Racial heterogeneity in coronary artery vasomotor reactivity: differences between Japanese and Caucasian patients

Two case reports of coronary spastic angina accompanied by the menstrual cycle

Background

Coronary spastic angina (CSA) in premenopausal women is not frequent but has also been suggested to be associated with oestrogen decline during the menstrual cycle and sometimes becomes refractory and difficult to control. We experienced two premenopausal women with CSA that showed the involvement of the menstrual cycle.

Case summary

Case 1: 41-year-old-woman had ST-segment elevation and chest pain during urosepsis, just 2 days after the onset of menstruation. The acetylcholine stress test was performed according to the menstrual cycle, and multiple coronary spasms were induced. Case 2: 40-year-old-woman had refractory chest pain as a symptom of premenstrual syndrome (PMS). Coronary angiography on drugs at the maximum dose revealed spontaneous multiple coronary spasms. Blood levels of oestrogen were normal, suggesting that hormonal change may be involved, and the introduction of low-dose pills made free from angina and the reduction of drug dose.

Discussion

In premenopausal female angina pectoris, oestrogen may play a role; it is important to ask about the menstrual cycle and history of PMS. Besides, the timing of catheterization in premenopausal women with suspected CSA should be considered. Low-dose pills may be effective in some cases, and active medical collaboration with other departments such as gynaecology is desirable.　.

Ischaemia with no obstructive coronary arteries: a review with focus on the Asian population

ABSTRACT

Ischaemia with no obstructive coronary arteries (INOCA) has been a diagnostic and therapeutic challenge for decades. Several studies have demonstrated that INOCA is associated with an increased risk of death, adverse cardiovascular events, poor quality of life and high healthcare cost. Although there is increasing recognition of this entity in the Western population, in the Asian population, INOCA remains elusive and its prevalence uncertain. Despite its prognostic significance, diagnosis of INOCA is often delayed. In this review, we identified the multiple barriers to its diagnosis and management, and proposed strategies to overcome them.

Prevalence of Coronary Vasomotor Disorders in Patients With Angina and Nonobstructive Coronary Arteries: A Sydney Experience

BACKGROUND

Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes.

METHOD

Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing.

RESULTS

This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007).

CONCLUSIONS

Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.

Effects of Smoking on Major Adverse Cardiovascular Events in Patients With Coronary Artery Spasm: A Systematic Review and Meta-Analysis

BACKGROUND

Smoking is an established independent risk factor for coronary artery spasm (CAS), but its effects on major adverse cardiovascular events (MACE) in patients with CAS have not been systematically assessed.

METHODS

This systematic review and meta-analysis of studies published from January 2000 to July 2023 was conducted to examine the relationship between smoking and MACE in patients with CAS. Data on MACE were obtained from both smoking and non-smoking CAS patient groups. The effects of smoking on MACE in patients with CAS were assessed through meta-analysis, utilising Stata 17.0 software for all statistical analyses.

RESULTS

Nine studies, encompassing 9,376 patients, from Japan (5 studies), Korea (4 studies) and Spain (1 study) were included in the final analysis. Meta-analysis revealed that smoking significantly impacted MACE in patients with CAS (RR 1.965; 95% CI 1.348-2.865), a finding further validated by sensitivity analyses. Subgroup analyses identified a stronger correlation between smoking and increased MACE endpoints in Japanese patients and in those with >3 years of follow-up.

CONCLUSIONS

This meta-analysis strongly indicates that smoking escalates the risk of MACE in patients with CAS, with a more pronounced association observed in Japanese patients and those with extended follow-up periods.

Sex-specific and ethnicity-specific differences in MINOCA

Suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) has received increasing attention over the past decade. Given the heterogeneity in the mechanisms underlying acute myocardial infarction in the absence of obstructive coronary arteries, the syndrome of MINOCA is considered a working diagnosis that requires further investigation after diagnostic angiography studies have been performed, including coronary magnetic resonance angiography and functional angiography. Although once considered an infrequent and low-risk form of myocardial infarction, recent data have shown that the prognosis of MINOCA is not as benign as previously assumed. However, despite increasing awareness of the condition, many questions remain regarding the diagnosis, risk stratification and treatment of MINOCA. Women seem to be more susceptible to MINOCA, but studies on the sex-specific differences of the disease are scarce. Similarly, ethnicity-specific factors might explain discrepancies in the observed prevalence or underlying pathophysiological mechanisms of MINOCA but data are also scarce. Therefore, in this Review, we provide an update on the latest evidence available on the sex-specific and ethnicity-specific differences in the clinical features, pathophysiological mechanisms, treatment and prognosis of MINOCA.

The diagnosis and treatment of women with recurrent cardiac ischemia and normal coronary arteries

Cardiac disease is the leading cause of death in women. Among women with recurrent chest pain, abnormal electrocardiograms, and/or stress tests who undergo coronary angiography, as many as 50% have normal or <50% coronary artery obstructive disease. Pharmacologic stress assessment of coronary artery flow reserve in these women frequently demonstrates an inability to increase blood flow to >2.5 times normal flow. Contributory factors include abnormal epicardial or microvascular reactivity, microvascular remodeling or rarefaction, autonomic dysfunction, or coronary plaque rupture/erosion. Assessment is necessary of serum biomarkers and coronary artery flow reserve, fractional flow reserve, microvascular resistance, and epicardial/microvascular spasm. Aggressive treatment of women with positive tests is necessary because these women have an increased incidence of recurrent chest pain, repeated hospitalizations and coronary angiograms, and cardiac death.

