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Michallek F, Nakamura S, Kurita T, Ota H, Nishimiya K, Ogawa R, Shizuka T, Nakashima H, Wang YN, Ito T, Sakuma H, Dewey M, Kitagawa K. Differentiating Macrovascular and Microvascular Ischemia Using Fractal Analysis of Dynamic Myocardial Perfusion Stress-CT. Invest Radiol 2024; 59:413-423. [PMID: 37812495 DOI: 10.1097/rli.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Fractal analysis of dynamic myocardial stress computed tomography perfusion imaging (4D-CTP) has shown potential to noninvasively differentiate obstructive coronary artery disease (CAD) and coronary microvascular disease (CMD). This study validates fractal analysis of 4D-CTP in a multicenter setting and assesses its diagnostic accuracy in subgroups with ischemia and nonobstructed coronary arteries (INOCA) and with mild to moderate stenosis. MATERIALS AND METHODS From the AMPLIFiED multicenter trial, patients with suspected or known chronic myocardial ischemia and an indication for invasive coronary angiography were included. Patients underwent dual-source CT angiography, 4D-CTP, and CT delayed-enhancement imaging. Coronary artery disease, CMD, and normal perfusion were defined by a combined reference standard comprising invasive coronary angiography with fractional flow reserve, and absolute or relative CT-derived myocardial blood flow. Nonobstructed coronary arteries were defined as ≤25% stenosis and mild to moderate stenosis as 26%-80%. RESULTS In 127 patients (27% female), fractal analysis accurately differentiated CAD (n = 61, 23% female), CMD (n = 23, 30% female), and normal perfusion (n = 34, 35% female) with a multiclass area under the receiver operating characteristic curve (AUC) of 0.92 and high agreement (multiclass κ = 0.89). In patients with ischemia (n = 84), fractal analysis detected CAD (n = 61) over CMD (n = 23) with sensitivity of 95%, specificity of 74%, accuracy of 89%, and AUC of 0.83. In patients with nonobstructed coronary arteries (n = 33), INOCA (n = 15) was detected with sensitivity of 100%, specificity of 78%, accuracy of 88%, and AUC of 0.94. In patients with mild to moderate stenosis (n = 27), fractal analysis detected CAD (n = 19) over CMD with sensitivity of 84%, specificity of 100%, accuracy of 89%, and AUC of 0.95. CONCLUSIONS In this multicenter study, fractal analysis of 4D-CTP accurately differentiated CAD and CMD including subgroups with INOCA and with mild to moderate stenosis.
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Affiliation(s)
- Florian Michallek
- From the Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (F.M., M.D.); Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Japan (F.M., K.K.); Department of Radiology, Mie University Graduate School of Medicine, Tsu, Japan (S.N., H.S.); Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (T.K.); Department of Advanced MRI Collaborative Research, Tohoku University Graduate School of Medicine, Sendai, Japan (H.O.); Department of Cardiology, Tohoku University Graduate School of Medicine, Sendai, Japan (K.N.); Saiseikai Matsuyama Hospital, Matsuyama, Japan (R.O.); Takasaki General Medical Center, Takasaki, Japan (T.S.); National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan (H.N.); Peking Union Medical College Hospital, Beijing, China (Y.-N.W.); Kobe University Graduate School of Medicine, Kobe, Japan (T.I.); German Center for Cardiovascular Research, Berlin, Germany (M.D.); and Deutsches Herzzentrum der Charité (M.D.), Berlin, Germany
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Milasinovic D, Tesic M, Nedeljkovic Arsenovic O, Maksimovic R, Sobic Saranovic D, Jelic D, Zivkovic M, Dedovic V, Juricic S, Mehmedbegovic Z, Petrovic O, Trifunovic Zamaklar D, Djordjevic Dikic A, Giga V, Boskovic N, Klaric M, Zaharijev S, Travica L, Dukic D, Mladenovic D, Asanin M, Stankovic G. Correlation of Non-Invasive Transthoracic Doppler Echocardiography with Invasive Doppler Wire-Derived Coronary Flow Reserve and Their Impact on Infarct Size in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention. J Clin Med 2024; 13:2484. [PMID: 38731013 PMCID: PMC11084315 DOI: 10.3390/jcm13092484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/01/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Coronary microvascular dysfunction is associated with adverse prognosis after ST-segment elevation myocardial infarction (STEMI). We aimed to compare the invasive, Doppler wire-based coronary flow reserve (CFR) with the non-invasive transthoracic Doppler echocardiography (TTDE)-derived CFR, and their ability to predict infarct size. Methods: We included 36 patients with invasive Doppler wire assessment on days 3-7 after STEMI treated with primary percutaneous coronary intervention (PCI), of which TTDE-derived CFR was measured in 47 vessels (29 patients) within 6 h of the invasive Doppler. Infarct size was assessed by cardiac magnetic resonance at a median of 8 months. Results: The correlation between invasive and non-invasive CFR was modest in the overall cohort (rho 0.400, p = 0.005). It improved when only measurements in the LAD artery were considered (rho 0.554, p = 0.002), with no significant correlation in the RCA artery (rho -0.190, p = 0.435). Both invasive (AUC 0.888) and non-invasive (AUC 0.868) CFR, measured in the recanalized culprit artery, showed a good ability to predict infarct sizes ≥18% of the left ventricular mass, with the optimal cut off values of 1.85 and 1.80, respectively. Conclusions: In patients with STEMI, TTDE- and Doppler wire-derived CFR exhibit significant correlation, when measured in the LAD artery, and both have a similarly strong association with the final infarct size.
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Affiliation(s)
- Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Milorad Tesic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Olga Nedeljkovic Arsenovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ruzica Maksimovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dragana Sobic Saranovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
- Center for Nuclear Medicine with PET, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dario Jelic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Milorad Zivkovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Vladimir Dedovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Stefan Juricic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Zlatko Mehmedbegovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Olga Petrovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Danijela Trifunovic Zamaklar
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Ana Djordjevic Dikic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Vojislav Giga
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Nikola Boskovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Marija Klaric
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Stefan Zaharijev
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Lazar Travica
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Djordje Dukic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Djordje Mladenovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
| | - Milika Asanin
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (D.M.); (D.J.); (M.Z.); (V.D.); (S.J.); (Z.M.); (D.T.Z.); (V.G.); (N.B.); (M.K.); (S.Z.); (L.T.); (D.D.); (D.M.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (O.N.A.); (R.M.); (D.S.S.)
