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Zhao Y, Ghaedi A, Azami P, Nabipoorashrafi SA, Drissi HB, Dezfouli MA, Sarejloo S, Lucke-Wold B, Cerillo J, Khanzadeh M, Jafari N, Khanzadeh S. Inflammatory biomarkers in cardiac syndrome X: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:276. [PMID: 38807048 PMCID: PMC11134643 DOI: 10.1186/s12872-024-03939-3] [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: 01/10/2023] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION In the current systematic review and meta-analysis, we aim to analyze the existing literature to evaluate the role of inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP), tumor necrosis factor-a (TNF-a), and interleukin-6 (IL-6) among individuals with cardiac syndrome X (CSX) compared to healthy controls. METHODS We used PubMed, Web of Science, Scopus, Science Direct, and Embase to systematically search relevant publications published before April 2, 2023. We performed the meta-analysis using Stata 11.2 software (Stata Corp, College Station, TX). So, we used standardized mean difference (SMD) with a 95% confidence interval (CI) to compare the biomarker level between patients and healthy controls. The I2 and Cochran's Q tests were adopted to determine the heterogeneity of the included studies. RESULTS Overall, 29 articles with 3480 participants (1855 with CSX and 1625 healthy controls) were included in the analysis. There was a significantly higher level of NLR (SMD = 0.85, 95%CI = 0.55-1.15, I2 = 89.0 %), CRP (SMD = 0.69, 95%CI = 0.38 to 1.02, p < 0.0001), IL-6 (SMD = 5.70, 95%CI = 1.91 to 9.50, p = 0.003), TNF-a (SMD = 3.78, 95%CI = 0.63 to 6.92, p = 0.019), and PLR (SMD = 1.38, 95%CI = 0.50 to 2.28, p = 0.02) in the CSX group in comparison with healthy controls. CONCLUSION The results of this study showed that CSX leads to a significant increase in inflammatory biomarkers, including NLR, CRP, IL-6, TNF-a, and PLR.
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Affiliation(s)
- Yuexia Zhao
- Shandong Mental Health Center, Jinan, Shandong Province, China
| | - Arshin Ghaedi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pouria Azami
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Nabipoorashrafi
- Endocrinology and Metabolism Research Center (EMRC), School of Medicine, Vali-Asr Hospital, Tehran, Iran
| | | | - Maryam Amin Dezfouli
- Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | | | - John Cerillo
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa Bay Regional Campus, Gulf to Bay Blvd, Clearwater, FL, 3375, USA
| | - Monireh Khanzadeh
- Geriatric & Gerontology Department, Medical School, Tehran University of medical and health sciences, Tehran, Iran
| | - Negar Jafari
- Department of cardiovascular medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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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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Tuttolomondo D, Niccoli G, Martini C, D’Ascenzo F, De Filippo O, Nicolini F, Formica F, Carino D, Gurgoglione FL, Denegri A, Magnani G, Vignali L, De Filippo M, Sverzellati N, Ticinesi A, Bergamaschi L, Pizzi C, Gherbesi E, Suma S, Gaibazzi N. Cardiovascular Disease from Pathophysiology to Risk Estimation: Is Inflammation Estimated through Perivascular Attenuation on Computed Tomography the Key? Life (Basel) 2024; 14:457. [PMID: 38672728 PMCID: PMC11051374 DOI: 10.3390/life14040457] [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: 02/10/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
(1) Background: Systemic inflammation stands as a well-established risk factor for ischemic cardiovascular disease, as well as a contributing factor in the development of cardiac arrhythmias, notably atrial fibrillation. Furthermore, scientific studies have brought to light the pivotal role of localized vascular inflammation in the initiation, progression, and destabilization of coronary atherosclerotic disease. (2) Methods: We comprehensively review recent, yet robust, scientific evidence elucidating the use of perivascular adipose tissue attenuation measurement on computed tomography applied to key anatomical sites. Specifically, the investigation extends to the internal carotid artery, aorta, left atrium, and coronary arteries. (3) Conclusions: The examination of perivascular adipose tissue attenuation emerges as a non-invasive and indirect means of estimating localized perivascular inflammation. This measure is quantified in Hounsfield units, indicative of the inflammatory response elicited by dense adipose tissue near the vessel or the atrium. Particularly noteworthy is its potential utility in assessing inflammatory processes within the coronary arteries, evaluating coronary microvascular dysfunction, appraising conditions within the aorta and carotid arteries, and discerning inflammatory states within the atria, especially in patients with atrial fibrillation. The widespread applicability of perivascular adipose tissue attenuation measurement underscores its significance as a diagnostic tool with considerable potential for enhancing our understanding and management of cardiovascular diseases.
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Affiliation(s)
- Domenico Tuttolomondo
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Giampaolo Niccoli
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Chiara Martini
- Department of Diagnostic, Parma University Hospital, 43126 Parma, Italy
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Turin, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Formica
- Department of Cardiac Surgery, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Davide Carino
- Department of Cardiac Surgery, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | | | - Andrea Denegri
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Giulia Magnani
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Luigi Vignali
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Massimo De Filippo
- Department of Medicine and Surgery (DiMec), Section of Radiology, University of Parma, Maggiore Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Nicola Sverzellati
- Scienze Radiologiche, Dipartimento di Medicina e Chirurgia, University-Hospital of Parma, 43126 Parma, Italy
| | - Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy
| | - Luca Bergamaschi
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences—DIMEC—Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Carmine Pizzi
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences—DIMEC—Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Elisa Gherbesi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy
| | - Sergio Suma
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
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Souza ACDAH, Rosenthal MH, Moura FA, Divakaran S, Osborne MT, Hainer J, Dorbala S, Blankstein R, Di Carli MF, Taqueti VR. Body Composition, Coronary Microvascular Dysfunction, and Future Risk of Cardiovascular Events Including Heart Failure. JACC Cardiovasc Imaging 2024; 17:179-191. [PMID: 37768241 PMCID: PMC10922555 DOI: 10.1016/j.jcmg.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Body mass index (BMI) is a controversial marker of cardiovascular prognosis, especially in women. Coronary microvascular dysfunction (CMD) is prevalent in obese patients and a better discriminator of risk than BMI, but its association with body composition is unknown. OBJECTIVES The authors used a deep learning model for body composition analysis to investigate the relationship between CMD, skeletal muscle (SM), subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT), and their contribution to adverse outcomes in patients referred for evaluation of coronary artery disease. METHODS Consecutive patients (n = 400) with normal perfusion and preserved left ventricular ejection fraction on cardiac stress positron emission tomography were followed (median, 6.0 years) for major adverse events, including death and hospitalization for myocardial infarction or heart failure. Coronary flow reserve (CFR) was quantified as stress/rest myocardial blood flow from positron emission tomography. SM, SAT, and VAT cross-sectional areas were extracted from abdominal computed tomography at the third lumbar vertebra using a validated automated algorithm. RESULTS Median age was 63, 71% were female, 50% non-White, and 50% obese. Compared with the nonobese, patients with obesity (BMI: 30.0-68.4 kg/m2) had higher SAT, VAT, and SM, and lower CFR (all P < 0.001). In adjusted analyses, decreased SM but not increased SAT or VAT was significantly associated with CMD (CFR <2; OR: 1.38; 95% CI: 1.08-1.75 per -10 cm2/m2 SM index; P < 0.01). Both lower CFR and SM, but not higher SAT or VAT, were independently associated with adverse events (HR: 1.83; 95% CI: 1.25-2.68 per -1 U CFR and HR: 1.53; 95% CI: 1.20-1.96 per -10 cm2/m2 SM index, respectively; P < 0.002 for both), especially heart failure hospitalization (HR: 2.36; 95% CI: 1.31-4.24 per -1 U CFR and HR: 1.87; 95% CI: 1.30-2.69 per -10 cm2/m2 SM index; P < 0.004 for both). There was a significant interaction between CFR and SM (adjusted P = 0.026), such that patients with CMD and sarcopenia demonstrated the highest rate of adverse events, especially among young, female, and obese patients (all P < 0.005). CONCLUSIONS In a predominantly female cohort of patients without flow-limiting coronary artery disease, deficient muscularity, not excess adiposity, was independently associated with CMD and future adverse outcomes, especially heart failure. In patients with suspected ischemia and no obstructive coronary artery disease, characterization of lean body mass and coronary microvascular function may help to distinguish obese phenotypes at risk for cardiovascular events.