What is the meaning of provoked spasm phenotypes by vasoreactivity testing?

Coronary artery epicardial spasm is involved in the pathogenesis of many cardiac disorders. Vasoreactivity testing, such as intracoronary injection of acetylcholine (ACH) or ergonovine (ER), is the gold standard method for the diagnosis of vasospastic angina. Provoked epicardial spasm phenotypes are classified as focal spasm and diffuse spasm. Multiple factors, including sex, ethnicity, and use of coronary vasoactive stimulators, are related to the provoked phenotypes of epicardial spasm. Diffuse-provoked spasm is often observed in females, where focal-provoked spasm is markedly more common in males. ACH provokes more diffuse and distal spasms, whereas ER induces more focal and proximal spasms. Yellow plaque and coronary thrombi are often observed in lesions with focal spasms, and intimal thickness with a sonolucent zone is significantly more common in lesions with focal spasm. Furthermore, clinical outcomes in patients with focal spasm are unsatisfactory compared with those in patients with diffuse spasm. However, the reproducibility and eternality of provoked spasm phenotypes by vasoreactivity testing is uncertain. Coronary atherosclerosis or endothelial damage may affect coronary vasomotor tone. Although coronary artery spasm may persist in the same coronary artery, provoked coronary spasm phenotypes may exhibit a momentary coronary reaction by intracoronary ACH or ER testing.

Left Main Coronary Artery Spasm During Cryoballoon Ablation for Atrial Fibrillation: A Case Report and Literature Review

Although phrenic nerve and esophageal injury are commonly known risks associated with cryoablation, there is limited literature regarding coronary artery spasm (CAS), a serious and potentially fatal complication of cryoablation. We report the case of a 68-year-old Caucasian female who developed a left main CAS with a significant hemodynamic compromise during cryoablation. The patient, with a history of hyperlipidemia, hypertension, and symptomatic persistent atrial fibrillation, was admitted for elective catheter ablation for atrial fibrillation. During the ablation of the left superior pulmonary vein (LSPV), the patient developed severe hypotension and bradycardia. The patient's monitor revealed ST elevation, confirmed by a 12-lead ECG. Immediate coronary angiography revealed the left main coronary spasm, which improved with nitroglycerine administration with resolution of ST elevation and return of the patient's hemodynamics to stability. The patient's left main CAS was induced by cryoablation of LSPV. Literature on atrial fibrillation ablation-induced CAS is scant, but a Japanese study has shown that it occurs more commonly in cryoablation than in radiofrequency, hot balloon, or laser ablation. The study showed LSPV as the most common site of ablation right before the spasms happened. Further studies about this topic are needed to delineate further the risk factors and the precautions that could prevent CAS. In the meantime, prompt recognition and appropriate intervention are critical for a good patient outcome.

Insights into the invasive diagnostic challenges of coronary artery vasospasm - A systematic review

Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included ≥50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.

Pathophysiology and diagnostic pathway of myocardial infarction with non-obstructive coronary arteries

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous and diverse disease entity, which accounts for about 6 % of all acute myocardial infarction (AMI) cases. In patients with chest pain and acute myocardial injury detected by a highly sensitive troponin assay, the absence of epicardial coronary stenosis of 50 % or greater on angiography leads to the working diagnosis of MINOCA. The updated JCS/CVIT/JCC 2023 Guideline described MINOCA as a new disease concept and recommended a multimodality approach to uncovering the underlying causes of MINOCA. Cardiac magnetic resonance (CMR) is useful in not only making a definite diagnosis of MINOCA, but also excluding non-ischemic causes that mimic AMI such as takotsubo cardiomyopathy and myocarditis. Meanwhile, intracoronary imaging, particularly optical coherence tomography (OCT), enables us to evaluate precisely intracoronary morphological alterations including plaque disruption and spontaneous coronary artery dissection which are not revealed by angiographic findings alone. Recent studies have shown that an initial workup with the combination of CMR and OCT could provide a definite diagnosis in a significant percentage of patients suspected of MINOCA. Consecutively, patients with inconclusive results of a series of CMR and OCT implementation are eligible for assessing the potential for coronary functional abnormalities or blood coagulopathy as another factor involved in the development of MINOCA. Although uncovering the pathogenesis of MINOCA might be essential for establishing an individualized treatment approach, significant knowledge gaps in terms of secondary prevention strategies for MINOCA focusing on the improvement of long-term prognosis remain to be overcome. In this review, we summarize our current understanding of MINOCA and highlight contemporary diagnostic approaches for patients with suspected MINOCA.

Familial risk of vasospastic angina: a nationwide family study in Sweden

OBJECTIVES

Vasospastic angina (VSA) is a complex coronary vasomotor disorder associated with an increased risk of myocardial infarction and sudden death. Despite considerable advances in understanding VSA pathophysiology, the interplay between genetic and environmental factors remains elusive. Accordingly, we aimed to determine the familial VSA risk among first-degree relatives of affected individuals.

METHODS

A population-based multigenerational cohort study was conducted, including full-sibling pairs born to Swedish parents between 1932 and 2018. Register-based diagnoses were ascertained through linkage to the Swedish Multigeneration Register and National Patient Register. Incidence rate ratios (IRRs) and adjusted HRs were calculated for relatives of individuals with VSA compared with relatives of individuals without VSA.