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Guerra E, Bergamaschi L, Tuttolomondo D, Pizzi C, Sartorio D, Gaibazzi N. Contrast Stress Echocardiography Findings in Myocardial Bridging Compared to Normal Coronary Course, With and Without Coronary Artery Disease. J Am Soc Echocardiogr 2023; 36:1092-1099. [PMID: 37356674 DOI: 10.1016/j.echo.2023.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD). METHODS We evaluated all consecutive patients who underwent contrast stress echocardiography and coronary computed tomography angiography (CCTA) due to suspected symptoms of CAD within 3 months in Parma Hospital. Coronary computed tomography angiography served as the reference standard for detecting MB and obstructive CAD. The patients were divided into 3 groups: (1) MB and no evidence of obstructive CAD (MB group, N = 64), (2) no evidence of obstructive CAD or MB (NoCAD group, N = 135), (3) obstructive CAD without MB (CAD group, N = 68). RESULTS The coronary flow velocity reserve in the LAD (CFVR-LAD) was reduced in the MB and CAD groups, measuring 1.91 ± 0.21 and 1.82 ± 0.28, respectively, whereas it was 2.27 ± 0.34 in the NoCAD group (P < .001). The MB and CAD groups exhibited a higher prevalence of reversible myocardial perfusion defects (rMPDs) compared to the NoCAD group (57.8% vs 64.7% vs 3.7%, P < .001). Reversible wall motion abnormalities were frequently observed in the CAD group and rarely found in the MB and NoCAD groups (47.1% vs 18.8% vs 4.4%, P < .001). In multivariable analyses, the presence of MB was independently associated with reduced CFVR-LAD (odds ratio = 14.55; 95% CI, 6.84-30.93; P < .001) and the presence of rMPD (odds ratio = 37.96; 95% CI, 13.49-106.84; P < .001). Patients with deep MB (>2 mm depth) and very deep MB (≥5 mm depth) exhibited significantly greater CFVR-LAD reduction and rMPD than those with superficial MB. CONCLUSIONS Myocardial bridging is capable of inducing rMPD and reducing CFVR-LAD similar to obstructive CAD. The depth of the MB correlates with the abnormalities found in the stress echo evaluation. Contrast stress echo may serve as a valuable noninvasive tool for evaluating patients with MB.
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Affiliation(s)
- Emiliano Guerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Luca Bergamaschi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Domenico Tuttolomondo
- Cardiology Division, Parma University Hospital, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Daniele Sartorio
- Cardiology Division, Parma University Hospital, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nicola Gaibazzi
- Cardiology Division, Parma University Hospital, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; PacC Heart Centre, Parma, Italy.
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Wu H, Xiao Z. A knowledge graph-based analytical model for mining clinical value of drug stress echocardiography for diagnosis, risk stratification and prognostic evaluation of coronary artery disease. Int J Cardiol 2023; 387:131107. [PMID: 37271285 DOI: 10.1016/j.ijcard.2023.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/04/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
The three major techniques for clinically diagnosing coronary heart disease, including angina associated with myocardial ischemia, are coronary angiography, myocardial perfusion imaging, and drug stress echocardiography. Compared to the first two methods, which are invasive or involve the use of radionuclides, drug stress echocardiography is increasingly used in clinical practice due to its non-invasive, low-risk, and controllable nature, and wide applicability. We developed a novel methodology to demonstrate knowledge graph-based efficacy analysis of drug stress echocardiography as a complement to traditional meta-analysis. By measuring coronary flow reserve (CFR), we discovered that regional ventricular wall abnormalities (RVWA) and drug-loaded cardiac ultrasound can be used to detect coronary artery disease. Additionally, drug-loaded cardiac ultrasound can be used to identify areas of cardiac ischemia, stratify risks, and determine prognosis. Furthermore, adenosine stress echocardiography(ASE) can determine atypical symptoms of coronary heart disease with associated cardiac events through CFR and related quantitative indices for risk stratification. Using a knowledge graph-based approach, we investigated the positive and negative effects of three drugs - Dipyridamole, Dobutamine, and Adenosine - for coronary artery disease analysis. Our findings show that Adenosine has the highest positive effect and the lowest negative effect among the three drugs. Due to its minimal and controlled side effects, and high sensitivity for diagnosing coronary microcirculation disorders and multiple lesions, adenosine is frequently used in clinical practice.
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Affiliation(s)
- Hongyi Wu
- Department of Cardiology, Zhongshan Hospital affiliated to Fudan University, Shanghai, China.
| | - Zhifeng Xiao
- School of Engineering, Penn State Erie, The Behrend College, Erie, 16563, PA, USA.
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Caiati C, Pollice P, Iacovelli F, Sturdà F, Lepera ME. Accelerated stenotic flow in the left anterior descending coronary artery explains the causes of impaired coronary flow reserve: an integrated transthoracic enhanced Doppler study. Front Cardiovasc Med 2023; 10:1186983. [PMID: 37745100 PMCID: PMC10515222 DOI: 10.3389/fcvm.2023.1186983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/10/2023] [Indexed: 09/26/2023] Open
Abstract
Background Accelerated stenotic flow (AsF) in the entire left anterior descending coronary artery (LAD), assessed by transthoracic enhanced color Doppler (E-Doppler TTE), can reveal coronary stenosis (CS) and its severity, enabling a distinction between the microcirculatory and epicardial causes of coronary flow reserve (CFR) impairment. Methods Eighty-four consecutive patients with a CFR <2.0 (1.5 ± 0.4), as assessed by E-Doppler TTE, scheduled for coronary angiography (CA) and eventually intracoronary ultrasounds (IVUS), were studied. CFR was calculated by the ratio of peak diastolic flow velocities: during i.v. adenosine (140 mcg/Kg/m) over resting; AsF was calculated as the percentage increase of localized maximal velocity in relation to a reference velocity. Results CA showed ≥50% lumen diameter narrowing of the LAD (critical CS) in 68% of patients (57/84) vs. non-critical CS in 32% (27/84). Based on the established CA/IVUS criteria, the non-critical CS subgroup was further subdivided into 2 groups: subcritical/diffuse [16/27 pts (57%)] and no atherosclerosis [11/27 pts (43%)]. CFR was similar in the three groups: 1.4 ± 0.3 in critical CS, 1.5 ± 0.4 in subcritical/diffuse CS, and 1.6 ± 0.4 in no atherosclerosis (p = ns). Overall, at least one segment of accelerated stenotic flow in the LAD was found in 73 patients (87%), while in 11 (13%) it was not. The AsF was very predictive of coronary segmental narrowing in both angio subgroups of atherosclerosis but as expected with the usage of different cutoffs. On the basis of the ROC curve, the optimal cutoff was 109% and 16% AsF % increment to successfully distinguish critical from non-critical CS (area under the curve [AUC] = 0.99, p < 0.001) and diffuse/subcritical from no CS (AUC = 0.91%, p < 0.001). Sensitivity and specificity were 96% and 100% and 82% and 100%, respectively. Conclusion E-Doppler TTE is highly feasible and reliable in detecting the CS of any grade of severity, distinguishing epicardial athero from microvascular causes of a severe CFR reduction.