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Affiliation(s)
- Ana Carolina do A H Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael H Rosenthal
- Department of Imaging, Dana-Farber Cancer Institute, and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Filipe A Moura
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center and Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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5
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Taqueti VR. Prevalence of Abnormal Coronary Function in Patients With Angina and No Obstructive Coronary Artery Disease on Coronary Computed Tomography Angiography: Insights From the CorCTA Trial. Circulation 2024; 149:24-27. [PMID: 38153994 DOI: 10.1161/circulationaha.123.066571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Affiliation(s)
- Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Sugiyama T, Kanaji Y, Hoshino M, Hada M, Misawa T, Nagamine T, Teng Y, Nogami K, Ueno H, Matsuda K, Sayama K, Usui E, Murai T, Lee T, Yonetsu T, Sasano T, Kakuta T. Relationship of OCT-defined plaque characteristics with CCTA-derived coronary inflammation and CMR-derived global coronary flow reserve in patients with acute coronary syndrome. PLoS One 2023; 18:e0286196. [PMID: 37228044 DOI: 10.1371/journal.pone.0286196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The relationship of layered plaque detected by optical coherence tomography (OCT) with coronary inflammation and coronary flow reserve (CFR) remains elusive. We aimed to investigate the association of OCT-defined layered plaque with pericoronary adipose tissue (PCAT) inflammation assessed by coronary computed tomography angiography (CCTA) and global (G)-CFR assessed by cardiac magnetic resonance imaging (CMR) in patients with acute coronary syndrome (ACS). METHODS We retrospectively investigated 88 patients with first ACS who underwent preprocedural CCTA, OCT imaging of the culprit lesion prior to primary/urgent percutaneous coronary intervention (PCI), and postprocedural CMR. All patients were divided into two groups according to the presence and absence of OCT-defined layered plaque at the culprit lesion. Coronary inflammation was assessed by the mean value of PCAT attenuation (-190 to -30 HU) of the three major coronary vessels. G-CFR was obtained by quantifying absolute coronary sinus flow at rest and during maximum hyperemia. CCTA and CMR findings were compared between the groups. RESULTS In a total of 88 patients, layered plaque was detected in 51 patients (58.0%). The patients with layered plaque had higher three-vessel-PCAT attenuation value (-68.58 ± 6.41 vs. -71.60 ± 5.21 HU, P = 0.021) and culprit vessel-PCAT attenuation value (-67.69 ± 7.76 vs. -72.07 ± 6.57 HU, P = 0.007) than those with non-layered plaque. The patients with layered plaque had lower G-CFR value (median, 2.26 [interquartile range, 1.78, 2.89] vs. 3.06 [2.41, 3.90], P = 0.003) than those with non-layered plaque. CONCLUSIONS The presence of OCT-defined layered plaque at the culprit lesion was associated with high PCAT attenuation and low G-CFR after primary/urgent PCI in patients with ACS. OCT assessment of culprit plaque morphology and detection of layered plaque may help identify increased pericoronary inflammation and impaired CFR, potentially providing the risk stratification in patients with ACS and residual microvascular dysfunction after PCI.
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Affiliation(s)
- Tomoyo Sugiyama
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Toru Misawa
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yun Teng
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kazuki Matsuda
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kodai Sayama
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tetsumin Lee
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
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Souza AC, Amelie S T, Jan P M, Filipe A M, Sanjay D, Jon H, Ron B, Sharmila D, Marcelo F DC, Florian J F, Viviany R T. Intermuscular Adiposity is Associated with Coronary Microvascular Dysfunction Independently of Body Mass Index and Modifies its Effect on Adverse Cardiovascular Outcomes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.03.23289408. [PMID: 37205484 PMCID: PMC10187458 DOI: 10.1101/2023.05.03.23289408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background: Skeletal muscle (SM) fat infiltration, or intermuscular adipose tissue (IMAT), reflects muscle quality and is associated with inflammation, a key determinant in cardiometabolic disease. Coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD), is independently associated with BMI, inflammation and risk of heart failure, myocardial infarction and death. We sought to investigate the relationship between skeletal muscle quality, CMD and cardiovascular outcomes. Methods: Consecutive patients (N=669) undergoing evaluation for CAD with cardiac stress PET demonstrating normal perfusion and preserved left ventricular ejection fraction were followed over median 6 years for major adverse cardiovascular events (MACE), including death and hospitalization for myocardial infarction or heart failure. CFR was calculated as stress/rest myocardial blood flow and CMD defined as CFR<2. Subcutaneous adipose tissue (SAT), SM and IMAT areas (cm 2 ) were obtained from simultaneous PET attenuation correction CTs using semi-automated segmentation at the twelfth thoracic vertebra (T12) level. Results: Median age was 63 years, 70% were female and 46% nonwhite. Nearly half of patients were obese (46%, BMI 30-61) and BMI correlated highly with SAT and IMAT (r=0.84 and 0.71, respectively, p<0.001) and moderately with SM (r=0.52, p<0.001). Decreased SM and increased IMAT, but not BMI or SAT, remained independently associated with decreased CFR (adjusted p=0.03 and p=0.04, respectively). In adjusted analyses, both lower CFR and higher IMAT were associated with increased MACE [HR 1.78 (1.23-2.58) per -1U CFR and 1.53 (1.30-1.80) per +10 cm 2 IMAT, adjusted p=0.002 and p<0.0001, respectively], while higher SM and SAT were protective [HR 0.89 (0.81-0.97) per +10 cm 2 SM and 0.94 (0.91-0.98) per +10 cm 2 SAT, adjusted p=0.01 and 0.003, respectively]. Every 1% increase in fatty muscle fraction [IMAT/(SM+IMAT)] conferred an independent 2% increased odds of CMD [CFR<2, OR 1.02 (1.01-1.04), adjusted p=0.04] and a 7% increased risk of MACE [HR 1.07 (1.04-1.09), adjusted p<0.001]. There was a significant interaction between CFR and IMAT, not BMI, such that patients with both CMD and fatty muscle demonstrated highest MACE risk (adjusted p=0.02). Conclusion: Increased intermuscular fat is associated with CMD and adverse cardiovascular outcomes independently of BMI and conventional risk factors. The presence of CMD and skeletal muscle fat infiltration identified a novel at-risk cardiometabolic phenotype.
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Taqueti VR, Shah AM, Everett BM, Pradhan AD, Piazza G, Bibbo C, Hainer J, Morgan V, Carolina do A. H. de Souza A, Skali H, Blankstein R, Dorbala S, Goldhaber SZ, Le May MR, Chow BJ, deKemp RA, Hage FG, Beanlands RS, Libby P, Glynn RJ, Solomon SD, Ridker PM, Di Carli MF. Coronary Flow Reserve, Inflammation, and Myocardial Strain: The CIRT-CFR Trial. JACC Basic Transl Sci 2023; 8:141-151. [PMID: 36908662 PMCID: PMC9998473 DOI: 10.1016/j.jacbts.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/17/2022] [Indexed: 12/24/2022]
Abstract
Inflammation is a key determinant of cardiovascular outcomes, but its role in heart failure is uncertain. In patients with cardiometabolic disease enrolled in the prospective, multicenter ancillary study of CIRT (Cardiovascular Inflammation Reduction Trial), CIRT-CFR (Coronary Flow Reserve to Assess Cardiovascular Inflammation), impaired coronary flow reserve was independently associated with increased inflammation and myocardial strain despite well-controlled lipid, glycemic, and hemodynamic profiles. Inflammation modified the relationship between CFR and myocardial strain, disrupting the association between cardiac blood flow and function. Future studies are needed to investigate whether an early inflammation-mediated reduction in CFR capturing microvascular ischemia may lead to heart failure in patients with cardiometabolic disease. (Cardiovascular Inflammation Reduction Trial [CIRT]; NCT01594333; Coronary Flow Reserve to Assess Cardiovascular Inflammation [CIRT-CFR]; NCT02786134).