RESULTS

The total study population included 5 764 770 individuals. Overall, 3461 (0.06%) individuals (median age at disease onset 59 years, IQR: 63-76) were diagnosed with VSA. Of these, 2236 (64.61%) were women. The incidence rate of VSA for individuals with an affected sibling was 0.31 (95% CI: 0.24 to 0.42) per 1000 person-years compared with 0.04 (95% CI: 0.04 to 0.04) per 1000 person-years for those without an affected sibling, yielding an IRR of 7.58 (95% CI: 5.71 to 10.07). The risk of VSA for siblings with an affected sibling was significantly increased in the fully adjusted model (HR: 2.56; 95% CI: 1.73 to 3.79). No increased risk of VSA was observed in spouses of affected individuals (HR: 0.63; 95% CI: 0.19 to 2.09).

CONCLUSIONS

In this nationwide family study, we identified high familial risk for VSA independent of shared environmental risk factors. Our findings indicate that VSA tends to cluster in families, emphasising the need to explore genetic and non-genetic factors that may contribute.

Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2

Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.

Angina and Non-Obstructive Coronary Artery (ANOCA) Patients with Coronary Vasomotor Disorders

Angina and Non-Obstructive Coronary Artery (ANOCA) patients often lack a clear explanation for their symptoms, and are frequently discharged with the label of "unspecified chest pain", despite the availability of functional coronary angiography (provocative spasm and microvascular function testing) to identify potential underlying coronary vasomotor disorders. This study compared the outcomes of ANOCA patients with a coronary vasomotor disorder diagnosis post elective coronary angiography to patients discharged with unspecified chest pain. Using the CADOSA (Coronary Angiogram Database of South Australia) registry, consecutive symptomatic patients (n = 7555) from 2012 to 2018 underwent elective angiography; 30% had ANOCA (stenosis <50%). Of this cohort, 9% had documented coronary vasomotor disorders diagnosed, and 91% had unspecified chest pain. Patients with coronary vasomotor disorders were younger and had a similar female prevalence compared with those with unspecified chest pain. New prescriptions of calcium channel blockers and long-acting nitrates were more common for the coronary vasomotor cohort at discharge. In the 3 years following angiography, both groups had similar all-cause mortality rates. However, those with coronary vasomotor disorders had higher rates of emergency department visits for chest pain (39% vs. 15%, p < 0.001) and readmissions for chest pain (30% vs. 10%, p < 0.001) compared with those with unspecified chest pain. This real-world study emphasizes the importance of identifying high-risk ANOCA patients for personalized management to effectively address their symptoms.

Intraoperative Coronary Spasm: A Potential Case of Vasospastic Angina

Prinzmetal's angina typically features spasms of the coronary arteries due to the hyperreactivity of the vascular smooth muscle cells of the vessels to a nonspecific stimulus. Reports of coronary spasm during general anesthesia are rare, but in such cases, diagnosis is suggested by a framework of angina at rest and changes in the electrocardiogram (ECG) or coronary reactivity tests with ergonovine or acetylcholine. The present study describes a case of coronary spasm induced by general anesthesia associated with several cardiovascular risk factors and the usage of vasoactive drugs that was documented by angiography without using stimulating drugs and treated with intracoronary nitroglycerin. The patient was a 58-year-old male who was designated for carotid endarterectomy due to the stenosis (70%) of the right internal carotid artery by an atheromatous plaque after visiting the emergency department with a sensorimotor deficit in the left upper limb and bifrontal headaches with sudden onset. During the surgical intervention, after the administration of 10 mg of intravenous ephedrine, cardiorespiratory arrest occurred, with alternation between defibrillable and non-defibrillable heart paces. After the recovery of spontaneous circulation after 50 minutes of resuscitation maneuvers, the patient was transported to the hemodynamics laboratory, where there were recurrent episodes of ventricular fibrillation during the angioplasty of the anterior descending artery. After direct stent implantation, pre- and post-stent spasms were verified and reversed after the administration of intracardiac nitroglycerin. The spasm was a possible complication of anesthesia and responded to treatment with nitrates and calcium channel blockers. We would like to emphasize the importance of cardiac monitoring during surgery and anesthesia.

Vasospastic angina: Past, present, and future

Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.

Coronary Spasm: Ethnic and Sex Differences

Coronary spasm (CS), which may occur at the epicardial (focal or diffuse spasm) and/or microvascular (microvascular spasm) level, is a well-established cause of myocardial ischaemia, in particular in patients with anginal chest pain despite unobstructed coronary arteries. The diagnosis of CS can be confirmed during coronary angiography by an additional provocation test with vasoactive substances such as acetylcholine. Due to partially inconsistent data from large clinical studies, especially between Asian and white CS patients, ethnic differences concerning the prevalence and angiographic patterns of CS seem to exist. Furthermore, several studies in patients with coronary vasomotor disorders pointed towards differences among male and female CS patients. This article gives an overview of ethnic- and sex-related differences in patients with CS.

Mechanisms of Coronary Artery Spasm

Recent clinical trials have highlighted that percutaneous coronary intervention in patients with stable angina provides limited additional benefits on top of optimal medical therapy. This has led to much more attention being paid to coronary vasomotion abnormalities regardless of obstructive or non-obstructive arterial segments. Coronary vasomotion is regulated by multiple mechanisms that include the endothelium, vascular smooth muscle cells (VSMCs), myocardial metabolic demand, autonomic nervous system and inflammation. Over the years, several animal models have been developed to explore the central mechanism of coronary artery spasm. This review summarises the landmark studies on the mechanisms of coronary vasospasm demonstrating the central role of Rho-kinase as a molecular switch of VSMC hypercontraction and the important role of coronary adventitial inflammation for Rho-kinase upregulation in VSMCs.