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Affiliation(s)
- Carlo Caiati
- Unit of Cardiovascular Diseases, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
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Prodel E, Cavalvanti T, Divino B, Rocha HNM, Nobrega ACL. Sympathetic control of the coronary circulation during trigeminal nerve stimulation in humans. Eur J Appl Physiol 2023; 123:2063-2071. [PMID: 37179503 DOI: 10.1007/s00421-023-05208-1] [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: 01/12/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE We sought to investigate the sympathetic mechanism controlling coronary circulation during trigeminal nerve stimulation in healthy women. METHODS The protocol consisted of 3 min of trigeminal nerve stimulation (TGS) with cold stimuli to the face, in two conditions: (1) control and β-blockade (oral propranolol), and (2) control and α-blockade (oral prazosin). RESULTS Thirty-one healthy young subjects (women: n = 13; men: n = 18) participated in the study. By design, TGS decreased heart rate (HR), and increased blood pressure (BP) and cardiac output (CO). Before the β-blockade coronary blood velocity (CBV-Δ1.4 ± 1.3 cm s-1) increased along with the decrease of coronary vascular conductance index (CVCi-Δ-0.04 ± 0.04 cm s-1 mmHg-1) during TGS and the β-blockade abolished the CBV increase and a further decrease of CVCi was observed with TGS (Δ-0.06 ± 0.07 cm s-1 mmHg-1). During the α-blockade condition before the blockade, the CBV increased (Δ0.93 ± 1.48 cm s-1) along with the decrease of CVCi (Δ-0.05 ± 1.12 cm s-1 mmHg-1) during TGS, after the α-blockade CBV (Δ0.98 ± cm s-1) and CVCi (Δ-0.03 ± 0.06 cm s-1 mmHg-1) response to TGS did not change. CONCLUSION Coronary circulation increases during sympathetic stimulation even with a decrease in heart rate.
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Affiliation(s)
- Eliza Prodel
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Alameda Barros Terra S/N, Niteroi, Rio de Janeiro, Brazil.
- National Institute for Science & Technology-INCT (In)Activity & Exercise, Rio de Janeiro, Brazil.
| | - Thiago Cavalvanti
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Alameda Barros Terra S/N, Niteroi, Rio de Janeiro, Brazil
- National Institute for Science & Technology-INCT (In)Activity & Exercise, Rio de Janeiro, Brazil
| | - Beatriz Divino
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Alameda Barros Terra S/N, Niteroi, Rio de Janeiro, Brazil
- National Institute for Science & Technology-INCT (In)Activity & Exercise, Rio de Janeiro, Brazil
| | - Helena N M Rocha
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Alameda Barros Terra S/N, Niteroi, Rio de Janeiro, Brazil
- National Institute for Science & Technology-INCT (In)Activity & Exercise, Rio de Janeiro, Brazil
| | - Antonio C L Nobrega
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Alameda Barros Terra S/N, Niteroi, Rio de Janeiro, Brazil
- National Institute for Science & Technology-INCT (In)Activity & Exercise, Rio de Janeiro, Brazil
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Kardos A, Soulis D, Becher H. Multiparametric Stress Echocardiography in the Diagnosis of IOCA and INOCA: Role of CFVR Measurement. JACC Case Rep 2023; 19:101941. [PMID: 37593587 PMCID: PMC10429733 DOI: 10.1016/j.jaccas.2023.101941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 08/19/2023]
Abstract
We present assessment of chest pain patients by multiparametric dobutamine stress echocardiography to differentiate inducible ischemia with obstructive coronary artery disease and with no obstructive coronary artery disease. In addition to the classical regional wall motion abnormality, we illustrate how coronary flow velocity reserve by Doppler echocardiography assists diagnosing coronary microvascular dysfunction. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Attila Kardos
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
- Faculty of Medicine and Health Sciences, University of Buckingham, Buckingham, UK
| | | | - Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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9
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Civieri G, Masiero G, Osto E, Gambino A, Angelini A, Fraiese A, Fedrigo M, Toscano G, Bottio T, Perazzolo Marra M, Iliceto S, Gerosa G, Tona F. Coronary Collateral Circulation: A New Predictor of Mortality in Heart Transplant Recipients With Allograft Vasculopathy. Transplant Direct 2023; 9:e1470. [PMID: 37090121 PMCID: PMC10118324 DOI: 10.1097/txd.0000000000001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 04/25/2023] Open
Abstract
Coronary collateral arteries (CCAs) are anastomotic channels between vessels; although beneficial in atherosclerosis, their role in heart transplantation (HT) recipients is underinvestigated. CCAs initially develop as microcirculation and cardiac allograft vasculopathy (CAV), promoting immune-dependent proliferative angiogenic response, and play a role in their development. In our hypothesis, ischemia induced by coronary microvascular dysfunction (CMD) triggers the development of CCAs, which are, in turn, less functional as affected by CAV themselves. Methods One hundred twenty-one patients receiving HT at our institution were retrospectively evaluated and were included if transthoracic echocardiography with coronary flow velocity reserve (CFVR) assessment and coronary angiography were performed. CMD was defined as CFVR of ≤2.5. Patients with CAV were enrolled, and their angiograms were reviewed to evaluate the presence of CCAs. Cardiovascular mortality was assessed as the main clinical outcome. Results Forty patients were found to have CCAs. Patients with CCAs have lower CFVR than those without CCAs (2.22 ± 0.72 versus 2.69 ± 0.92;P = 0.003), reflecting in different rates of CMD in the 2 groups (72.5% versus 37%; P < 0.001). CMD is associated with higher CAV grades (P < 0.001), which are also associated with CCAs (P < 0.001). Patients with poorly developed CCAs have lower CFVR (P < 0.001). At multivariable analysis, CMD (P = 0.008) and higher CAV grades (P = 0.005) are independent predictors of CCAs. During the median follow-up time of 10.2 (6.6-13.3) y, patients with CCAs have been found to have higher mortality than those without CCAs (57.5% versus 32.1%; P = 0.007). CCAs are associated with a lower probability of survival also in patients with CMD (P < 0.001) and are independent predictors of mortality (P < 0.001). Conclusions Our results demonstrate an interplay between CAV, CMD, and CCAs. We confirm that CAV is associated with CMD, and we show, for the first time, that CMD is associated with CCAs. CCAs are pathophysiologically associated with more severe graft vasculopathy and independently predict mortality after HT.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Masiero
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elena Osto
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
- Institute for Clinical Chemistry, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Antonio Gambino
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Annalisa Angelini
- Cardiac Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Angela Fraiese
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Marny Fedrigo
- Cardiac Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Toscano
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Tomaso Bottio
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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10
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Montisci R, Marchetti MF, Ruscazio M, Biddau M, Secchi S, Zedda N, Casula R, Tuveri F, Kerkhof PLM, Meloni L, Tona F. Non-invasive coronary flow velocity reserve assessment predicts adverse outcome in women with unstable angina without obstructive coronary artery stenosis. J Public Health Res 2023; 12:22799036231181716. [PMID: 37333028 PMCID: PMC10264896 DOI: 10.1177/22799036231181716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Background Evaluation of coronary flow velocity reserve (CFVR) is the physiological approach to assess the severity of coronary stenosis and microvascular dysfunction. Impaired CFVR occurs frequently in women with suspected or known coronary artery disease. The aim of this study was to assess the role of CFVR to predict long-term cardiovascular event rate in women with unstable angina (UA) without obstructive coronary artery stenosis. Methods CFVR in left anterior descending coronary artery was assessed by adenosine transthoracic echocardiograhy in 161 women admitted at our Department with UA and without obstructive coronary artery disease. Results During a mean FU of 32.5 ± 19.6 months, 53 cardiac events occurred: 6 nonfatal acute myocardial infarction, 22 UA, 7 coronary revascularization by percutaneous transluminal coronary angioplasty, 1 coronary bypass surgery, 3 ischemic stroke, and 8 episodes of congestive heart failure with preserved ejection fraction and 6 cardiac deaths. Using a ROC curve analysis, CFVR 2.14 was the best predictor of cardiac events and was considered as abnormal CFVR. Abnormal CFVR was associated with lower cardiac event-free survival (30 vs 80%, p < 0.0001). During FU, 70% of women with reduced CFVR had cardiac events whereas only 20% with normal CFVR (p = 0.0001). At multivariate Cox analysis, smoke habitus (p = 0.003), metabolic syndrome (p = 0.01), and CFVR (p < 0.0001) were significantly associated with cardiac events at FU. Conclusion Noninvasive CFVR provides an independent predictor of cardiovascular prognosis information in women with UA without obstructive coronary artery disease whereas, impaired CFVR seems to be associated with higher CV events at FU.