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Key Words
- BMI, body mass index
- CAD, coronary artery disease
- CFR, coronary flow reserve
- CT, computed tomography
- GLS, global longitudinal strain
- HDL, high-density lipoprotein cholesterol
- HFpEF, heart failure with preserved ejection fraction
- IL, interleukin
- LDL, low-density lipoprotein cholesterol
- LDM, low-dose methotrexate
- LVEF, left ventricular ejection fraction
- MBF, myocardial blood flow
- MI, myocardial infarction
- NHLBI, National Heart, Lung, and Blood Institute
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- PET, positron emission tomography
- cardiometabolic disease
- cardiovascular trial coronary flow reserve
- coronary microvascular dysfunction
- heart failure
- hsCRP, high-sensitivity C-reactive protein
- hsTNT, high-sensitivity troponin T
- inflammation
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Affiliation(s)
- Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amil M. Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendan M. Everett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aruna D. Pradhan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Morgan
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Carolina do A. H. de Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michel R. Le May
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Benjamin J.W. Chow
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Robert A. deKemp
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Fadi G. Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Rob S. Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Peter Libby
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J. Glynn
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D. Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Ridker
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Lee SH, Shin D, Lee JM, van de Hoef TP, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ. Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction. J Am Heart Assoc 2022; 11:e025171. [PMID: 35475358 PMCID: PMC9238617 DOI: 10.1161/jaha.121.025171] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background In the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown. Methods and Results From the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve >0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all‐cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD (P<0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HRadjusted], 2.88; 95% CI, 1.52–7.19; P=0.024; group 4: HRadjusted, 4.00; 95% CI, 1.41–11.35; P=0.009). Conclusions In stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long‐term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4‐fold difference in long‐term cardiovascular events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology Department of Internal Medicine Chonnam National University HospitalChonnam National University Medical School Gwangju Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Joo Myung Lee
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Tim P van de Hoef
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands.,Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands.,Department of Cardiology NoordWest Ziekenhuisgroep The Netherlands
| | - David Hong
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Ki Hong Choi
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Doyeon Hwang
- Department of Internal Medicine Cardiovascular CenterSeoul National University Hospital Seoul Korea
| | - Coen K M Boerhout
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands
| | - Guus A de Waard
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Ji-Hyun Jung
- Sejong General HospitalSejong Heart Institute Bucheon Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San CarlosIDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Masahiro Hoshino
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de MedicinaUniversidad Autónoma de Querétaro Querétaro México
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease University of Cincinnati Cincinnati Ohio
| | - Tadashi Murai
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Koen Marques
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Joon-Hyung Doh
- Department of Medicine Inje University Ilsan Paik Hospital Goyang Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering University of CincinnatiVeterans Affairs Medical Center Cincinnati Ohio
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University HospitalUniversity of Chosun College of Medicine Gwangju Korea
| | - Chang-Wook Nam
- Department of Medicine Keimyung University Dongsan Medical Center Daegu Korea
| | | | - Masafumi Nakayama
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan.,Toda Central General HospitalCardiovascular Center Toda Japan
| | - Nobuhiro Tanaka
- Department of Cardiology Tokyo Medical University Hachioji Medical Center Tokyo Japan
| | - Eun-Seok Shin
- Department of Cardiology Ulsan University HospitalUniversity of Ulsan College of Medicine Ulsan Korea
| | - Steven A J Chamuleau
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands.,Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Bon Kwon Koo
- Department of Internal Medicine Cardiovascular CenterSeoul National University Hospital Seoul Korea
| | - Tsunekazu Kakuta
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Javier Escaned
- Hospital Clínico San CarlosIDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Jan J Piek
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands
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10
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Fopiano KA, Jalnapurkar S, Davila AC, Arora V, Bagi Z. Coronary Microvascular Dysfunction and Heart Failure with Preserved Ejection Fraction - implications for Chronic Inflammatory Mechanisms. Curr Cardiol Rev 2022; 18:e310821195986. [PMID: 34488616 PMCID: PMC9413735 DOI: 10.2174/1573403x17666210831144651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Coronary Microvascular Dysfunction (CMD) is now considered one of the key underlying pathologies responsible for the development of both acute and chronic cardiac complications. It has been long recognized that CMD contributes to coronary no-reflow, which occurs as an acute complication during percutaneous coronary interventions. More recently, CMD was proposed to play a mechanistic role in the development of left ventricle diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF). Emerging evidence indicates that a chronic low-grade pro-inflammatory activation predisposes patients to both acute and chronic cardiovascular complications raising the possibility that pro-inflammatory mediators serve as a mechanistic link in HFpEF. Few recent studies have evaluated the role of the hyaluronan-CD44 axis in inflammation-related cardiovascular pathologies, thus warranting further investigations. This review article summarizes current evidence for the role of CMD in the development of HFpEF, focusing on molecular mediators of chronic proinflammatory as well as oxidative stress mechanisms and possible therapeutic approaches to consider for treatment and prevention.
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Affiliation(s)
- Katie Anne Fopiano
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Sawan Jalnapurkar
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Alec C Davila
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Vishal Arora
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Zsolt Bagi
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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11
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Groarke JD, Divakaran S, Nohria A, Killoran JH, Dorbala S, Dunne RM, Hainer J, Taqueti VR, Blankstein R, Mamon HJ, Di Carli MF. Coronary vasomotor dysfunction in cancer survivors treated with thoracic irradiation. J Nucl Cardiol 2021; 28:2976-2987. [PMID: 32691348 PMCID: PMC7855471 DOI: 10.1007/s12350-020-02255-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND We sought to test the hypothesis that thoracic radiation therapy (RT) is associated with impaired myocardial flow reserve (MFR), a measure of coronary vasomotor dysfunction. METHODS We retrospectively studied thirty-five consecutive patients (71% female, mean ± standard deviation (SD) age: 66 ± 11 years) referred clinically for positron emission tomography/computed tomography (PET/CT) myocardial perfusion imaging at a median (interquartile range, IQR) interval of 4.3 (2.1, 9.7) years following RT for a variety of malignancies. Radiation dose-volume histograms were generated for the heart and coronary arteries for each patient. RESULTS The median (IQR) of mean cardiac radiation doses was 12.0 (1.2, 24.2) Gray. There were significant inverse correlations between mean radiation dose and global MFR (MFRGlobal) and MFR in the left anterior descending artery territory (MFRLAD): Pearson's correlation coefficient = - .37 (P = .03) and - .38 (P = .03), respectively. For every one Gray increase in mean cardiac radiation dose, there was a mean ± standard error decrease of .02 ± .01 in MFRGlobal (P = .04) and MFRLAD (P = .03) after adjustment. CONCLUSIONS In patients with a history of RT clinically referred for cardiac stress PET, we found an inverse correlation between mean cardiac radiation dose and coronary vasomotor function.
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Affiliation(s)
- John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Killoran
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ruth M Dunne
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Wenzl FA, Ambrosini S, Mohammed SA, Kraler S, Lüscher TF, Costantino S, Paneni F. Inflammation in Metabolic Cardiomyopathy. Front Cardiovasc Med 2021; 8:742178. [PMID: 34671656 PMCID: PMC8520939 DOI: 10.3389/fcvm.2021.742178] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/31/2021] [Indexed: 12/24/2022] Open
Abstract
Overlapping pandemics of lifestyle-related diseases pose a substantial threat to cardiovascular health. Apart from coronary artery disease, metabolic disturbances linked to obesity, insulin resistance and diabetes directly compromise myocardial structure and function through independent and shared mechanisms heavily involving inflammatory signals. Accumulating evidence indicates that metabolic dysregulation causes systemic inflammation, which in turn aggravates cardiovascular disease. Indeed, elevated systemic levels of pro-inflammatory cytokines and metabolic substrates induce an inflammatory state in different cardiac cells and lead to subcellular alterations thereby promoting maladaptive myocardial remodeling. At the cellular level, inflammation-induced oxidative stress, mitochondrial dysfunction, impaired calcium handling, and lipotoxicity contribute to cardiomyocyte hypertrophy and dysfunction, extracellular matrix accumulation and microvascular disease. In cardiometabolic patients, myocardial inflammation is maintained by innate immune cell activation mediated by pattern recognition receptors such as Toll-like receptor 4 (TLR4) and downstream activation of the NLRP3 inflammasome and NF-κB-dependent pathways. Chronic low-grade inflammation progressively alters metabolic processes in the heart, leading to a metabolic cardiomyopathy (MC) phenotype and eventually to heart failure with preserved ejection fraction (HFpEF). In accordance with preclinical data, observational studies consistently showed increased inflammatory markers and cardiometabolic features in patients with HFpEF. Future treatment approaches of MC may target inflammatory mediators as they are closely intertwined with cardiac nutrient metabolism. Here, we review current evidence on inflammatory processes involved in the development of MC and provide an overview of nutrient and cytokine-driven pro-inflammatory effects stratified by cell type.
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Affiliation(s)
- Florian A Wenzl
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Samuele Ambrosini
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Shafeeq A Mohammed
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Royal Brompton and Harefield Hospitals and Imperial College, London, United Kingdom
| | - Sarah Costantino
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Francesco Paneni
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,University Heart Center, Cardiology, University Hospital Zurich, Zurich, Switzerland.,Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
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13
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Physiological significance of pericoronary inflammation in epicardial functional stenosis and global coronary flow reserve. Sci Rep 2021; 11:19026. [PMID: 34561466 PMCID: PMC8463533 DOI: 10.1038/s41598-021-97849-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/26/2021] [Indexed: 12/15/2022] Open
Abstract
Both fractional flow reserve (FFR) and global coronary flow reserve (g-CFR) provide prognostic information in patients with stable coronary artery disease (CAD). Inflammation plays a vital role in impaired endothelial dysfunction and atherosclerotic progression, potentially predicting cardiovascular mortality. This study aimed to evaluate the physiological significance of pericoronary adipose tissue inflammation assessed by CT attenuation (PCATA) in epicardial functional stenosis severity and g-CFR in patients with CAD. A total of 131 CAD patients with a single de novo epicardial coronary stenosis who underwent coronary CT-angiography (CCTA), phase-contrast cine-magnetic resonance imaging (PC-CMR) and FFR measurement were studied. PCATA was assessed using the mean CT attenuation value. G-CFR was obtained by quantifying absolute coronary sinus flow (ml/min/g) by PC-CMR at rest and during maximum hyperemia. Median FFR, g-CFR, and PCATA values were 0.75, 2.59, and − 71.3, respectively. Serum creatinine, NT-proBNP, left ventricular end-diastolic volume, and PCATA were independently associated with g-CFR. PCATA showed a significant incremental predictive efficacy for impaired g-CFR (< 2.0) when added to the clinical risk model. PCATA was significantly associated with g-CFR, independent of FFR. Our results suggest the pathophysiological mechanisms linking perivascular inflammation with g-CFR in CAD patients.
