarli M, Adler GK, Grinspoon SK. Randomized Placebo-Controlled Trial to Evaluate Effects of Eplerenone on Myocardial Perfusion and Function Among Persons With Human Immunodeficiency Virus (HIV)-Results From the MIRACLE HIV Study. Clin Infect Dis 2023; 77:1166-1175. [PMID: 37243345 PMCID: PMC10573745 DOI: 10.1093/cid/ciad310] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Increased renin angiotensin aldosterone system (RAAS) activity may contribute to excess cardiovascular disease in people with HIV (PWH). We investigated how RAAS blockade may improve myocardial perfusion, injury, and function among well-treated PWH. METHODS Forty PWH, on stable ART, without known heart disease were randomized to eplerenone 50 mg PO BID (n = 20) or identical placebo (n = 20) for 12 months. The primary endpoints were (1) myocardial perfusion assessed by coronary flow reserve (CFR) on cardiac PET or stress myocardial blood flow (sMBF) on cardiac MRI or (2) myocardial inflammation by extracellular mass index (ECMi) on cardiac MRI. RESULTS Beneficial effects on myocardial perfusion were seen for sMBF by cardiac MRI (mean [SD]: 0.09 [0.56] vs -0.53 [0.68] mL/min/g; P = .03) but not CFR by cardiac PET (0.01 [0.64] vs -0.07 [0.48]; P = .72, eplerenone vs placebo). Eplerenone improved parameters of myocardial function on cardiac MRI including left ventricular end diastolic volume (-13 [28] vs 10 [26] mL; P = .03) and global circumferential strain (GCS; median [interquartile range 25th-75th]: -1.3% [-2.9%-1.0%] vs 2.3% [-0.4%-4.1%]; P = .03), eplerenone versus placebo respectively. On cardiac MRI, improvement in sMBF related to improvement in global circumferential strain (ρ = -0.65, P = .057) among those treated with eplerenone. Selecting for those with impaired myocardial perfusion (CFR <2.5 and/or sMBF <1.8), there was a treatment effect of eplerenone versus placebo to improve CFR (0.28 [0.27] vs -0.05 [0.36]; P = .04). Eplerenone prevented a small increase in troponin (0.00 [-0.13-0.00] vs 0.00 [0.00-0.74] ng/L; P = .03) without effects on ECMi (0.9 [-2.3-4.3] vs -0.7 [-2.2--0.1] g/m2; P = .38). CD4+ T-cell count (127 [-38-286] vs -6 [-168-53] cells/μL; P = .02) increased in the eplerenone- versus placebo-treated groups. CONCLUSIONS RAAS blockade with eplerenone benefitted key indices and prevented worsening of myocardial perfusion, injury, and function among PWH with subclinical cardiac disease when compared with placebo. CLINICAL TRIALS REGISTRATION NCT02740179 (https://clinicaltrials.gov/ct2/show/NCT02740179?term=NCT02740179&draw=2&rank=1).
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Affiliation(s)
- Suman Srinivasa
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Allie R Walpert
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Teressa S Thomas
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel M Huck
- Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sabeeh Islam
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tricia H Burdo
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | | | - Carolyn N Dunderdale
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan Feldpausch
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjna Iyengar
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Shen
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Baak
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Martin Torriani
- Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory K Robbins
- Division of Infectious Disease, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Kwong
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo DiCarli
- Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gail K Adler
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Steven K Grinspoon
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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Takahashi T, Gupta A, Samuels BA, Wei J. Invasive Coronary Assessment in Myocardial Ischemia with No Obstructive Coronary Arteries. Curr Atheroscler Rep 2023; 25:729-740. [PMID: 37682498 PMCID: PMC10564835 DOI: 10.1007/s11883-023-01144-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is threefold: (i) to give an overview of well-established invasive methods for assessing patients with ischemia with no obstructive coronary arteries (INOCA) in the cardiac catheterization laboratory; (ii) to describe the prognostic and treatment implications based on these findings, and (iii) to discuss current knowledge gaps and future perspectives. RECENT FINDINGS Recent studies have demonstrated that invasive coronary function testing not only allows for risk stratification of patients with INOCA but also guides medical therapy with improvement in symptoms and quality of life. Based on these findings, invasive coronary function assessment is now a class 2a recommendation in the 2021 ACC/AHA chest pain guideline to improve the diagnosis of coronary microvascular dysfunction and to enhance risk stratification. Invasive functional testing for patients with INOCA is well established and easily performed in the catheterization laboratory. Comprehensive invasive assessment is a key to differentiating INOCA endotypes and optimizing both medical therapy and preventive strategies including lifestyle modification.