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Affiliation(s)
- Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Maria Francesca Marchetti
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Massimo Ruscazio
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Mattia Biddau
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Sara Secchi
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Norma Zedda
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Roberto Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Francesca Tuveri
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Peter LM Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Luigi Meloni
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Francesco Tona
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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11
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Hausvater A, Schlamp F, Smilowitz NR. A Multi-Biomarker Approach to Understanding Coronary Microvascular Dysfunction: Making Sense of a Complex Disease. JACC. ADVANCES 2023; 2:100282. [PMID: 38938302 PMCID: PMC11198315 DOI: 10.1016/j.jacadv.2023.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Anaïs Hausvater
- Leon H. Charney Division of Cardiology, Department of Medicine, Sarah Ross Soter Center for Women’s Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA
| | - Florencia Schlamp
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Nathaniel R. Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, Sarah Ross Soter Center for Women’s Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA
- Section of Cardiology, Department of Medicine, VA NY Harbor Health Care System, New York, New York, USA
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12
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Heart Rate Lowering Significantly Increases Feasibility in Doppler Recording Blood Flow Velocity in Coronaries during Transthoracic Doppler Echocardiography. Diagnostics (Basel) 2023; 13:diagnostics13040670. [PMID: 36832158 PMCID: PMC9955744 DOI: 10.3390/diagnostics13040670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023] Open
Abstract
Background: Coronary blood flow Doppler recording by Transthoracic Doppler in convergent mode (E-Doppler TTE) might be further improved by lowering heart rate (HRL) down to <60 bpm, since low HR < 60 b/m causes a disproportional lengthening of the diastole, so the coronaries are still for a longer time, very much improving the Doppler signal/noise ratio. Methods: A group of 26 patients underwent E-Doppler TTE before and after HR lowering in four branches of the coronary tree, namely, the left main (LMCA); left anterior descending (LAD), subdivided into three segments: proximal, mid and distal; proximal left circumflex (LCx); and obtuse marginal (OM). Color and PW coronary Doppler signal was judged by two expert observers as undetectable (SCORE 1), weak or with clutter artifacts (SCORE 2), or well delineated (SCORE 3). In addition, local accelerated stenotic flow (AsF) was measured in the LAD before and after HRL. Results: Beta-blockers significantly decreased the mean HR from 76 ± 5 to 57 ± 6 bpm (p < 0.001). Before HRL, the Doppler quality was very poor in the proximal and mid-LAD segments (median score value = 1 in both), while in the distal LAD, it was significantly better but still suboptimal (median score value = 1.5, p = 0.009 vs. proximal and mid-LAD score). After HRL, blood flow Doppler recording in the three LAD segments was strikingly improved (median score value = 3, 3 and 3, p = ns), so the effect of HRL was more efficacious in the two more proximal LAD segments. In 10 patients undergoing coronary angiography (CA), no AsF as expression of transtenotic velocity was detected at baseline. After HRL, thanks to the better quality and length of color flow, ASF was detected in five patients while in five others, it was not in perfect agreement with CA (Spearman correlation coefficient = 1, p < 0.01). The color flow in the proximal LCx and OM was extremely poor at baseline (color flow length 0 and 0, median (interquartile range) mm, respectively) and improved considerably after HRL (color flow length 23 [13.5] and 25 [12.0] mm, respectively, p < 0.001). Conclusions: HRL greatly improved the success rate of blood flow Doppler recording in coronaries, not only in the LAD, but also in the LCx. Therefore, AsF for stenosis detection and coronary flow reserve assessment can have wider clinical applications. However, further studies with larger samples are needed to confirm these results.
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Li Y, Xu W, Guo L. Anxiety is associated with coronary microvascular dysfunction: Results from the CAMADA study. Microcirculation 2023; 30:e12798. [PMID: 36633351 DOI: 10.1111/micc.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/25/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) is an important component of ischemic heart disease. Here, we assessed the associations between anxiety/depression and CMD using coronary microvascular function indicators. METHODS The study included 81 patients (26 males and 55 females) with nonobstructive coronary artery disease. The symptoms of anxiety and depression were measured with Self-rating Anxiety Scale and Self-rating Depression Scale. Coronary microvascular function was assessed using coronary flow reserve (CFR) measured by transthoracic Doppler echocardiography. RESULTS The anxiety group had significantly lower CFR than that in the no-anxiety group (2.97 ± 0.63 vs. 3.40 ± 0.61, p = .029). In bivariate correlation analysis, anxiety was negatively associated with CFR (r = -.333, p = .002). In the multiple linear regression model, after adjusting for age, sex, BMI, hypertension, dyslipidemia, smoking status, and family history of premature coronary heart disease, anxiety was negatively associated with CFR (β = -.314, p = .008). When both anxiety and depression were included in the multiple linear regression model, anxiety was also negatively associated with CFR (β = -.345, p = .012). CONCLUSION Anxiety patients had lower CFR, anxiety was independently associated with CFR. Psychological disorders may play an important role in coronary microvascular dysfunction.