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14
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Human coronary inflammation by computed tomography: Relationship with coronary microvascular dysfunction. Int J Cardiol 2021; 336:8-13. [PMID: 34052238 DOI: 10.1016/j.ijcard.2021.05.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
Background A new imaging metric using coronary computed tomography angiography (CCTA), addressing the peri-coronary adipose tissue (PCAT) computed tomography (CT) attenuation, has been clinically validated. This method provides information regarding coronary inflammation. It is unclear how coronary inflammation affects microvascular function. The non-invasive evaluation of coronary flow velocity reserve is widely used in clinical practice using Doppler measurement on the left anterior descending coronary artery (CFVR-lad) during stress-echocardiography (SE). We hypothesize that coronary inflammation affects CFVR-lad and, in the absence of overt CAD, they are significantly correlated. Methods We evaluated the relationship between coronary inflammation (by PCAT CT attenuation) and coronary microvascular function (by CFVR-lad) in subjects with no or non-obstructive (diameter stenosis <70%) coronary artery disease (CAD). Results Two-hundred and two subjects were enrolled in the study. The relationship between PCAT CT attenuation and CFVR-lad show a significant inverse relationship in the entire group of subjects enrolled in the study (r = -0.32, p < 0.001). Correlation between PCAT CT attenuation and CFVR-lad was significant in subjects with no or mild CAD-lad, while this was not the case in subjects with intermediate CAD-lad. The R and R2 were respectively -0.40, -0.16 in subjects without CAD (p < 0.001) and - 0.35 and - 0.12 in subjects with mild CAD-lad (p = 0.001). Conclusions The main finding of the current study is the independent relationship between coronary microvascular function, by Doppler CFVR-lad during SE, in subjects without severely obstructive CAD in the left anterior descending coronary artery, and the level of local coronary inflammation, by PCAT attenuation measurement on CCTA.
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15
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Ries W, Torzewski J, Heigl F, Pfluecke C, Kelle S, Darius H, Ince H, Mitzner S, Nordbeck P, Butter C, Skarabis H, Sheriff A, Garlichs CD. C-Reactive Protein Apheresis as Anti-inflammatory Therapy in Acute Myocardial Infarction: Results of the CAMI-1 Study. Front Cardiovasc Med 2021; 8:591714. [PMID: 33778017 PMCID: PMC7988098 DOI: 10.3389/fcvm.2021.591714] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/18/2021] [Indexed: 12/26/2022] Open
Abstract
Background: C-reactive protein (CRP) is a well-known marker of inflammation. It is less known that CRP mediates tissue damage in acute myocardial infarction (AMI) thus potentially worsening prognosis. A newly developed specific CRP adsorber allows efficient lowering of CRP levels and may improve survival. Objectives: Aim of this multi-center, controlled, non-randomized first-in-man CRP apheresis in Acute Myocardial Infarction study (CAMI-1) was to investigate the relationship between CRP levels (CRP gradient), myocardial infarct size and function as well as safety and efficacy of CRP apheresis in the setting of acute ST-segment Elevation Myocardial Infarction (STEMI) in humans. Methods: Eighty-three patients (45 apheresis, 38 controls) were recruited. CRP apheresis was performed 24 ± 12, 48 ± 12, and optionally 72 ± 12 h after onset of symptoms. First aphereses were performed at a median CRP concentration of 23.0 mg/L (range 9–279). In each apheresis session, 5,900 ± 400 mL plasma was processed via peripheral venous access. Primary study endpoint was a reduction in myocardial infarct size after STEMI as determined by cardiovascular magnetic resonance (CMR). Results: In controls, the CRP concentration significantly correlated with infarct size (p = 0.002) and decreased myocardial function (p ≤ 0.001). The CRP concentration in apheresis patients did not correlate with infarct size (p = 0.66) or left ventricular (LV) function (p = 0.79) and global strains and therefore significantly differed from controls (p = 0.03 and p = 0.002). Three major adverse cardiac events occurred in the control group after 12 months, none occurred in the apheresis group. Mean CRP depletion achieved over all apheresis procedures was 53.0 ± 15.1%. Apheresis sessions were well-tolerated. Reduced infarct size in the apheresis group compared to the control group (primary endpoint) was not achieved according to the original statistical analysis plan. Taking into account the individual CRP levels, however, revealed significant results. Modifications of the analysis plan were introduced in order to recruit a sufficient number of patients. Conclusions: This pilot study in humans reveals a correlation between CRP concentration and myocardial infarct size. CRP concentrations in STEMI can effectively be reduced by CRP apheresis without relevant side effects. CRP apheresis has the potential to interfere with deleterious aspects of STEMI. By lowering CRP levels, it resulted in the loss of correlation of CRP concentrations with myocardial infarct sizes as well as LV function. These results encourage a larger, randomized clinical trial. Clinical Trial Registration:https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008988, DRKS00008988.
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Affiliation(s)
- Wolfgang Ries
- Medical Clinic, Diakonissenhospital Flensburg, Flensburg, Germany
| | - Jan Torzewski
- Cardiovascular Center Oberallgäu-Kempten, Kempten, Germany
| | - Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | - Christian Pfluecke
- Department for Internal Medicine/Cardiology, Heart Center Dresden, Dresden, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Charité University Medicine Berlin, Campus Virchow, Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Harald Darius
- Clinic for Cardiology, Angiology, Nephrology, Intensive Care Medicine, Vivantes Clinic Neukölln, Berlin, Germany
| | - Hueseyin Ince
- Divisions of Cardiology and Nephrology, Department of Internal Medicine, University Medicine Rostock, Rostock, Germany
| | - Steffen Mitzner
- Divisions of Cardiology and Nephrology, Department of Internal Medicine, University Medicine Rostock, Rostock, Germany
| | - Peter Nordbeck
- Medical Clinic (Cardiology), University Clinic Würzburg, Würzburg, Germany
| | - Christian Butter
- Immanuel Clinic Bernau, Heart Center Brandenburg, Bernau, Germany
| | | | - Ahmed Sheriff
- Department of Gastroenterology/Infectiology/Rheumatology, Charité University Medicine Berlin, Berlin, Germany
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16
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Hoshino M, Kanaji Y, Hamaya R, Kanno Y, Hada M, Yamaguchi M, Sumino Y, Usui E, Murai T, Lee T, Yonetsu T, Kakuta T. Prognostic significance of thermodilution-derived coronary flow capacity in patients with deferred revascularisation. EUROINTERVENTION 2021; 16:1195-1203. [PMID: 31186227 PMCID: PMC9724992 DOI: 10.4244/eij-d-19-00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to investigate the prognostic value of thermodilution-derived coronary flow capacity (T-CFC) in patients with stable coronary artery disease and deferred revascularisation. METHODS AND RESULTS We evaluated 308 lesions in 308 patients with deferred revascularisation, stratifying the cohort according to T-CFC. Ischaemic T-CFC was defined as a composite of mildly, moderately, and severely reduced T-CFC. Clinical outcomes were assessed by vessel-oriented composite endpoints (VOCE) and major adverse cardiac events (MACE). VOCE and MACE occurred in 19 and 28 patients, respectively. Ischaemic T-CFC was found in 88 lesions (28.6%). Kaplan-Meier analysis revealed that lesions with ischaemic T-CFC had a significantly higher risk of both VOCE and MACE. The net reclassification index and integrated discrimination improvement index were both significantly improved when ischaemic T-CFC was added to the clinical risk model (age, sex, prior stent implantation, and lesion length) for predicting VOCE and MACE. Furthermore, ischaemic T-CFC showed significant incremental predictive ability for VOCE and MACE when compared with the clinical risk model + fractional flow reserve ≤0.8, or with the clinical model + coronary flow reserve ≤2.0. CONCLUSIONS T-CFC categorisation improved the risk stratification for both VOCE and MACE and showed incremental prognostic value in patients with deferred revascularisation.
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Affiliation(s)
- Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Rikuta Hamaya
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshinori Kanno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masao Yamaguchi
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yohei Sumino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, 4-4-1 Otsuno, Tsuchiura City, Ibaraki 300-0028, Japan
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Coronary Microvascular Dysfunction and the Role of Noninvasive Cardiovascular Imaging. Diagnostics (Basel) 2020; 10:diagnostics10090679. [PMID: 32916881 PMCID: PMC7555249 DOI: 10.3390/diagnostics10090679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with coronary microvascular dysfunction (CMD) have significantly higher rates of cardiovascular events, including hospitalization for heart failure, sudden cardiac death, and myocardial infarction (MI). In CMD, several pathophysiological changes lead to functional and structural abnormalities in the coronary microvasculature, which disrupt the ability of the vessels to vasodilate and augment myocardial blood flow in response to increased myocardial oxygen demand, causing ischemia and angina. With the advent of more advanced non-invasive cardiac imaging techniques, the coronary microvasculature has been subjected to more intense study in the past two decades-this has led to further insights into the diagnosis, pathophysiology, treatment, prognosis and follow-up of CMD. This review will highlight and compare the salient features of the currently available non-invasive imaging modalities used in these patients, and discuss the clinical utility of these techniques in the workup and management of these patients.