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Affiliation(s)
| | - Aakriti Gupta
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd A3212, Los Angeles, CA, 90048, USA.
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44
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Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, Jeremias A, Albadri A, Blair JA, Kearney KE, Wei J, Park K, Barseghian El-Farra A, Holoshitz N, Janaszek KB, Kesarwani M, Lerman A, Prasad M, Quesada O, Reynolds HR, Savage MP, Smilowitz NR, Sutton NR, Sweeny JM, Toleva O, Henry TD, Moses JW, Fearon WF, Tremmel JA. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1245-1263. [PMID: 37704315 DOI: 10.1016/j.jacc.2023.06.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 09/15/2023]
Abstract
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
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Affiliation(s)
- Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Jay Widmer
- Baylor Scott and White Health, Temple, Texas, USA
| | - Yuhei Kobayashi
- New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Steven E S Miner
- Southlake Regional Medical Centre, Newmarket, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen Jeremias
- St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Ahmed Albadri
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John A Blair
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kathleen E Kearney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Noa Holoshitz
- Ascension Columbia St Mary's, Milwaukee, Wisconsin, USA
| | | | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael P Savage
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph M Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olga Toleva
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Jeffery W Moses
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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Piko N, Bevc S, Hojs R, Petreski T, Ekart R. Higher Body Mass Index is associated with increased arterial stiffness prior to target organ damage: a cross-sectional cohort study. BMC Cardiovasc Disord 2023; 23:460. [PMID: 37710152 PMCID: PMC10503091 DOI: 10.1186/s12872-023-03503-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/07/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Obesity is associated with several neurohumoral changes that play an essential role in organ damage. Increased arterial stiffness causes functional vessel wall changes and can therefore lead to accelerated target organ damage as well. Whether obesity causes an independent increase in central arterial stiffness is, however, not yet fully known. METHODS One hundred thirty-three patients (63.2% male) were included. Body Mass Index (BMI) was defined as body weight in kilograms, divided by the square of body height in meters. Chronic Kidney Disease Epidemiology Collaboration creatinine 2009 equation was used to estimate the glomerular filtration rate (eGFR). Non-invasive applanation tonometry was used for arterial stiffness measurements (Sphygmocor Atcor Medical, Sydney, Australia). All patients underwent coronarography. RESULTS The mean age of our patients was 65.0 ± 9.2 years. Their mean BMI was 28.5 ± 4.4 kg/m2, eGFR 75.5 ± 17.2 ml/min/1.73 m2 and ankle-brachial index (ABI) 1.0 ± 0.1. Their arterial stiffness measurements showed mean carotid-femoral pulse wave velocity (cfPWV) 10.3 ± 2.7 m/s, subendocardial viability ratio (SEVR) 164.4 ± 35.0%, and pulse pressure (PP) 47.8 ± 14.5 mmHg. Spearman's correlation test revealed a statistically significant correlation between BMI and SEVR (r = -0.193; p = 0.026), BMI and cfPWV (r = 0.417; p < 0.001) and between BMI and PP (r = 0.227; p = 0.009). Multiple regression analysis confirmed an independent connection between BMI and cfPWV (B = 0.303; p < 0.001) and between BMI and SEVR (B = -0.186; p = 0.040). There was no association between BMI and kidney function, ABI, or coronary artery disease. CONCLUSION Increased BMI is independently associated with augmented central arterial stiffness and reduced subendocardial perfusion but not with coronary artery disease, kidney function, or ABI.