Utility of optical coherence tomography in acute coronary syndromes

Studies utilizing intravascular imaging have replicated the findings of histopathological studies, identifying the most common substrates for acute coronary syndromes (ACS) as plaque rupture, erosion, and calcified nodule, with spontaneous coronary artery dissection, coronary artery spasm, and coronary embolism constituting the less common etiologies. The purpose of this review is to summarize the data from clinical studies that have used high-resolution intravascular optical coherence tomography (OCT) to assess culprit plaque morphology in ACS. In addition, we discuss the utility of intravascular OCT for effective treatment of patients presenting with ACS, including the possibility of culprit lesion-based treatment by percutaneous coronary intervention.

Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review

Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.

New Insights into Pathophysiology and New Risk Factors for ACS

Cardiovascular disease still represents the main cause of mortality worldwide. Despite huge improvements, atherosclerosis persists as the principal pathological condition, both in stable and acute presentation. Specifically, acute coronary syndromes have received substantial research and clinical attention in recent years, contributing to improve overall patients' outcome. The identification of different evolution patterns of the atherosclerotic plaque and coronary artery disease has suggested the potential need of different treatment approaches, according to the mechanisms and molecular elements involved. In addition to traditional risk factors, the finer portrayal of other metabolic and lipid-related mediators has led to higher and deep knowledge of atherosclerosis, providing potential new targets for clinical management of the patients. Finally, the impressive advances in genetics and non-coding RNAs have opened a wide field of research both on pathophysiology and the therapeutic side that are extensively under investigation.

Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan

AIMS

Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts.

METHODS AND RESULTS

We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P < 0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P < 0.001).

CONCLUSIONS

Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.

Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management

In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.

Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis

Background

Coronary artery spasm (CAS), encompassing epicardial and microvascular spasm, is increasingly recognized as cause of angina in patients with non-obstructive coronary artery disease (ANOCA). However, various spasm provocation testing protocols and diagnostic criteria are used, making diagnosis and characterization of these patients difficult and interpretation of study results cumbersome. This review provides a structured overview of the prevalence, characterization and prognosis of CAS worldwide in men and women.

Methods

A systematic review identifying studies describing ANOCA patients with CAS was performed. Multiple outcomes (prevalence, clinical features, and prognosis) were assessed. Data, except for prognosis were pooled and analysed using random effects meta-analysis models.

Results

Twenty-five publications (N = 14.554) were included (58.2 years; 44.2% women). Percentages of epicardial constriction to define epicardial spasm ranged from >50% to >90%. Epicardial spasm was prevalent in 43% (range 16-73%), with a higher prevalence in Asian vs. Western World population (52% vs. 33%, p = 0.014). Microvascular spasm was prevalent in 25% (range 7-39%). Men were more likely to have epicardial spasm (61%), women were more likely to have microvascular spasm (64%). Recurrent angina is frequently reported during follow-up ranging from 10 to 53%.

Conclusion

CAS is highly prevalent in ANOCA patients, where men more often have epicardial spasm, women more often have microvascular spasm. A higher prevalence of epicardial spasm is demonstrated in the Asian population compared to the Western World. The prevalence of CAS is high, emphasizing the use of unambiguous study protocols and diagnostic criteria and highlights the importance of routine evaluation of CAS in men and women with ANOCA.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272100.

Prognostic impact of nitrate therapy in patients with myocardial bridge and coexisting coronary artery spasm

The aim of this study was to investigate the prognostic impact of nitrate therapy in patients with myocardial bridge (MB) and coexisting coronary artery spasm (CAS). MB often accompanies CAS. Nitrates have been widely used as anti-ischemic drugs in CAS patients, while it is not recommended in MB patients. Thus, we investigated the long-term impact of nitrate on clinical outcomes in patients with both CAS and MB. A retrospective observational study was performed using propensity score matching (PSM) in a total of 757 consecutive MB patients with positive acetylcholine (Ach) provocation test. Patients were divided into two groups according to the regular administration of nitrates (nitrate group: n = 504, No nitrate group; n = 253). The PSM was used to adjust for selection bias and potential confounding factors, and major clinical outcomes were compared between the two groups up to 5 years. Baseline characteristics were well-matched between the two groups following PSM (n = 211 for both groups). There was no significant difference in the incidence of death, myocardial infarction, and major adverse cardiovascular events (MACEs) between the two groups. However, the nitrate group showed a significantly higher rate of recurrent angina which subsequently needed re-evaluation of coronary arteries by follow-up angiography (15.7 vs. 5.7%, Log-rank p = 0.012) compared to the non-nitrate group. Long-term nitrate administration in patients with MB and coexisting CAS did not show benefit in reducing MACE, rather it was associated with a higher incidence of recurrent angina requiring follow-up angiography.

Surgical revascularization for severe spasm in the left main coronary artery

A 46-year-old woman who presented with severe stenosis with endothelial damage caused by recurrent spasm in the left main coronary artery received medical therapy. However, she developed severe coronary artery spasm, resulting in circulatory collapse, which was successfully treated with coronary artery bypass grafting.