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Kanaji Y, Hirano H, Sugiyama T, Hoshino M, Horie T, Misawa T, Nogami K, Ueno H, Hada M, Yamaguchi M, Sumino Y, Hamaya R, Usui E, Yonetsu T, Sasano T, Kakuta T. Pre-percutaneous Coronary Intervention Pericoronary Adipose Tissue Attenuation Evaluated by Computed Tomography Predicts Global Coronary Flow Reserve After Urgent Revascularization in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome. J Am Heart Assoc 2020; 9:e016504. [PMID: 32856503 PMCID: PMC7660767 DOI: 10.1161/jaha.120.016504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Impaired global coronary flow reserve (g‐CFR) is related to worse outcomes. Inflammation has been postulated to play a role in atherosclerosis. This study aimed to evaluate the relationship between pre‐procedural pericoronary adipose tissue inflammation and g‐CFR after the urgent percutaneous coronary intervention in patients with first non–ST‐segment–elevation acute coronary syndrome. Methods and Results Phase‐contrast cine‐magnetic resonance imaging was performed to obtain g‐CFR by quantifying coronary sinus flow at 1 month after percutaneous coronary intervention in a total of 116 first non–ST‐segment–elevation acute coronary syndrome patients who underwent pre‐percutaneous coronary intervention computed tomography angiography. On proximal 40‐mm segments of 3 major coronary vessels on computed tomography angiography, pericoronary adipose tissue attenuation was assessed by the crude analysis of mean computed tomography attenuation value. The patients were divided into 2 groups with and without impaired g‐CFR divided by the g‐CFR value of 1.8. There were significant differences in age, culprit lesion location, N‐terminal pro‐B‐type natriuretic peptide levels, high‐sensitivity C‐reactive protein (hs‐CRP) levels, mean pericoronary adipose tissue attenuation between patients with impaired g‐CFR and those without (g‐CFR, 1.47 [1.16, 1.68] versus 2.66 [2.22, 3.28]; P<0.001). Multivariable logistic regression analysis revealed that age (odds ratio [OR], 1.060; 95% CI, 1.012–1.111, P=0.015) and mean pericoronary adipose tissue attenuation (OR, 1.108; 95% CI, 1.026–1.197, P=0.009) were independent predictors of impaired g‐CFR (g‐CFR <1.8). Conclusions Mean pericoronary adipose tissue attenuation, a marker of perivascular inflammation, obtained by computed tomography angiography performed before urgent percutaneous coronary intervention, but not hs‐CRP, a marker of systemic inflammation was significantly associated with g‐CFR at 1‐month after revascularization. Our results may suggest the pathophysiological mechanisms linking perivascular inflammation and g‐CFR in patients with non–ST‐segment–elevation acute coronary syndrome.
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Affiliation(s)
- Yoshihisa Kanaji
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Hidenori Hirano
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Tomoyo Sugiyama
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Tomoki Horie
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Toru Misawa
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Masao Yamaguchi
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Yohei Sumino
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Rikuta Hamaya
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine Tokyo Medical and Dental University Tokyo Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine Tokyo Medical and Dental University Tokyo Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
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19
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Chung JH, Lee KE, Lee JM, Her AY, Kim CH, Choi KH, Song YB, Hahn JY, Kim HY, Choi JH, Garg S, Doh JH, Nam CW, Koo BK, Shin ES. Effect of Sex Difference of Coronary Microvascular Dysfunction on Long-Term Outcomes in Deferred Lesions. JACC Cardiovasc Interv 2020; 13:1669-1679. [PMID: 32593698 DOI: 10.1016/j.jcin.2020.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study investigated the sex difference of long-term cardiovascular outcomes on coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) in patients with deferred coronary artery lesions. BACKGROUND Coronary microvascular dysfunction is associated with poorer long-term outcomes. It can be assessed by CFR and the IMR. METHODS The study prospectively enrolled 434 patients (133 women and 301 men) and analyzed CFR, IMR, fractional flow reserve, and quantitative coronary angiography. Clinical outcomes were assessed by major adverse cardiovascular event(s) (MACE) of cardiac death, myocardial infarction, and revascularization during 5 years of follow-up. The study protocol was approved by the Institutional Review Board or Ethics Committee at each participating center, and all patients provided written informed consent. The study protocol was in accordance with the Declaration of Helsinki. RESULTS Women had milder epicardial disease compared with men (fractional flow reserve: 0.91 [interquartile range (IQR): 0.87 to 0.96] vs. 0.90 [IQR: 0.86 to 0.95]; p = 0.037). IMR was similar between the sexes, but CFR was lower in women (2.69 [IQR: 2.08 to 3.90] vs. 3.20 [IQR: 2.20 to 4.31]; p = 0.006) due to a shorter resting mean transit time, whereas hyperemic mean transit times were similar. At 5-year follow-up, MACE was significantly lower in women compared with men (1.1% vs. 5.5%; p = 0.017). Sex, diabetes mellitus, and CFR were independent predictors for MACE for all patients. The risk of MACE was significantly higher in men with low versus high CFR (hazard ratio: 4.58; 95% confidence interval: 1.85 to 11.30; p = 0.011) which was not seen in women. CONCLUSIONS There was no sex difference in microvascular function by IMR. CFR was lower in women due to a higher resting coronary flow; however, long-term clinical outcomes in deferred lesions were better in women compared with men. (Clinical, Physiological and Prognostic Implication of Microvascular Status; NCT02186093).
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Affiliation(s)
- Ju-Hyun Chung
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, Republic of Korea
| | - Kyung Eun Lee
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, Republic of Korea; Department of Mechanical Engineering, Inha University, Incheon, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Chee Hae Kim
- Division of Cardiology, Department of Internal Medicine, VHS Medical Center, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Heart Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Joon-Hyung Doh
- Division of Cardiology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Chang-Wook Nam
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, Republic of Korea.
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20
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Lee JM, Choi KH, Doh JH, Nam CW, Shin ES, Hoshino M, Murai T, Yonetsu T, Mejía-Rentería H, Kakuta T, Escaned J, Koo BK. Long-term Patient Prognostication by Coronary Flow Reserve and Index of Microcirculatory Resistance: International Registry of Comprehensive Physiologic Assessment. Korean Circ J 2020; 50:890-903. [PMID: 32725991 PMCID: PMC7515763 DOI: 10.4070/kcj.2020.0083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent guideline recommends evaluation using of coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) in patients with functionally insignificant stenosis. We evaluated clinical implications of CFR and IMR in patients with high fractional flow reserve (FFR) and deferred revascularization. METHODS A total of 867 patients (1,152 vessels) consigned to deferred revascularization who underwent comprehensive physiologic assessments were enrolled. Patients with high FFR (>0.80) were categorized by CFR (≤2) and IMR (≥23 U). Clinical outcome was assessed by patient-oriented composite outcome (POCO), a composite of any death, myocardial infarction (MI), and revascularization at 5 years. RESULTS Patients with low CFR (≤2) showed significantly greater risk of POCO than those with high CFR (>2) in both high-FFR (p=0.024) and low-FFR (p=0.034) groups. In patients with high FFR, those with low CFR and high IMR (overt microvascular disease) displayed the greatest risk of POCO overall (p=0.015), surpassing those with high CFR and low IMR (HR, 2.873; 95% CI, 1.476-5.594; p=0.002) and showing significantly greater risk of cardiac death or MI (HR, 5.662; 95% CI, 1.984-16.154; p=0.001). Overt microvascular disease was independently associated with POCO in the high-FFR population (HR, 2.282; 95% CI, 1.176-4.429; p=0.015). CONCLUSION Among patients with deferred revascularization, those with low CFR showed significantly greater risk of POCO than those with high CFR, regardless of FFR. In patients with high FFR, those with overt microvascular disease showed significantly greater risk of POCO and cardiac death or MI at 5-year, compared with the others. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03690713.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan 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
| | - Joon Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea and Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.,Centro Nacional de Investigaciónes Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Bon Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.,Institute on Aging, Seoul National University, Seoul, Korea.