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Affiliation(s)
- Ying Li
- Department of Geriatrics, Peking University Third Hospital, Beijing, China
| | - Weixian Xu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
| | - Lijun Guo
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
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14
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Civieri G, Montisci R, Kerkhof PLM, Iliceto S, Tona F. Coronary Flow Velocity Reserve by Echocardiography: Beyond Atherosclerotic Disease. Diagnostics (Basel) 2023; 13:diagnostics13020193. [PMID: 36673004 PMCID: PMC9858233 DOI: 10.3390/diagnostics13020193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Coronary flow velocity reserve (CFVR) is defined as the ratio between coronary flow velocity during maximal hyperemia and coronary flow at rest. Gold-standard techniques to measure CFVR are either invasive or require radiation and are therefore inappropriate for large-scale adoption. More than 30 years ago, echocardiography was demonstrated to be a reliable tool to assess CFVR, and its field of application rapidly expanded. Although initially validated to assess the hemodynamic relevance of a coronary stenosis, CFVR by echocardiography was later used to investigate coronary microcirculation. Microvascular dysfunction was detected in many different conditions, ranging from organ transplantation to inflammatory disorders and from metabolic diseases to cardiomyopathies. Moreover, it has been proven that CFVR by echocardiography not only detects coronary microvascular involvement but is also an effective prognostic factor that allows a precise risk stratification of the patients. In this review, we will summarize the many applications of CFVR by echocardiography, focusing on the coronary involvement of systemic diseases.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, 09124 Cagliari, Italy
| | - Peter L. M. Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, 1081 HV Amsterdam, The Netherlands
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
- Correspondence: ; Tel.: +39-049-8211844
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15
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Caiati C, Iacovelli F, Mancini G, Lepera ME. Hidden Coronary Atherosclerosis Assessment but Not Coronary Flow Reserve Helps to Explain the Slow Coronary Flow Phenomenon in Patients with Angiographically Normal Coronary Arteries. Diagnostics (Basel) 2022; 12:diagnostics12092173. [PMID: 36140575 PMCID: PMC9497914 DOI: 10.3390/diagnostics12092173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/27/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
The significance of the slow coronary flow phenomenon (SCFph), as visualized in patients (pts) with angiographically normal coronary arteries, is controversial. Absolute coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD), non-invasively assessed by a transthoracic color-guided pulsed-wave Doppler (E-Doppler TTE), is a reliable parameter to assess coronary microcirculatory dysfunction (CMD). Mild and angiographically hidden epicardial atherosclerosis (Hath), as visualized by intracoronary ultrasound (IVUS), which could be the clue to atherosclerotic coronary microvascular involvement, has never been investigated together with CFR in patients. This study was aimed at assessing the value of CFR and HA in explaining the SCFph. Methods. Both non-invasive assessment of CFR in the LAD and corrected TIMI frame count assessment of the coronary contrast runoff were performed in 124 pts with angiographically normal coronary arteries. Among the whole group, 32 patients also underwent intracoronary ultrasounds in the LMCA and LAD, and the maximal plaque burden was assessed (Lesion external elastic (EEM) cross sectional area (CSA)—Lesion Lumen CSA/Lesion EEM CSA * 100). We found that 24 of the 124 pts (group 1) had the SCFph and the remaining 100 had a normal runoff (group 2). CFR, evaluated in both groups, was not significantly different, being 2.79 ± 0.79 (Mean ± SD) in group 1 and 2.90 ± 0.8 in group 2 (p = ns); in the pts also examined by IVUS (32 pts), the SCFph was always associated with hidden atherosclerosis, and a plaque burden of ≥33%. On the contrary, in the normal runoff group, any grade of PB was observed (from no athero to a PB > 70%) and remarkably, 10 pts had no signs of athero or just a minimal plaque burden. This resulted in a ROC curve analysis in which PB < 33% had a high negative predictive value (100%) in ruling out the SCFph. In addition, considering a CFR value < 2.21 as an index of coronary microcirculatory dysfunction, we found CMD in 15 pts (15%) in group 1 and in 7 pts (29%) in group 2 (p = ns). In conclusion, the SCFph is strongly connected to epicardial athero to the extent that the absence of hidden coronary athero has a very high negative predictive power in ruling out SCFph. CFR that is based on an endothelium-independent mechanism remains fairly normal in this condition. An endothelium-dependent microcirculatory constriction at rest due to atherosclerotic involvement of the coronary microvascular network is a possible explanation of the SCFph.
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Affiliation(s)
- Carlo Caiati
- Correspondence: ; Tel.: +39-080-5592117; Fax: +39-080-5478796
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Cecere A, Kerkhof PLM, Civieri G, Angelini A, Gambino A, Fraiese A, Bottio T, Osto E, Famoso G, Fedrigo M, Giacomin E, Toscano G, Montisci R, Iliceto S, Gerosa G, Tona F. Coronary Flow Evaluation in Heart Transplant Patients Compared to Healthy Controls Documents the Superiority of Coronary Flow Velocity Reserve Companion as Diagnostic and Prognostic Tool. Front Cardiovasc Med 2022; 9:887370. [PMID: 35811712 PMCID: PMC9263115 DOI: 10.3389/fcvm.2022.887370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDistinct contributions by functional or structural alterations of coronary microcirculation in heart transplantation (HT) and their prognostic role have not been fully elucidated. We aimed to identify the mechanisms of coronary microvascular dysfunction (CMD) in HT and their prognostic implications.Methods134 patients, surviving at least 5 years after HT, without evidence of angiographic vasculopathy or symptoms/signs of rejection were included. 50 healthy volunteers served as controls. All underwent the assessment of rest and hyperemic coronary diastolic peak flow velocity (DPVr and DPVh) and coronary flow velocity reserve (CFVR) and its inherent companion that is based on the adjusted quadratic mean: CCFVR = √{(DPVr)2 + (DPVh)2}. Additionally, basal and hyperemic coronary microvascular resistance (BMR and HMR) were estimated.ResultsBased on CFVR and DPVh, HT patients can be assigned to four endotypes: endotype 1, discordant with preserved CFVR (3.1 ± 0.4); endotype 2, concordant with preserved CFVR (3.4 ± 0.5); endotype 3, concordant with impaired CFVR (1.8 ± 0.3) and endotype 4, discordant with impaired CFVR (2.0 ± 0.2). Intriguingly, endotype 1 showed lower DPVr (p < 0.0001) and lower DPVh (p < 0.0001) than controls with lower CFVR (p < 0.0001) and lower CCFVR (p < 0.0001) than controls. Moreover, both BMR and HMR were higher in endotype 1 than in controls (p = 0.001 and p < 0.0001, respectively), suggesting structural microvascular remodeling. Conversely, endotype 2 was comparable to controls. A 13/32 (41%) patients in endotype 1 died in a follow up of 28 years and mortality rate was comparable to endotype 3 (14/31, 45%). However, CCFVR was < 80 cm/s in all 13 deaths of endotype 1 (characterized by preserved CFVR). At multivariable analysis, CMD, DPVh < 75 cm/s and CCFVR < 80 cm/s were independent predictors of mortality. The inclusion of CCFVR < 80 cm/s to models with clinical indicators of mortality better predicted survival, compared to only adding CMD or DPVh < 75 cm/s (p < 0.0001 and p = 0.03, respectively).ConclusionA normal CFVR could hide detection of microvasculopathy with high flow resistance and low flow velocities at rest. This microvasculopathy seems to be secondary to factors unrelated to HT (less rejections and more often diabetes). The combined use of CFVR and CCFVR provides more complete clinical and prognostic information on coronary microvasculopathy in HT.
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Affiliation(s)
- Annagrazia Cecere
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Peter L. M. Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Giovanni Civieri
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Annalisa Angelini
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Antonio Gambino
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Angela Fraiese
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Tomaso Bottio
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Elena Osto
- Cardiology, University Heart Center, University Hospital of Zürich, Zurich, Switzerland
- Institute of Clinical Chemistry, University of Zurich, University Hospital of Zürich, Zurich, Switzerland
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marny Fedrigo
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Enrico Giacomin
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
- *Correspondence: Francesco Tona,
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Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SE, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. A Practical Approach to Invasive Testing in Ischemia with No Obstructive Coronary Arteries (INOCA). CJC Open 2022; 4:709-720. [PMID: 36035733 PMCID: PMC9402961 DOI: 10.1016/j.cjco.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
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Affiliation(s)
- Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
- Corresponding author: Dr Alexandra Bastiany, Thunder Bay Regional Health Sciences Centre, Catheterization Laboratory, 980 Oliver Rd, Thunder Bay, Ontario P7B 6V4, Canada. Tel.: +1-807-622-3091; fax: +1-807-333-0903.