Effect of Statins on Major Adverse Cardiovascular Events in Patients with Coronary Artery Spasm: A Meta-Analysis of the Asia Region

Background

Whether statins can reduce major cardiovascular adverse events (MACE) in patients with coronary artery spasm (CAS) is controversial. And most of the relevant research to date has been conducted in Asia.

Methods

We systematically searched electronic databases for studies on the effect of statins on MACE in patients with CAS in Asia and published up to September 2022. We included data on MACE in a statin therapy patient group and a no-statin therapy control group. We then evaluated the effect of statin therapy on MACE in patients with CAS in Asia by meta-analysis and trial sequential analysis (TSA). All statistical analyses were performed using Stata 16.0 software and TSA software.

Results

A total of 10 studies (n = 9333 patients) were included in the final analysis. Meta-analysis showed that the use of statins had a significant effect on MACE in CAS patients (with RR, 0.70; 95% CI, 0.49-0.99), and the sensitivity analysis further confirmed this finding. Subgroup analysis suggested that the correlation between statin therapy and reduced MACE endpoint was stronger in Japanese patients and patients followed up for more than 4 years. But our TSA results indicated that the available samples were insufficient and further research is needed.

Conclusions

Our meta-analysis suggests that statin therapy can reduce MACE in patients with CAS in Asia, and the correlation between the two was stronger in Japanese patients and patients followed up for more than 4 years.

Management of vasospastic angina

Vasospastic angina is a well-established cause of chest pain that is caused by coronary artery spasm. It can be clinically diagnosed during a spontaneous episode by documenting nitrate-responsive rest angina with associated transient ischaemic ECG changes but more often requires provocative coronary spasm testing with acetylcholine during coronary angiography. Vasospastic angina may result in recurrent episodes of angina (including nocturnal angina), which can progress on to major adverse cardiac events. Calcium channel blockers are first-line therapy for this condition, given their anti-anginal and cardioprotective benefits. Despite an established diagnostic and therapeutic management pathway for vasospastic angina, this diagnosis is often overlooked in patients presenting with chest pain. Thus, there is need for increased clinical awareness of vasospastic angina to improve outcomes in affected patients.

Increased plasma glutamate in non-smokers with vasospastic angina pectoris is associated with plasma cystine and antioxidant capacity

Objectives. Endothelial dysfunction caused by oxidative stress plays an important role in the development of vasospastic angina pectoris (VSAP). Glutamate causes endothelial dysfunction by generating oxidative stress, and it inhibits cystine import into endothelial cells via the cystine/glutamate antiporter (X_C^-), which leads to depletion of antioxidant glutathione. However, whether glutamate and cystine are implicated in the pathogenesis of VSAP remains unclear. We investigated plasma glutamate and cystine levels, oxidative stress markers and antioxidant capacity in non-smoker patients with VSAP to determine whether glutamate and cystine are associated with the development of VSAP. We assessed 49 non-smokers assigned to groups with (n = 27) and without (n = 22) VSAP, and also measured plasma glutamate, cystine, nitrotyrosine, reactive oxygen metabolites and biological antioxidant potential. Results. Plasma glutamate and cystine values were significantly higher in the group with, than without VSAP (59.8 ± 25.7 vs. 43.5 ± 18.7 µmol/L, p = .016 and 35.3 ± 14.2 vs. 25.2 ± 9.1 µmol/L, p = .0056, respectively). Plasma glutamate and cystine values were significantly and positively associated (r = 0.32, p = .027). Levels of the oxidative stress markers nitrotyrosine and reactive oxygen metabolites, and biological antioxidant potential of as a measure of antioxidant capacity, did not significantly differ between the two groups. However, glutamate and biological antioxidant potential values were significantly and negatively associated (r = -0.3, p = .036). Conclusion. Plasma glutamate levels were increased in patients with VSAP who did not smoke, and they were positively associated with plasma cystine and negatively associated with the biological antioxidant potential levels.

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

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

Ischemic Heart Disease in Young Women: JACC Review Topic of the Week

The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade.

Mechanisms of Coronary Ischemia in Women

PURPOSE OF REVIEW

Obstructive coronary artery disease is a major cause of ischemia in both men and women; however, women are more likely to present with ischemia in the setting of no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA), conditions that are associated with adverse cardiovascular prognosis despite absence of coronary stenosis. In this review, we focus on mechanisms of coronary ischemia that should be considered in the differential diagnosis when routine anatomic clinical investigation leads to the finding of non-obstructive coronary artery disease on coronary angiography in the setting of acute myocardial infarction.

RECENT FINDINGS

There are multiple mechanisms that contribute to MINOCA, including atherosclerotic plaque disruption, coronary artery spasm, coronary microvascular dysfunction (CMD), coronary embolism and/or thrombosis, and spontaneous coronary artery dissection. Non-coronary causes such as myocarditis or supply-demand mismatch should also be considered on the differential when there is an unexplained troponin elevation. Use of advanced imaging and diagnostic techniques to determine the underlying etiology of MINOCA is feasible and helpful, as this has the potential to guide management and secondary prevention. Failure to identify the underlying cause(s) may result in inappropriate treatment and inaccurate counseling to patients. MINOCA predominates in young women and is associated with a guarded prognosis. The diagnosis of MINOCA should prompt further investigation to determine the underlying cause of troponin elevation. Patients with INOCA and MINOCA are heterogeneous, and response to treatments can be variable. Large randomized controlled trials to determine longer-term optimal medical therapy for management of these conditions are under investigation.

Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management

Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.

Role of Intracoronary Imaging in Acute Coronary Syndromes

Intravascular imaging with optical coherence tomography (OCT) and intravascular ultrasound provides superior visualization of the culprit plaques for acute coronary syndromes (ACS) compared with coronary angiography. Combined with angiography, intravascular imaging can be used to instigate ‘precision therapy’ for ACS. Post-mortem histopathology identified atherothrombosis at the exposed surface of a ruptured fibrous cap as the main cause of ACS. Further histopathological studies identified intact fibrous caps and calcified nodules as other culprit lesions for ACS. These plaque types were subsequently also identified on intravascular imaging, particularly with the high-resolution OCT. The less-common non-atherothrombotic causes of ACS are coronary artery spasm, coronary artery dissection, and coronary embolism. In this review, the authors provide an overview of clinical studies using intravascular imaging with OCT in the diagnosis and management of ACS.

Safety of Provocative Testing With Intracoronary Acetylcholine and Implications for Standard Protocols

BACKGROUND

Heterogeneity in diagnostic criteria and provocation protocols has posed challenges in understanding the safety of coronary provocation testing with intracoronary acetylcholine (ACh) for the contemporary diagnosis of epicardial and microvascular spasm.

OBJECTIVES

We examined the safety of testing and subgroup differences in procedural risks based on ethnicity, diagnostic criteria, and provocation protocols.

METHODS

PubMed and Embase were searched in November 2021 to identify original articles reporting procedural complications associated with intracoronary ACh administration. The primary outcome was the pooled estimate of the incidence of major complications including death, myocardial infarction, ventricular tachycardia/fibrillation, and shock.

RESULTS

A total of 16 studies with 12,585 patients were included in the meta-analysis. The overall pooled estimate of the incidence of major complications was 0.5% (95% CI: 0.0%-1.3%) without any reports of death. Exploratory subgroup analyses revealed that the pooled incidence of major complications was significantly higher in the studies that followed the contemporary diagnosis criteria for epicardial spasm defined as ≥90% diameter reduction (1.0%; 95% CI: 0.3%-2.0%) but significantly lower in Western populations (0.0%; 95% CI: 0.0%-0.45%). The rate of positive epicardial spasm and the incidence of major complications were similar between provocation protocols using the maximum ACh doses of 100 μg and 200 μg.

CONCLUSIONS

Intracoronary ACh administration for the contemporary diagnosis of epicardial and microvascular spasm is a safe procedure. Moreover, excellent safety records are observed in Western populations primarily presenting with myocardial ischemia and/or infarction with nonobstructive coronary arteries. This study will help standardize ACh testing to improve clinical diagnosis and ensure procedural safety.

Percutaneous coronary intervention in patients with documented coronary vasospasm during long-term follow-up

Objective

Although recurring coronary artery spasm (CAS) may lead to the development of fixed atherosclerotic coronary stenosis (FS), the relationship between coronary atherosclerosis and CAS is still speculative. We evaluated the incidence of FS requiring percutaneous coronary intervention (PCI) in patients with documented CAS during long-term follow-up and analysed their clinical features.

Methods

Clinical data of 3556 patients during a median follow-up of 9.4 years after non-invasive ergonovine spasm provocation testing with echocardiographic monitoring of left ventricular wall motion (erg echo) were analysed.

Results

Erg echo documented CAS in 830 (23.3%) patients, who had higher frequencies of coronary risk factors than those without CAS. Patients with documented CAS on erg echo showed significantly lower 10-year overall (90.5% vs 94.2%, p<0.001) and PCI-free (97.4% vs 98.4%, p=0.002) survival rates than those without CAS. Documented CAS was an independent factor associated with later PCI after adjustment by either Cox regression model or Fine-Gray competing risk model. There was no significant difference in baseline clinical characteristics between patients who needed later PCI and those who did not. Among 28 patients who needed later PCI after documentation of CAS, the original CAS and later PCI territory were concordant in 25 (89.3%), while 3 (10.7%) showed discordance.

Conclusions

CAS is a risk factor for the development of FS requiring PCI during long-term follow-up, and warrants physicians’ vigilance and careful follow-up of patients with documented CAS and insignificant stenosis of major epicardial coronary arteries at the time of initial diagnosis.

Apolipoprotein (a)/Lipoprotein(a)-Induced Oxidative-Inflammatory α7-nAChR/p38 MAPK/IL-6/RhoA-GTP Signaling Axis and M1 Macrophage Polarization Modulate Inflammation-Associated Development of Coronary Artery Spasm