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21
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Bangash MN, Abbott TEF, Patel NSA, Hinds CJ, Thiemermann C, Pearse RM. The Effect of β 2-Adrenoceptor Agonists on Leucocyte-Endothelial Adhesion in a Rodent Model of Laparotomy and Endotoxemia. Front Immunol 2020; 11:1001. [PMID: 32670267 PMCID: PMC7326121 DOI: 10.3389/fimmu.2020.01001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/27/2020] [Indexed: 11/21/2022] Open
Abstract
Background: The β2-adrenoceptor agonist dopexamine may possess anti-inflammatory actions which could reduce organ injury during endotoxemia and laparotomy. Related effects on leucocyte-endothelial adhesion remain unclear. Methods: Thirty anesthetized Wistar rats underwent laparotomy followed by induction of endotoxemia with lipopolysaccharide and peptidoglycan (n = 24) or sham (n = 6). Animals received dopexamine at 0.5 or 1 μg kg−1 min−1 (D0.5 and D1), salbutamol at 0.1 μg kg−1 min−1, or saline vehicle (Sham and Control) for 5 h. Intravital microscopy was performed in the ileum of the small intestine to assess leucocyteendothelial adhesion, arteriolar diameter, and functional capillary density. Global hemodynamics and biochemical indices of renal and hepatic function were also measured. Results: Endotoxemia was associated with an increase in adherent leucocytes in post-capillary venules, intestinal arteriolar vasoconstriction as well-reduced arterial pressure and relative cardiac index, but functional capillary density in the muscularis was not significantly altered. Dopexamine and salbutamol administration were associated with reduced leucocyte-endothelial adhesion in post-capillary venules compared to control animals. Arteriolar diameter, arterial pressure and relative cardiac index all remained similar between treated animals and controls. Functional capillary density was similar for all groups. Control group creatinine was significantly increased compared to sham and higher dose dopexamine. Conclusions: In a rodent model of laparotomy and endotoxemia, β2-agonists were associated with reduced leucocyte-endothelial adhesion in post-capillary venules. This effect may explain some of the anti-inflammatory actions of these agents.
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Affiliation(s)
- Mansoor Nawaz Bangash
- Department of Critical Care & Anaesthesia, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
| | - Tom E F Abbott
- Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Nimesh S A Patel
- Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Charles Johnston Hinds
- Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christoph Thiemermann
- Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rupert Mark Pearse
- Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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22
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Coronary Flow Velocity Reserve Reduction Is Associated with Cardiovascular, Cancer, and Noncancer, Noncardiovascular Mortality. J Am Soc Echocardiogr 2020; 33:594-603. [DOI: 10.1016/j.echo.2020.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/18/2022]
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23
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Nomura CH, Assuncao-Jr AN, Guimarães PO, Liberato G, Morais TC, Fahel MG, Giorgi MCP, Meneghetti JC, Parga JR, Dantas-Jr RN, Cerri GG. Association between perivascular inflammation and downstream myocardial perfusion in patients with suspected coronary artery disease. Eur Heart J Cardiovasc Imaging 2020; 21:599-605. [DOI: 10.1093/ehjci/jeaa023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/14/2019] [Accepted: 01/27/2020] [Indexed: 01/02/2023] Open
Abstract
Abstract
Aims
To investigate the association between pericoronary adipose tissue (PCAT) computed tomography (CT) attenuation derived from coronary computed tomography angiography (CTA) and coronary flow reserve (CFR) by positron emission tomography (PET) in patients with suspected coronary artery disease (CAD).
Methods and results
PCAT CT attenuation was measured in proximal segments of all major epicardial coronary vessels of 105 patients with suspected CAD. We evaluated the relationship between PCAT CT attenuation and other quantitative/qualitative CT-derived anatomic parameters with CFR by PET. Overall, the mean age was 60 ± 12 years and 93% had intermediate pre-test probability of obstructive CAD. Obstructive CAD (≥50% stenosis) was detected in 37 (35.2%) patients and impaired CFR (<2.0) in 32 (30.5%) patients. On a per-vessel analysis (315 vessels), obstructive CAD, non-calcified plaque volume, and PCAT CT attenuation were independently associated with CFR. In patients with coronary calcium score (CCS) <100, those with high-PCAT CT attenuation presented significantly lower CFR values than those with low-PCAT CT attenuation (2.47 ± 0.95 vs. 3.13 ± 0.89, P = 0.003). Among those without obstructive CAD, CFR was significantly lower in patients with high-PCAT CT attenuation (2.51 ± 0.95 vs. 3.02 ± 0.84, P = 0.021).
Conclusion
Coronary perivascular inflammation by CTA was independently associated with downstream myocardial perfusion by PET. In patients with low CCS or without obstructive CAD, CFR was lower in the presence of higher perivascular inflammation. PCAT CT attenuation might help identifying myocardial ischaemia particularly among patients who are traditionally considered non-high risk for future cardiovascular events.
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Affiliation(s)
- Cesar H Nomura
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
- Department of Radiology, Institute of Radiology, InRad, University of Sao Paulo Medical School, R. Dr. Ovidio Pires de Campos 75, Cerqueira Cesar, Sao Paulo - SP, 05403-010, Brazil
| | - Antonildes N Assuncao-Jr
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Patricia O Guimarães
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Gabriela Liberato
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Thamara C Morais
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Mateus G Fahel
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Maria C P Giorgi
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - José C Meneghetti
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Jose R Parga
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Roberto N Dantas-Jr
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
| | - Giovanni G Cerri
- Heart Institute, InCor, Cardiovascular Imaging Department, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Andar AB, Cerqueira Cesar, Sao Paulo – SP, 05403-000, Brazil
- Department of Radiology, Institute of Radiology, InRad, University of Sao Paulo Medical School, R. Dr. Ovidio Pires de Campos 75, Cerqueira Cesar, Sao Paulo - SP, 05403-010, Brazil
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24
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Thackeray JT, Taqueti VR. Imaging inflammation in cardiovascular disease: translational perspective and overview. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2020; 64:1-3. [PMID: 32043341 DOI: 10.23736/s1824-4785.20.03247-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- James T Thackeray
- Unit of Translational Cardiovascular Molecular Imaging, Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Division of Nuclear Medicine, Department of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA -
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25
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Mayala HA, Yan W, Jing H, Shuang-Ye L, Gui-Wen Y, Chun-Xia Q, Ya W, Xiao-Li L, Zhao-Hui W. Clinical characteristics and biomarkers of coronary microvascular dysfunction and obstructive coronary artery disease. J Int Med Res 2019; 47:6149-6159. [PMID: 31397218 PMCID: PMC7045648 DOI: 10.1177/0300060519859134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective The purpose of this study was to determine the clinical characteristics and biomarkers in patients with coronary microvascular dysfunction (CMVD) and to compare them with patients with obstructive coronary artery disease (OCAD). Methods We conducted a single-center, hospital-based, observational, descriptive, comparative, clinical study of 40 patients, including 20 patients with CMVD and 20 with OCAD. We assessed laboratory biomarkers (low-density lipoprotein [LDL], high-density lipoprotein [HDL], red blood cell distribution width [RDW], brain natriuretic protein [BNP], troponin I), and PET/CT coronary flow reserve was performed. Results The mean coronary flow reserve (CFR) in patients with CMVD was 1.96±0.55. Mean low-density lipoprotein cholesterol (LDL-C) levels were significantly higher in the CMVD subgroup (2.53±0.63 mmol/L) compared with the OCAD subgroup (1.76±0.97 mmol/L). Logistic regression analysis identified LDL-C as a predictor for the development of CMVD (odds ratio, 5.24). Conclusion It is difficult to differentiate between OCAD and CMVD based on the patient’s medical history, clinical characteristics, and coronary angiography results. Further investigations may be needed to allow an accurate diagnosis. CFR measurements based on non-invasive positron emission tomography/computed tomography may aid the diagnosis of CMVD. We also identified LDL-C as a predictor for the development of CMVD.
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Affiliation(s)
- Henry Anselmo Mayala
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Yan
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hu Jing
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liu Shuang-Ye
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Gui-Wen
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qin Chun-Xia
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Ya
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Xiao-Li
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Zhao-Hui
- Department of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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26
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Bajaj NS, Osborne MT, Gupta A, Tavakkoli A, Bravo PE, Vita T, Bibbo CF, Hainer J, Dorbala S, Blankstein R, Bhatt DL, Di Carli MF, Taqueti VR. Coronary Microvascular Dysfunction and Cardiovascular Risk in Obese Patients. J Am Coll Cardiol 2019; 72:707-717. [PMID: 30092946 DOI: 10.1016/j.jacc.2018.05.049] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Besides body mass index (BMI), other discriminators of cardiovascular risk are needed in obese patients, who may or may not undergo consideration for bariatric surgery. Coronary microvascular dysfunction (CMD), defined as impaired coronary flow reserve (CFR) in the absence of flow-limiting coronary artery disease, identifies patients at risk for adverse events independently of traditional risk factors. OBJECTIVES The study sought to investigate the relationship among obesity, CMD, and adverse outcomes. METHODS Consecutive patients undergoing evaluation for coronary artery disease with cardiac stress positron emission tomography demonstrating normal perfusion (N = 827) were followed for median 5.6 years for events, including death and hospitalization for myocardial infarction or heart failure. RESULTS An inverted independent J-shaped relationship was observed between BMI and CFR, such that in obese patients CFR decreased linearly with increasing BMI (adjusted p < 0.0001). In adjusted analyses, CFR but not BMI remained independently associated with events (for a 1-U decrease in CFR, adjusted hazard ratio: 1.95; 95% confidence interval: 1.41 to 2.69; p < 0.001; for a 10-U increase in BMI, adjusted hazard ratio: 1.20; 95% confidence interval: 0.95 to 1.50; p = 0.125) and improved model discrimination (C-index 0.71 to 0.74). In obese patients, individuals with impaired CFR demonstrated a higher adjusted rate of events (5.7% vs. 2.6%; p = 0.002), even in those not currently meeting indications for bariatric surgery (6.4% vs. 2.6%; p = 0.04). CONCLUSIONS In patients referred for testing, CMD was independently associated with elevated BMI and adverse outcomes, and was a better discriminator of risk than BMI and traditional risk factors. CFR may facilitate management of obese patients beyond currently used markers of risk.