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Université de Montréal, Montreal, Quebec, Canada
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Tara Sedlak
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaqueline Saw
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Shuangbo Liu
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Lavoie
- Saskatchewan Health Authority and Regina Mosaic Heart Centre, Regina, Saskatchewan, Canada
| | - Daniel H. Kim
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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18
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Tona F, Osto E, Kerkhof PLM, Montisci R, Famoso G, Lorenzoni G, De Michieli L, Cecere A, Zanetti I, Civieri G, Iliceto S, Piaserico S. Multiparametric analysis of coronary flow in psoriasis using a coronary flow reserve companion. Eur J Clin Invest 2022; 52:e13711. [PMID: 34780064 PMCID: PMC9286413 DOI: 10.1111/eci.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is usually evaluated measuring coronary flow velocity reserve (CFVR). A more comprehensive analysis of CFVR including additional consideration of the associated logical companion-CFVR, where hyperemic diastolic coronary flow velocity may act as surrogate, was applied in this study to elucidate the mechanism of CMD in psoriasis. METHODS AND RESULTS Coronary flow velocity reserve was analysed using transthoracic echocardiographs of 127 psoriasis patients (age 36 ± 8 years; 104 males) and of 52 sex- and age-matched healthy controls. CFVR determination was repeated in the patient subgroup (n = 78) receiving anti-inflammatory therapy. Baseline and hyperemic microvascular resistance (MR) were calculated. CMD was defined as CFVR ≤ 2.5. Four endotypes of CMD were identified referring to concordant or discordant impairments of hyperemic flow or CFVR. We evaluated the companion-CFVR, as derived from the quadratic mean of hyperemic and diastolic flow velocity at rest. Coronary flow parameters, including CFVR (p = 0.01), were different among the two endotypes having CFVR > 2.5. Specifically, all 11 (14%) patients with CFVR deterioration despite therapy, belonged to endotype 1, and had higher baseline and hyperemic MR (p < 0.0001, both). Interestingly, while CFVR was comparable in patients with worsened versus those with improved CFVR, the companion-CFVR could discriminate by being lower in patients with worsened CFVR (p = 0.01). CONCLUSIONS The reduced CFVR in psoriasis is driven by decreased companion-CFVR, combined with increased hyperemic MR. Adoption of the mandatory companion-CFVR enables a personalized characterization superior to that achieved by exclusive consideration of CFVR.
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Affiliation(s)
- Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Elena Osto
- University Heart Center, University Hospital Zurich & University of Zurich, Zurich, Switzerland.,Institute of Clinical Chemistry, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Peter L M Kerkhof
- Amsterdam University Medical Centers, VUmc, Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Annagrazia Cecere
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Irene Zanetti
- Dermatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Giovanni Civieri
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padova, Padova, Italy
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19
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Spione F, Arevalos V, Gabani R, Sabaté M, Brugaletta S. Coronary Microvascular Angina: A State-of-the-Art Review. Front Cardiovasc Med 2022; 9:800918. [PMID: 35433857 PMCID: PMC9005807 DOI: 10.3389/fcvm.2022.800918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/08/2022] [Indexed: 12/28/2022] Open
Abstract
Up to 60–70% of patients, undergoing invasive coronary angiography due to angina and demonstrable myocardial ischemia with provocative tests, do not have any obstructive coronary disease. Coronary microvascular angina due to a dysfunction of the coronary microcirculation is the underlying cause in almost 50% of these patients, associated with a bad prognosis and poor quality of life. In recent years, progress has been made in the diagnosis and management of this condition. The aim of this review is to provide an insight into current knowledge of this condition, from current diagnostic methods to the latest treatments.
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Affiliation(s)
- Francesco Spione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Victor Arevalos
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rami Gabani
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- *Correspondence: Salvatore Brugaletta,
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20
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Wellens’ Syndrome from COVID-19 Infection Assessed by Enhanced Transthoracic Coronary Echo Doppler: A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12040804. [PMID: 35453852 PMCID: PMC9029647 DOI: 10.3390/diagnostics12040804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/23/2022] [Accepted: 03/23/2022] [Indexed: 12/26/2022] Open
Abstract
Wellens’ syndrome (WS) is a preinfarction state caused by a sub-occlusion of the proximal left anterior descending coronary artery (LAD). In this case report, for the first time, we describe how this syndrome can be caused by COVID-19 infection and, most importantly, that it can be assessed bedside by enhanced transthoracic coronary echo Doppler (E-Doppler TTE). This seasoned technique allows blood flow Doppler to be recorded in the coronaries and at the stenosis site but has never been tested in an acute setting. Two weeks after clinical recovery from bronchitis allegedly caused by COVID-19 infection on the basis of epidemiologic criteria (no swab performed during the acute phase but only during recovery, at which time it was negative), our patient developed typical angina for the first time, mainly during effort but also at rest. He was admitted to our tertiary center, where pharyngeal swabs tested positive for COVID-19. A typical EKG finding supporting WS prompted an assessment of the left main coronary artery (LMCA) and the whole LAD blood flow velocity by E-Doppler TTE. Localized high velocity (transtenotic velocity) (100 cm/s) was recorded in the proximal LAD, with the reference velocity being 20 cm/s. This indicated severe stenosis with 90% area narrowing according to the continuity equation, as confirmed by coronary angiography. During follow-up after successful stenting, E-Doppler TTE showed a decrease in the transtenotic acceleration, confirming stent patency and a normal coronary flow reserve (3.2) and illustrating a normal microcirculatory function. Conclusion: COVID infection can trigger a coronary syndrome like WS. E-Doppler TTE, an ionizing radiation-free method, allows safe and rapid bedside management of the syndrome. This new strategy can be pivotal in distinguishing true WS from pseudo-WS. In cases of pseudo-WS, coronary angiography can be avoided. If E-Doppler TTE confirms the stenosis and PCI (percutaneous coronary intervention) is performed, the same method can allow assessment over time of the precise residual stenosis after stenting and verify the microvasculature status by evaluating coronary flow reserve.
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Fu B, Wei X, Lin Y, Chen J, Yu D. Pathophysiologic Basis and Diagnostic Approaches for Ischemia With Non-obstructive Coronary Arteries: A Literature Review. Front Cardiovasc Med 2022; 9:731059. [PMID: 35369287 PMCID: PMC8968033 DOI: 10.3389/fcvm.2022.731059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/31/2022] [Indexed: 02/05/2023] Open
Abstract
Ischemia with non-obstructive coronary arteries (INOCA) has gained increasing attention due to its high prevalence, atypical clinical presentations, difficult diagnostic procedures, and poor prognosis. There are two endotypes of INOCA-one is coronary microvascular dysfunction and the other is vasospastic angina. Diagnosis of INOCA lies in evaluating coronary flow reserve, microcirculatory resistance, and vasoreactivity, which is usually obtained via invasive coronary interventional techniques. Non-invasive diagnostic approaches such as echocardiography, single-photon emission computed tomography, cardiac positron emission tomography, and cardiac magnetic resonance imaging are also valuable for assessing coronary blood flow. Some new techniques (e.g., continuous thermodilution and angiography-derived quantitative flow reserve) have been investigated to assist the diagnosis of INOCA. In this review, we aimed to discuss the pathophysiologic basis and contemporary and novel diagnostic approaches for INOCA, to construct a better understanding of INOCA evaluation.