Objective. Apolipoprotein (a)/lipoprotein(a) (Lp(a)), a major carrier of oxidized phospholipids, and α7-nicotinic acetylcholine receptor (α7-nAChR) may play an important role in the development of coronary artery spasm (CAS). In CAS, the association between Lp(a) and the α7-nAChR-modulated inflammatory macrophage polarization and activation and smooth muscle cell dysfunction remains unknown. Methods. We investigated the relevance of Lp(a)/α7-nAChR signaling in patient monocyte-derived macrophages and human coronary artery smooth muscle cells (HCASMCs) using expression profile correlation analyses, fluorescence-assisted cell sorting flow cytometry, immunoblotting, quantitative real-time polymerase chain reaction, and clinicopathological analyses. Results. There are increased serum Lp(a) levels (3.98-fold, $p=0.011$ ) and macrophage population (3.30-fold, $p=0.013$ ) in patients with CAS compared with patients without CAS. Serum Lp(a) level was positively correlated with high-sensitivity C-reactive protein ( $r^2=0.48$ , $p<0.01$ ), IL-6 ( $r^2=0.38$ , $p=0.03$ ), and α7-nAChR ( $r^2=0.45$ , $p<0.01$ ) in patients with CAS, but not in patients without CAS. Compared with untreated or low-density lipoprotein- (LDL-) treated macrophages, Lp(a)-treated macrophages exhibited markedly enhanced α7-nAChR mRNA expression ( $p<0.01$ ) and activity ( $p<0.01$ ), in vitro and ex vivo. Lp(a) but not LDL preferentially induced CD80+ macrophage (M1) polarization and reduced the inducible nitric oxide synthase expression and the subsequent NO production. While shRNA-mediated loss of α7-nAChR function reduced the Lp(a)-induced CD80+ macrophage pool, both shRNA and anti-IL-6 receptor tocilizumab suppressed Lp(a)-upregulated α7-nAChR, p-p38 MAPK, IL-6, and RhoA-GTP protein expression levels in cultures of patient monocyte-derived macrophages and HCASMCs. Conclusions. Elevated Lp(a) levels upregulate α7-nAChR/IL-6/p38 MAPK signaling in macrophages of CAS patients and HCASMC, suggesting that Lp(a)-triggered inflammation mediates CAS through α7-nAChR/p38 MAPK/IL-6/RhoA-GTP signaling induction, macrophage M1 polarization, and HCASMC activation.

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies

Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.

TLR4-Myd88 pathway upregulated caveolin-1 expression contributes to coronary artery spasm

AIM

To study the role of toll-like receptors 4-myeloid differentiation factor 88 (TLR4-Myd88) dependent caveolin-1 (Cav-1) expression modulation in coronary artery spasm (CAS) and explore the underlying pathogenic mechanisms.

METHODS AND RESULTS

Lipopolysaccharide (LPS) and acetylcholine (Ach) were used to develop the in vitro and in vivo models mimicking the physiological CAS microenvironment. LPS-induced upregulation of Cav-1 expression in mouse coronary and aorta endothelial cells was shown by western blot and immunofluorescence (IF) staining (p < 0.01). Caveolin-1-knockout (Cav-1^-/-) mice had reduced aortic inflammation after LPS challenge, and fewer ST segment changes were observed through electrocardiogram (ECG) monitoring compared to wild type mice after LPS and ACh administration. In vitro, pretreating human umbilical vein endothelial cells (HUVECs) with siCav-1 to knock down Cav-1 expression reduced the endothelial inflammation following LPS challenge. SiCav-1 also partially reversed the attenuated Ca²⁺ concentration after LPS and ACh administration compared to the control group, which was evaluated by fluorescent molecular probing for Ca²⁺ alternation monitoring (p < 0.05). TLR4 and Myd88 downregulation by siRNA partially blocked the increased Cav-1 mRNA and protein expressions following LPS treatment, as well as partially reversed the decreased NO production evaluated by nitrate reductase method and the impaired Ca²⁺ concentration of endothelial cells induced by LPS and ACh.

CONCLUSION

These findings suggested that Cav-1, which was upregulated by TLR4-Myd88, served as an important modulator of CAS microenvironment establishment in vivo and in vitro, making it a potential pharmacologic target for the treatment of vasospasm via reduced endothelial cell inflammation.

The Pivotal Role of Invasive Functional Assessment in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA)

Myocardial infarction with non-obstructive coronary arteries (MINOCA) encompasses several pathophysiological mechanisms not yet fully understood. Among the latter, vasomotion abnormalities and coronary microvascular dysfunction (CMD) play a major role for both epidemiological and prognostic reasons. Despite current guidelines do not recommend routine physiological assessment of both epicardial and microvascular coronary compartments within the context of an acute myocardial infarction, several recent evidence support the critical role of a comprehensive invasive functional assessment in order to identify the underlying pathophysiological mechanism and consequently to select an appropriate therapeutic strategy. Unfortunately, optimal medical therapy for these patients is not currently established due to the lack of dedicated trials evaluating clinical outcomes of commonly used medications for secondary prevention in MINOCA patients. For this reason, additional research is warranted to provide personalized treatments for patients affected by this puzzling clinical entity.

[Infarto agudo de miocardio: revisión sobre factores de riesgo, etiología, hallazgos angiográficos y desenlaces en pacientes jóvenes]

La enfermedad cardiovascular persiste como primera causa mundial de muerte en los adultos. La población de adultos jóvenes ha cursado con cambios en el estilo de vida con el paso de las décadas, favoreciendo la aparición de ateroesclerosis en etapas más tempranas y como consecuencia la aparición de eventos cardiovasculares de manera más prematura. Se ha identificado que dentro de los factores de riesgo más comunes, la mayoría de ellos son potencialmente modificables. En comparación con adultos mayores, se ha identificado con mayor prevalencia la presencia de etiologías no ateroescleróticas de infarto de miocardio, como la disección coronaria espontánea, alteraciones anatómicas, embolia y espasmo coronarios. Los hallazgos angiográficos y desenlaces son diferentes de acuerdo con el grupo de edad y el sexo. Por dicho motivo realizamos una búsqueda en PubMed de los estudios y registros publicados para el estudio del infarto agudo de miocardio en paciente jóvenes. Con dicha información realizamos la presente revisión con el objetivo de una mejor comprensión de los hallazgos comunes en este grupo y realizar su comparación con grupos de mayor edad.