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Affiliation(s)
- Navkaranbir S Bajaj
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael T Osborne
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiac MR/PET/CT Program, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ali Tavakkoli
- Center for Weight Management and Metabolic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paco E Bravo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tomas Vita
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBHATTMD
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts.
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Khachirova EA, Samoylenko LE, Shevchenko OP. Assessment of diastolic function in patients with chest pain and angiographically normal coronary arteries using ECG-gated spect. BULLETIN OF RUSSIAN STATE MEDICAL UNIVERSITY 2019. [DOI: 10.24075/brsmu.2019.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diagnosis and treatment of patients with angiographically normal or near normal coronary arteries remains a clinically relevant problem. The aim of this study was to assess diastolic function in patients with chest pain and normal/near normal coronary arteries (NECA) using ECG-gated SPECT/CT. The study recruited 49 patients presenting with chest pain, a positive cardiac stress test and normal coronary arteries, as demonstrated by coronary angiography. All patients were ordered a myocardial SPECT/CT scan, which was performed according to a two-day protocol. After the scan, the patients were divided into 3 groups. Group 1 consisted of 17 patients with microvascular angina. Group 2 was composed of 22 patients with borderline-high blood pressure or stage I hypertensive heart disease associated with secondary microvascular dysfunction. Ten seemingly healthy individuals constituted the control group. According to coronary angiography, the controls had no cardiovascular pathologies accompanied by coronary artery disorders or impaired myocardial perfusion (SPECT). The majority of patients from groups 1 and 2 were found to have impaired diastolic function. The impairments were more pronounced in group 2 tended to exacerbate with stress. The most sensitive parameter of diastolic function, MFR/3, was outside the reference range in almost all patients in groups 1 and 2. MFR/3 characterizes the mean filling rate of the left ventricle in the first third of diastole. The control group showed no symptoms of diastolic dysfunction. Thus, the patients with chest pain, a positive stress test and NECA had signs of left ventricular diastolic dysfunction exacerbated with stress. Such patients are at risk for heart failure with preserved ejection fraction.
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Affiliation(s)
- EA Khachirova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - LE Samoylenko
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - OP Shevchenko
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
PURPOSE OF THE REVIEW Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part due to biological variations in pathophysiology between the two sexes, and in part related to inadequate understanding of these differences, subconscious referral bias, and suboptimal application of existing women-specific guidelines. We sought to review the contemporary literature and provide an update on risk assessment, diagnosis, and management of IHD in women. RECENT FINDINGS IHD in women is often secondary to diffuse non-obstructive atherosclerosis, coronary spasm, inflammation, and endothelial and microvascular dysfunction, and less commonly due to the male pattern of flow-limiting epicardial stenosis. Both IHD patterns likely represent sex-specific manifestations of the same disease process. Additionally, there is a differential expression of risk factors and symptoms between men and women. Application of male-pattern IHD risk factors and presentation to women contributes to under-recognition, under-testing, and under-treatment of IHD in women compared to men. Traditional diagnostic evaluation has focused on detection of epicardial disease, amenable to revascularization. Our improved understanding of sex-specific pathophysiology of IHD has enabled us to also develop tools for detection of microvascular disease. Advances in stress MRI, flow quantification on stress PET, and provocative invasive angiography have filled this void and offer important diagnostic and prognostic information. Despite our improved understanding of sex-specific differences in presentation, risk factors, pathophysiology, diagnostic testing, and management strategies of IHD, women with IHD continue to experience worse outcomes than men. This disparity underscores the need for improved research and understanding of biological sex differences, elimination of subconscious gender bias in referral patterns, and improved application of existing research into clinical practice.
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Prognostic Implication of Thermodilution Coronary Flow Reserve in Patients Undergoing Fractional Flow Reserve Measurement. JACC Cardiovasc Interv 2018; 11:1423-1433. [DOI: 10.1016/j.jcin.2018.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 11/18/2022]
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30
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Taqueti VR, Solomon SD, Shah AM, Desai AS, Groarke JD, Osborne MT, Hainer J, Bibbo CF, Dorbala S, Blankstein R, Di Carli MF. Coronary microvascular dysfunction and future risk of heart failure with preserved ejection fraction. Eur Heart J 2018; 39:840-849. [PMID: 29293969 PMCID: PMC5939665 DOI: 10.1093/eurheartj/ehx721] [Citation(s) in RCA: 370] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/08/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023] Open
Abstract
Aims Coronary microvascular ischaemia, cardiomyocyte injury and stiffness may play an important role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). To date, the relationship between coronary flow reserve (CFR), myocardial injury, diastolic dysfunction, and future HFpEF risk is unknown. Methods and results Consecutive patients (n = 201) undergoing evaluation for suspected coronary artery disease (CAD) with stress myocardial perfusion positron emission tomography, serum troponin, and transthoracic echocardiography who did not have flow-limiting CAD or reduced left ventricular ejection fraction were identified. Patients were followed up (median 4.1 years) for cardiovascular death and hospitalization for non-fatal myocardial infarction or heart failure. Coronary flow reserve was quantified as stress/rest myocardial blood flow. Early diastolic flow (E) and relaxation (e') velocities were obtained via transmitral and tissue Doppler, respectively. Patients with impaired CFR (<2, n = 108) demonstrated linearly decreasing e' and increasing E/e' consistent with worsening diastolic function (P for trend <0.0001). A detectable troponin was associated with diastolic dysfunction only in the presence of impaired CFR (interaction P = 0.002). In adjusted analyses, impaired CFR was independently associated with diastolic dysfunction (E/e'septal > 15, adjusted OR 2.58, 95%CI 1.22-5.48) and composite cardiovascular outcomes or HFpEF hospitalization alone (adjusted HR 2.47, 95%CI 1.09-5.62). Patients with both impaired CFR and diastolic dysfunction demonstrated >five-fold increased risk of HFpEF hospitalization (P < 0.001). Conclusion In symptomatic patients without overt CAD, impaired CFR was independently associated with diastolic dysfunction and adverse events, especially HFpEF hospitalization. The presence of both coronary microvascular and diastolic dysfunctions was associated with a markedly increased risk of HFpEF events.
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Affiliation(s)
- Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amil M Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Osborne
- Cardiac MR/PET/CT Program, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Cardiovascular disease remains the leading cause of morbidity and mortality for both women and men. Emerging evidence supports that ischemic heart disease (IHD) may manifest differently in women and men, in ways ranging from the clinical presentation, diagnosis, and management of disease to the basic biology and biomechanics of cardiomyocyte function and the coronary circulation. Women consistently present with a higher burden of symptoms and comorbidities as compared with men and experience worse outcomes. These data have proved perplexing given the decreased likelihood of women to demonstrate obstructive coronary artery disease (CAD) on coronary angiography. Reported sex differences have long been influenced by the practice of defining heart disease primarily as obstructive CAD, but obstructive plaque is now recognized as neither necessary nor sufficient to explain symptoms of IHD, and it is no longer adequate to tailor diagnostic and treatment strategies only to this subset of patients. To date, women remain underrepresented in guideline-changing heart disease research and trials, creating important limitations in the evidence base for cardiovascular medicine. Smaller epicardial coronary arteries in women as compared to men, coupled with differences in shear stress and inflammatory mediators over the life span, may modify the development of CAD in susceptible patients into a diffuse pattern with more contribution from coronary vasomotor dysfunction than focal obstruction. Newer studies corroborate that symptomatic women are more likely than men to present with nonobstructive CAD and coronary microvascular dysfunction. When present, these processes increase cardiovascular risk in both women and men but may constitute an especially malignant phenotype in a subset of severely affected women, with implications for the management of not only CAD but also heart failure with preserved ejection fraction. This represents a state-of-the-art review of sex differences in the coronary system, with an eye toward how diverse pathophysiological processes may contribute to IHD phenotypes prevalent in women and men. Beyond providing women and men with equitable optimal care according to current paradigms, understanding the pathophysiology of IHD beyond a conventional focus on obstructive CAD is needed to address what is likely a combination of biological as well as environmental determinants of their prognosis.
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Affiliation(s)
- Viviany R Taqueti
- Heart and Vascular Center; Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology (Nuclear Medicine and Molecular Imaging), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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32
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Mejía-Rentería H, van der Hoeven N, van de Hoef TP, Heemelaar J, Ryan N, Lerman A, van Royen N, Escaned J. Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests. Int J Cardiovasc Imaging 2017; 33:1041-1059. [PMID: 28501910 DOI: 10.1007/s10554-017-1136-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/08/2017] [Indexed: 01/10/2023]
Abstract
The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.