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Affiliation(s)
- Bingqi Fu
- Shantou University Medical College, Shantou, China
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuebiao Wei
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Division of Geriatric Intensive Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingwen Lin
- Shantou University Medical College, Shantou, China
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiyan Chen
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Danqing Yu
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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22
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Ischemia and no obstructive coronary arteries in patients with stable ischemic heart disease. Int J Cardiol 2022; 348:1-8. [PMID: 34902504 PMCID: PMC8779638 DOI: 10.1016/j.ijcard.2021.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 11/30/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.
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Myocardial Microvascular Physiology in Acute and Chronic Coronary Syndromes, Aortic Stenosis, and Heart Failure. J Interv Cardiol 2022; 2022:9846391. [PMID: 35935124 PMCID: PMC9297731 DOI: 10.1155/2022/9846391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 01/10/2023] Open
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24
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Gaibazzi N, Tuttolomondo D, Guaricci AI, De Marco F, Pontone G. Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide. J Cardiovasc Med (Hagerstown) 2022; 23:12-21. [PMID: 34366402 DOI: 10.2459/jcm.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.
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Affiliation(s)
| | | | | | - Federico De Marco
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese
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25
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Aleksandric SB, Djordjevic-Dikic AD, Giga VL, Tesic MB, Soldatovic IA, Banovic MD, Dobric MR, Vukcevic V, Tomasevic MV, Orlic DN, Boskovic N, Jovanovic I, Nedeljkovic MA, Stankovic G, Ostojic MC, Beleslin BD. Coronary Flow Velocity Reserve Using Dobutamine Test for Noninvasive Functional Assessment of Myocardial Bridging. J Clin Med 2021; 11:jcm11010204. [PMID: 35011945 PMCID: PMC8745827 DOI: 10.3390/jcm11010204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background: It has been shown that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during dobutamine (DOB) provocation provides a more accurate functional evaluation of myocardial bridging (MB) compared to adenosine. However; the cut-off value of CFVR during DOB for identification of MB associated with myocardial ischemia has not been fully clarified. Purpose: This prospective study aimed to determine the cut-off value of TTDE-CFVR during DOB in patients with isolated-MB, as compared with stress-induced wall motion abnormalities (VMA) during exercise stress-echocardiography (SE) as reference. Methods: Eighty-one symptomatic patients (55 males [68%], mean age 56 ± 10 years; range: 27–74 years) with the existence of isolated-MB on the left anterior descending artery (LAD) and systolic MB-compression ≥50% diameter stenosis (DS) were eligible to participate in the study. Each patient underwent treadmill exercise-SE, invasive coronary angiography, and TTDE-CFVR measurements in the distal segment of LAD during DOB infusion (DOB: 10–40 μg/kg/min). Using quantitative coronary angiography, both minimal luminal diameter (MLD) and percent DS at MB-site at end-systole and end-diastole were determined. Results: Stress-induced myocardial ischemia with the occurrence of WMA was found in 23 patients (28%). CFVR during peak DOB was significantly lower in the SE-positive group compared with the SE-negative group (1.94 ± 0.16 vs. 2.78 ± 0.53; p < 0.001). ROC analyses identified the optimal CFVR cut-off value ≤ 2.1 obtained during high-dose dobutamine (>20 µg/kg/min) for the identification of MB associated with stress-induced WMA, with a sensitivity, specificity, positive and negative predictive value of 96%, 95%, 88%, and 98%, respectively (AUC 0.986; 95% CI: 0.967–1.000; p < 0.001). Multivariate logistic regression analysis revealed that MLD and percent DS, both at end-diastole, were the only independent predictors of ischemic CFVR values ≤2.1 (OR: 0.023; 95% CI: 0.001–0.534; p = 0.019; OR: 1.147; 95% CI: 1.042–1.263; p = 0.005; respectively). Conclusions: Noninvasive CFVR during dobutamine provocation appears to be an additional and important noninvasive tool to determine the functional severity of isolated-MB. A transthoracic CFVR cut-off ≤2.1 measured at a high-dobutamine dose may be adequate for detecting myocardial ischemia in patients with isolated-MB.
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Affiliation(s)
- Srdjan B. Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
- Correspondence:
| | - Ana D. Djordjevic-Dikic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Vojislav L. Giga
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Milorad B. Tesic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Ivan A. Soldatovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Marko D. Banovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Milan R. Dobric
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Vladan Vukcevic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Miloje V. Tomasevic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Dejan N. Orlic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Nikola Boskovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
| | - Ivana Jovanovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
| | - Milan A. Nedeljkovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Goran Stankovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
| | - Miodrag C. Ostojic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
- Institute for Cardiovascular Diseases Dedinje, 11000 Belgrade, Serbia
| | - Branko D. Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.D.D.-D.); (V.L.G.); (M.B.T.); (M.D.B.); (M.R.D.); (V.V.); (M.V.T.); (D.N.O.); (N.B.); (I.J.); (M.A.N.); (G.S.); (B.D.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.A.S.); (M.C.O.)
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Tanno M, Osanami A. Insulin Resistance - Beginning of the Road to Coronary Microvascular Dysfunction and Beyond. Circ J 2021; 86:874-876. [PMID: 34937818 DOI: 10.1253/circj.cj-21-0979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masaya Tanno
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Arata Osanami
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
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Sagris M, Theofilis P, Antonopoulos AS, Oikonomou E, Paschaliori C, Galiatsatos N, Tsioufis K, Tousoulis D. Inflammation in Coronary Microvascular Dysfunction. Int J Mol Sci 2021; 22:ijms222413471. [PMID: 34948272 PMCID: PMC8703507 DOI: 10.3390/ijms222413471] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic low-grade inflammation is involved in coronary atherosclerosis, presenting multiple clinical manifestations ranging from asymptomatic to stable angina, acute coronary syndrome, heart failure and sudden cardiac death. Coronary microvasculature consists of vessels with a diameter less than 500 μm, whose potential structural and functional abnormalities can lead to inappropriate dilatation and an inability to meet the required myocardium oxygen demands. This review focuses on the pathogenesis of coronary microvascular dysfunction and the capability of non-invasive screening methods to detect the phenomenon. Anti-inflammatory agents, such as statins and immunomodulators, including anakinra, tocilizumab, and tumor necrosis factor-alpha inhibitors, have been assessed recently and may constitute additional or alternative treatment approaches to reduce cardiovascular events in atherosclerotic heart disease characterized by coronary microvascular dysfunction.
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Affiliation(s)
- Marios Sagris
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
- Correspondence: ; Tel.:+30-213-2088099; Fax: +30-213-2088676
| | - Panagiotis Theofilis
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
| | - Alexios S. Antonopoulos
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
| | - Evangelos Oikonomou
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
- Department of Cardiology, “Sotiria” Thoracic Diseases Hospital of Athens, University of Athens Medical School, 11527 Athens, Greece
| | - Christina Paschaliori
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
| | - Nikolaos Galiatsatos
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
| | - Kostas Tsioufis
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
| | - Dimitris Tousoulis
- Cardiology Clinic, ‘Hippokration’ General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (A.S.A.); (E.O.); (C.P.); (N.G.); (K.T.); (D.T.)