Current Evidence on Long-Term Prognostic Factors in Vasospastic Angina

Vasospastic angina (VSA) is characterized by a reversible spasm of the coronary arteries and is more prevalent in Asians. Vasodilators, such as calcium channel blockers, are effective in relieving coronary spasms and preventing clinical events. Therefore, the prognosis of VSA is generally known to be better than for significant organic stenosis caused by atherosclerosis. However, coronary vasospasm is sometimes associated with fatal complications such as sudden death, ventricular arrhythmia, and myocardial infarction. Thus, it is very important to identify and actively treat high-risk patients to prevent VSA complications. Here, we will review clinical factors associated with long-term prognosis in patients with VSA.

Prognostic implications of coronary artery stenosis and coronary spasm in patients with stable angina: 5-year follow-up of the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries (ACOVA) study

BACKGROUND

In the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries study, we showed that 62% of patients with stable angina and unobstructed coronary arteries had coronary spasm. In this study, we sought to assess the 5-year prognosis in these patients.

METHODS

Data regarding the following endpoints were obtained: death, non-fatal myocardial infarction, coronary event (=cardiac death or non-fatal myocardial infarction), persistent angina and repeated coronary angiography. Quality of life was assessed using the Seattle Angina Questionnaire.

RESULTS

Among patients with unobstructed coronary arteries there were three deaths (2.9%) and no non-fatal myocardial infarction. Among those with obstructive CAD 15 died (13.8%) and three had a non-fatal myocardial infarction (2.8%). Patients with obstructive CAD had a higher rate of all-cause death and coronary events compared to those without (P = 0.004). Persistent angina was more prevalent in patients with unobstructed coronaries (P = 0.042). Prognosis of patients with unobstructed coronaries regarding hard clinical events, persistent angina and repeated coronary angiography was independent of the presence of coronary spasm (all P > 0.05). However, spasm patients were more likely to take nitrate medication at follow-up (P = 0.029).

CONCLUSION

Patients with stable angina and unobstructed coronary arteries have a favorable prognosis regarding mortality and non-fatal myocardial infarction after 5 years compared to patients with obstructive CAD irrespective of the presence of coronary artery spasm. However, persistent angina remains a common issue in patients with unobstructed coronary arteries leading to a similar frequency of repeated invasive procedures as in patients with obstructive CAD.

Optical Coherence Tomography in Acute Coronary Syndromes

Advances in intravascular imaging have enabled assessment of the underlying plaque morphology in acute coronary syndromes, which allows for the initiation of individualized therapy. The atherothrombotic substrates for acute coronary syndromes consist of plaque rupture, erosion, and calcified nodule, whereas spontaneous coronary artery dissection, coronary artery spasm, and coronary embolism constitute rarer nonatherothrombotic etiologies. This review provides a brief overview of the data from clinical studies that have used intravascular optical coherence tomography to assess the culprit plaque morphology. We discuss the usefulness of intravascular imaging for effective treatment of patients presenting with acute coronary syndromes by percutaneous coronary intervention.

An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group

This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.

Revisiting the use of the provocative acetylcholine test in patients with chest pain and nonobstructive coronary arteries: A five-year follow-up of the AChPOL registry, with special focus on patients with MINOCA

This study aimed to assess the angiographic characteristics, feasibility and safety of the provocative test with acetylcholine (AChT), and the influence on further treatment and prognosis of Middle European patients in 5-year follow-up, especially focusing on those with a history of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA). The AChPOL Registry was an ongoing prospective single-center registry that included patients undergoing AChT from December 2010 to March 2013 for further diagnostic evaluation of a suspicious variant angina or coronary microvascular spasm, based on the COVADIS criteria. AChT was injected in incremental doses of 25, 50, and 75µg into the right coronary artery and 25, 50, and 100 µg into the left coronary artery, and the patients were followed up for 5 years. We enrolled 211 patients in the AChPOL Registry. Their mean age was 60.5 ± 7.8 years, with women accounting for 67.8%. The median follow-up was 56 months. AChT revealed variant angina in 99 patients (46.9%) and coronary microvascular spasm in the remaining 72 patients (34.1%). In patients with variant angina, spasm was most frequently observed in the left anterior descending artery (89.9%) and was most frequently diffuse (61.6%). In the microvascular spasm subgroup, there was a significantly higher rate of recurrent chest pain requiring hospitalization in the follow-up than in AChT negative patients. Interestingly, patients with a history of MINOCA had higher rates of MI and recurrent chest pain requiring hospitalization in the follow-up. We showed that AChT was safe in Middle European patients. In the follow-up patients with microvascular spasm and a history of MINOCA had the highest risk of MI and recurrent chest pain requiring hospitalization.

Review Article--Clinical Overview of Myocardial Infarction Without Obstructive Coronary Artey Disease (MINOCA)

The term myocardial infarction with non-obstructive coronary arteries (MINOCA) applies to patients who have clinical evidence of AMI but coronary angiography reveals no coronary obstructions and an alternative diagnosis is not possible. It is a heterogenous group of disease. Its prognosis, predictors of mortality and optimum management is unclear. In this review, we present a disease overview for MINOCA including the clinical features, adopted definitions, prevalence, diagnosis, treatment, and prognosis.