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Affiliation(s)
- Hernán Mejía-Rentería
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Tim P van de Hoef
- AMC Heart Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Nicola Ryan
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
| | | | | | - Javier Escaned
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain.
- Universidad Complutense de Madrid (UCM), Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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33
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Coronary Flow Reserve and Microcirculatory Resistance in Patients With Intermediate Coronary Stenosis. J Am Coll Cardiol 2016; 67:1158-1169. [DOI: 10.1016/j.jacc.2015.12.053] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 11/21/2022]
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Taqueti VR, Everett BM, Murthy VL, Gaber M, Foster CR, Hainer J, Blankstein R, Dorbala S, Di Carli MF. Interaction of impaired coronary flow reserve and cardiomyocyte injury on adverse cardiovascular outcomes in patients without overt coronary artery disease. Circulation 2014; 131:528-35. [PMID: 25480813 DOI: 10.1161/circulationaha.114.009716] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Minimally elevated serum cardiac troponin reflects myocardial injury and is associated with increased mortality, even absent coronary artery disease (CAD). We sought to investigate the relationship between low-level troponin elevation and impaired coronary flow reserve (CFR), an integrated measure of coronary vasomotor function, and to assess their contributions to adverse outcomes in patients without overt CAD. METHODS AND RESULTS Consecutive patients (n=761) undergoing evaluation for suspected CAD with troponin before stress myocardial perfusion positron emission tomography were followed up (median, 2.8 years) for major adverse cardiovascular events, including cardiovascular death, nonfatal myocardial infarction, or late revascularization. Patients with flow-limiting CAD, left ventricular ejection fraction <40%, or revascularization within 60 days of imaging were excluded. CFR was quantified from stress/rest myocardial blood flow with the use of positron emission tomography. Compared with patients with negative troponin, those with at least 1 positive troponin (n=97) had higher pretest clinical scores, more renal dysfunction, and lower left ventricular ejection fraction and CFR. In adjusted analysis, impaired CFR remained independently associated with positive troponin (odds ratio, 2.18; 95% confidence interval, 1.37-3.47; P=0.001), and both impaired CFR and positive troponin were independently associated with major adverse cardiovascular events (hazard ratio, 2.25; 95% confidence interval, 1.31-3.86; P=0.003; and hazard ratio, 2.42; 95% confidence interval, 1.34-4.40; P=0.004, respectively). Impaired CFR and positive troponin identified patients at highest risk of major adverse cardiovascular events (log-rank P<0.0001), with a significant interaction (P<0.007) seen between CFR and troponin. CONCLUSIONS In patients without overt CAD, impaired CFR was independently associated with minimally elevated troponin and major adverse cardiovascular events. Impaired CFR, here reflecting microvascular dysfunction, modified the effect of a positive troponin on adverse outcomes.
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Affiliation(s)
- Viviany R Taqueti
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Brendan M Everett
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Venkatesh L Murthy
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Mariya Gaber
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Courtney R Foster
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Jon Hainer
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Ron Blankstein
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Sharmila Dorbala
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Marcelo F Di Carli
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.G., C.R.F., J.H., R.B., S.D., M.F.D.C.); Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.M.E.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.).
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35
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Taqueti VR, Hachamovitch R, Murthy VL, Naya M, Foster CR, Hainer J, Dorbala S, Blankstein R, Di Carli MF. Global coronary flow reserve is associated with adverse cardiovascular events independently of luminal angiographic severity and modifies the effect of early revascularization. Circulation 2014; 131:19-27. [PMID: 25400060 DOI: 10.1161/circulationaha.114.011939] [Citation(s) in RCA: 353] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Coronary flow reserve (CFR), an integrated measure of focal, diffuse, and small-vessel coronary artery disease (CAD), identifies patients at risk for cardiac death. We sought to determine the association between CFR, angiographic CAD, and cardiovascular outcomes. METHODS AND RESULTS Consecutive patients (n=329) referred for invasive coronary angiography after stress testing with myocardial perfusion positron emission tomography were followed (median 3.1 years) for cardiovascular death and heart failure admission. The extent and severity of angiographic disease were estimated with the use of the CAD prognostic index, and CFR was measured noninvasively by positron emission tomography. A modest inverse correlation was seen between CFR and CAD prognostic index (r=-0.26; P<0.0001). After adjustment for clinical risk score, ejection fraction, global ischemia, and early revascularization, CFR and CAD prognostic index were independently associated with events (hazard ratio for unit decrease in CFR, 2.02; 95% confidence interval, 1.20-3.40; P=0.008; hazard ratio for 10-U increase in CAD prognostic index, 1.17; 95% confidence interval, 1.01-1.34; P=0.032). Subjects with low CFR experienced rates of events similar to those of subjects with high angiographic scores, and those with low CFR or high CAD prognostic index showed the highest risk of events (P=0.001). There was a significant interaction (P=0.039) between CFR and early revascularization by coronary artery bypass grafting, such that patients with low CFR who underwent coronary artery bypass grafting, but not percutaneous coronary intervention, experienced event rates comparable to those with preserved CFR, independently of revascularization. CONCLUSIONS CFR was associated with outcomes independently of angiographic CAD and modified the effect of early revascularization. Diffuse atherosclerosis and associated microvascular dysfunction may contribute to the pathophysiology of cardiovascular death and heart failure, and impact the outcomes of revascularization.
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Affiliation(s)
- Viviany R Taqueti
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Rory Hachamovitch
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Venkatesh L Murthy
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Masanao Naya
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Courtney R Foster
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Jon Hainer
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Sharmila Dorbala
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Ron Blankstein
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Marcelo F Di Carli
- From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.); Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.); and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.).
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Murthy VL, Naya M, Taqueti VR, Foster CR, Gaber M, Hainer J, Dorbala S, Blankstein R, Rimoldi O, Camici PG, Di Carli MF. Effects of sex on coronary microvascular dysfunction and cardiac outcomes. Circulation 2014; 129:2518-27. [PMID: 24787469 DOI: 10.1161/circulationaha.113.008507] [Citation(s) in RCA: 406] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is a prevalent and prognostically important finding in patients with symptoms suggestive of coronary artery disease. The relative extent to which CMD affects both sexes is largely unknown. METHODS AND RESULTS We investigated 405 men and 813 women who were referred for evaluation of suspected coronary artery disease with no previous history of coronary artery disease and no visual evidence of coronary artery disease on rest/stress positron emission tomography myocardial perfusion imaging. Coronary flow reserve was quantified, and coronary flow reserve <2.0 was used to define the presence of CMD. Major adverse cardiac events, including cardiac death, nonfatal myocardial infarction, late revascularization, and hospitalization for heart failure, were assessed in a blinded fashion over a median follow-up of 1.3 years (interquartile range, 0.5-2.3 years). CMD was highly prevalent both in men and women (51% and 54%, respectively; Fisher exact test =0.39; equivalence P=0.0002). Regardless of sex, coronary flow reserve was a powerful incremental predictor of major adverse cardiac events (hazard ratio, 0.80 [95% confidence interval, 0.75-086] per 10% increase in coronary flow reserve; P<0.0001) and resulted in favorable net reclassification improvement (0.280 [95% confidence interval, 0.049-0.512]), after adjustment for clinical risk and ventricular function. In a subgroup (n=404; 307 women/97 men) without evidence of coronary artery calcification on gated computed tomography imaging, CMD was common in both sexes, despite normal stress perfusion imaging and no coronary artery calcification (44% of men versus 48% of women; Fisher exact test P=0.56; equivalence P=0.041). CONCLUSIONS CMD is highly prevalent among at-risk individuals and is associated with adverse outcomes regardless of sex. The high prevalence of CMD in both sexes suggests that it may be a useful target for future therapeutic interventions.
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Affiliation(s)
- Venkatesh L Murthy
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Masanao Naya
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Viviany R Taqueti
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Courtney R Foster
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Mariya Gaber
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Jon Hainer
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Sharmila Dorbala
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Ron Blankstein
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Ornella Rimoldi
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Paolo G Camici
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.)
| | - Marcelo F Di Carli
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, and Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI (V.L.M.); Noninvasive Cardiovascular Imaging Program, Departments of Internal Medicine and Radiology (V.L.M., M.N., V.R.T., S.D., R.B., M.F.D.C.), and Division of Cardiovascular Medicine, Department of Medicine (V.L.M., V.R.T., J.H., S.D., R.B., M.F.D.C.), Brigham & Women's Hospital, Boston, MA; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology (C.R.F., M.G., J.H., S.D., M.F.D.C.), and Istituto di Bioimmagini e Fisiologia Molecolare (O.R.), Consiglio Nazionale delle Ricerche and Scientific Institute San Raffaele, Milan, Italy; Division of Cardiology, Vita Salute University and Scientific Institute San Raffaele, Milan, Italy (P.G.C.).
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