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Affiliation(s)
- Nejc Piko
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia.
| | - Sebastjan Bevc
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
- Medical Faculty, University of Maribor, Taborska Ulica 8, 2000, Maribor, Slovenia
| | - Radovan Hojs
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
- Medical Faculty, University of Maribor, Taborska Ulica 8, 2000, Maribor, Slovenia
| | - Tadej Petreski
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
- Medical Faculty, University of Maribor, Taborska Ulica 8, 2000, Maribor, Slovenia
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Welén Schef K, Tornvall P, Alfredsson J, Hagström E, Ravn-Fischer A, Soderberg S, Yndigegn T, Jernberg T. Prevalence of angina pectoris and association with coronary atherosclerosis in a general population. Heart 2023; 109:1450-1459. [PMID: 37225242 PMCID: PMC10511980 DOI: 10.1136/heartjnl-2023-322345] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To assess the contemporary prevalence of, and factors associated with angina pectoris symptoms, and to examine the relationship to coronary atherosclerosis in a middle-aged, general population. METHODS Data were based on the Swedish CArdioPulmonary bioImage Study (SCAPIS), in which 30 154 individuals were randomly recruited from the general population between 2013 and 2018. Participants that completed the Rose Angina Questionnaire were included and categorised as angina or no angina. Subjects with a valid coronary CT angiography (CCTA) were categorised by degree of coronary atherosclerosis; ≥50% obstruction (obstructive coronary atherosclerosis), <50% obstruction or any atheromatosis (non-obstructive coronary atherosclerosis) or none (no coronary atherosclerosis). RESULTS The study population consisted of 28 974 questionnaire responders (median age 57.4 years, female 51.6%, hypertension 19.9%, hyperlipidaemia 7.9%, diabetes mellitus 3.7%), of which 1025 (3.5%) fulfilled the criteria of angina. Coronary atherosclerosis was more common in individuals having angina compared with those with no angina (n=24 602, obstructive coronary atherosclerosis 11.8% vs 5.4%, non-obstructive coronary atherosclerosis 38.9% vs 37.0%, no coronary atherosclerosis 49.4% vs 57.7%, all p<0.001). Factors independently associated with angina were birthplace outside of Sweden (OR 2.58 (95% CI 2.10 to 2.92)), low educational level (OR 1.41 (1.10 to 1.79)), unemployment (OR 1.51 (1.27 to 1.81)), poor economic status (OR 1.85 (1.38 to 2.47)), symptoms of depression (OR 1.63 (1.38 to 1.92)) and high degree of stress (OR 2.92 (1.80 to 4.73)). CONCLUSION Angina pectoris symptoms are common (3.5%) among middle-aged individuals of the general population of Sweden, though with low association to obstructive coronary atherosclerosis. Sociodemographic and psychological factors are highly associated with angina symptoms, irrespective of degree of coronary atherosclerosis.
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Affiliation(s)
- Kerstin Welén Schef
- Department of Clinical Sciences, Danderyd Hospital division of Cardiology, Karolinska Institutet, Stockholm, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala Universitet, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital Institute of Medicine, Göteborg, Sweden
- Department of Molecular and Clinical Medicine Sahlgrenska, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Stefan Soderberg
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Lunds Universitet, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital division of Cardiology, Karolinska Institutet, Stockholm, Sweden
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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Ruddy TD, Tavoosi A, Taqueti VR. Role of nuclear cardiology in diagnosis and risk stratification of coronary microvascular disease. J Nucl Cardiol 2023; 30:1327-1340. [PMID: 35851643 DOI: 10.1007/s12350-022-03051-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/22/2022] [Indexed: 10/17/2022]
Abstract
Coronary flow reserve (CFR) with positron emission tomography/computed tomography (PET/CT) has an important role in the diagnosis of coronary microvascular disease (CMD), aids risk stratification and may be useful in monitoring therapy. CMD contributes to symptoms and a worse prognosis in patients with coronary artery disease (CAD), nonischemic cardiomyopathies, and heart failure. CFR measurements may improve our understanding of the role of CMD in symptoms and prognosis in CAD and other cardiovascular diseases. The clinical presentation of CAD has changed. The prevalence of nonobstructive CAD has increased to about 50% of patients with angina undergoing angiography. Ischemia with nonobstructive arteries (INOCA) is recognized as an important cause of symptoms and has an adverse prognosis. Patients with INOCA may have ischemia due to CMD, epicardial vasospasm or diffuse nonobstructive CAD. Reduced CFR in patients with INOCA identifies a high-risk group that may benefit from management strategies specific for CMD. Although measurement of CFR by PET/CT has excellent accuracy and repeatability, use is limited by cost and availability. CFR measurement with single-photon emission tomography (SPECT) is feasible, validated, and would increase availability and use of CFR. Patients with CMD can be identified by reduced CFR and selected for specific therapies.
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Affiliation(s)
- Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
| | - Anahita Tavoosi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Viviany R Taqueti
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Marano P, Wei J, Merz CNB. Coronary Microvascular Dysfunction: What Clinicians and Investigators Should Know. Curr Atheroscler Rep 2023; 25:435-446. [PMID: 37338666 PMCID: PMC10412671 DOI: 10.1007/s11883-023-01116-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Abnormal structure and function of the coronary microvasculature have been implicated in the pathophysiology of multiple cardiovascular disease processes. This article reviews recent research progress related to coronary microvascular dysfunction (CMD) and salient clinical takeaways. RECENT FINDINGS CMD is prevalent in patients with signs and symptoms of ischemia and no obstructive epicardial coronary artery disease (INOCA), particularly in women. CMD is associated with adverse outcomes, including most frequently the development of heart failure with preserved ejection fraction. It is also associated with adverse outcomes in patient populations including hypertrophic cardiomyopathy, dilated cardiomyopathy, and acute coronary syndromes. In patients with INOCA, stratified medical therapy guided by invasive coronary function testing to define the subtype of CMD leads to improved symptoms. There are invasive and non-invasive methodologies to diagnose CMD that provide prognostic information and mechanistic information to direct treatment. Available treatments improve symptoms and myocardial blood flow; ongoing investigations aim to develop therapy to improve adverse outcomes related to CMD.
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Affiliation(s)
- Paul Marano
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA.
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
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Colombo M, Chaudhry P, Oberholzer Y, deMello AJ. Integrative modeling of hemodynamic changes and perfusion impairment in coronary microvascular disease. Front Bioeng Biotechnol 2023; 11:1204178. [PMID: 37564992 PMCID: PMC10410158 DOI: 10.3389/fbioe.2023.1204178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction: Coronary microvascular disease is one of the responsible factors for cardiac perfusion impairment. Due to diagnostic and treatment challenges, this pathology (characterized by alterations to microvasculature local hemodynamics) represents a significant yet unsolved clinical problem. Methods: Due to the poor understanding of the onset and progression of this disease, we propose a new and noninvasive strategy to quantify in-vivo hemodynamic changes occurring in the microvasculature. Specifically, we here present a conceptual workflow that combines both in-vitro and in-silico modelling for the analysis of the hemodynamic alterations in the microvasculature. Results: First, we demonstrate a hybrid additive manufacturing process to fabricate circular cross-section, biocompatible fluidic networks in polytetrafluoroethylene. We then use these microfluidic devices and computational fluid dynamics to simulate different degrees of perfusion impairment. Discussion: Ultimately, we show that the developed workflow defines a robust platform for the multiscale analysis of multifactorial events occurring in coronary microvascular disease.
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Affiliation(s)
- Monika Colombo
- Department of Chemistry and Applied Biosciences, Institute for Chemical and Bioengineering, ETH Zurich, Zürich, Switzerland
- Department of Mechanical and Production Engineering, Aarhus University, Aarhus, Denmark
| | - Palak Chaudhry
- Department of Chemistry and Applied Biosciences, Institute for Chemical and Bioengineering, ETH Zurich, Zürich, Switzerland
| | - Yvonne Oberholzer
- Department of Chemistry and Applied Biosciences, Institute for Chemical and Bioengineering, ETH Zurich, Zürich, Switzerland
| | - Andrew J. deMello
- Department of Chemistry and Applied Biosciences, Institute for Chemical and Bioengineering, ETH Zurich, Zürich, Switzerland
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