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Preda A, Liberale L, Montecucco F. Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome. Heart Fail Rev 2021; 27:1883-1897. [PMID: 34796433 DOI: 10.1007/s10741-021-10195-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 12/23/2022]
Abstract
Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.
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Affiliation(s)
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132, Genoa, Italy.,Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland.,IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132, Genoa, Italy. .,IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy.
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29
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Tsuda E, Hashimoto S. Characteristics of coronary flow velocity reserve on transthoracic Doppler echocardiography in patients with a history of Kawasaki disease. Cardiol Young 2021; 32:1-5. [PMID: 34763747 DOI: 10.1017/s104795112100439x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Whether the acute inflammation caused by Kawasaki disease will have an effect on the endothelial function of coronary arteries in the future is unknown. METHODS The coronary flow velocity reserve of the left anterior descending artery was examined by transthoracic Doppler echocardiography in 189 patients (male 125, female 64) with a history of Kawasaki disease and 10 volunteers (control). Their ages ranged from 6 to 40 years (median 22 years). The patients were divided into nine groups based on the left anterior descending artery lesions. The coronary flow velocity reserve was measured by intravenous administration of adenosine triphosphate (0.15 mg/kg/minute) while fasting. The coronary flow velocity reserve was calculated as the ratio of hyperaemic to basal mean diastolic flow velocities. The respective groups were as follows: control, no coronary artery lesions (n = 39), no coronary artery lesions in the right coronary artery (n = 29), regression (n = 11), aneurysm at the bifurcation of the left coronary artery (n = 26), aneurysm of the left anterior descending artery (n = 15), localised stenosis <75% (n = 12), localised stenosis ≥75% (n = 17), segmental stenosis (n = 5) and coronary artery bypass grafting (n = 36). One-factor ANOVA followed by Tukey's test was used to compare the coronary flow velocity reserve among the groups. RESULTS The coronary flow velocity reserve was significantly lower in the localised stenosis ≥75%, segmental stenosis and coronary artery grafting groups than in the other groups (p < 0.05). CONCLUSIONS The endothelial function in the epicoronary artery was preserved in patients with a history of Kawasaki disease and dilated coronary artery lesions.
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Affiliation(s)
- Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shuji Hashimoto
- Department of Physiological Laboratory, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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30
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Prodel E, Cavalcanti T, Rocha HNM, Gondim ML, Mira PAC, Fisher JP, Nobrega ACL. Sympathetic regulation of coronary circulation during handgrip exercise and isolated muscle metaboreflex activation in men. Exp Physiol 2021; 106:2400-2411. [PMID: 34719804 DOI: 10.1113/ep089954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/29/2021] [Indexed: 01/10/2023]
Abstract
NEW FINDINGS What is the central question of this study? What is the role of β- and α-adrenergic receptors in the control of the coronary circulation during handgrip exercise and isolated muscle metaboreflex activation in humans? What is the main finding and its importance? β-Adrenergic receptor, but not α-adrenergic receptor, blockade significantly blunted the increases in coronary blood velocity observed during handgrip. Coronary blood velocity was unchanged from baseline during isolated muscle metaboreflex activation. This highlights the important role of β-adrenergic receptors in the coronary circulation during handgrip in humans, and the more limited involvement of the α-adrenergic receptors. ABSTRACT We sought to investigate the role of β- and α-adrenergic receptors in coronary circulation during static handgrip exercise and isolated muscle metaboreflex activation in humans. Seventeen healthy young men underwent two experimental sessions, consisting of 3 min of static handgrip exercise at a target force of 40% maximum voluntary force (not achieved for the full 3 min), and 3 min of metaboreflex activation (post-exercise ischaemia) in two conditions: (1) control and β-blockade (oral propranolol), and (2) control and α-blockade (oral prazosin). In both sessions, coronary blood velocity (CBV, echocardiography) was increased during handgrip (Δ8.0 ± 7.4 cm s-1 ) but unchanged with metaboreflex activation (Δ2.5 ± 3.2 cm s-1 ) under control conditions. β-Blockade abolished the increase in CBV during handgrip, while CBV was unchanged from control with α-blockade. Cardiac work, estimated from rate pressure product (RPP; systolic blood pressure multiplied by heart rate), increased during handgrip and metaboreflex in control conditions in both sessions. β-Blockade reduced RPP responses to handgrip and metaboreflex, whereas α-blockade increased RPP, but the responses to handgrip and metaboreflex were unchanged. CBV and RPP were only significantly correlated during handgrip under control (r = 0.71, P < 0.01) and β-blockade (r = 0.54, P = 0.03) conditions, and the slope of this relationship was unaltered with β-blockade. Collectively, these findings indicate that β-adrenergic receptors play the primary role to the increase of coronary circulation during handgrip exercise, but CBV is unchanged with metaboreflex activation, while α-adrenergic receptor stimulation seems to exert no effect in the control of the coronary circulation during handgrip exercise and isolated muscle metaboreflex activation in humans.
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Affiliation(s)
- Eliza Prodel
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
| | - Thiago Cavalcanti
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
| | - Helena N M Rocha
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
| | - Maitê L Gondim
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
| | - Pedro A C Mira
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
| | - James P Fisher
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Antonio C L Nobrega
- Laboratory of Exercise Science, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, Brazil
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Schroder J, Prescott E. Doppler Echocardiography Assessment of Coronary Microvascular Function in Patients With Angina and No Obstructive Coronary Artery Disease. Front Cardiovasc Med 2021; 8:723542. [PMID: 34778394 PMCID: PMC8585781 DOI: 10.3389/fcvm.2021.723542] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023] Open
Abstract
Echocardiographic evaluation is an essential part of the diagnostic work-up in patients with known or suspected cardiovascular disease. Transthoracic Doppler echocardiography (TTDE) enables straightforward and reliable visualization of flow in the left anterior descending artery. In the absence of obstructive coronary artery disease, low TTDE-derived coronary flow velocity reserve (CFVR) is considered a marker of coronary microvascular dysfunction (CMD). TTDE CFVR is free from ionizing radiation and widely available, utilizing high-frequency transducers, pharmacologic vasodilator stress, and pulsed-wave Doppler quantification of diastolic peak flow velocities. European Society of Cardiology guidelines recommend TTDE CFVR evaluation only following preceding anatomic invasive or non-invasive coronary imaging excluding obstructive CAD. Accordingly, clinical use of TTDE CFVR is limited and CMD frequently goes undiagnosed. An evolving body of evidence underlines that low CFVR is an important and robust predictor of adverse prognosis and continuing symptoms in angina patients both with and without obstructive CAD. The majority of angina patients have no obstructive CAD, particularly among women. This has led to the suggestion that there may be a gender-specific female atherosclerotic phenotype with less epicardial obstruction, and a low CFVR signifying CMD instead. Nevertheless, available evidence indicates low CFVR is an equally important prognostic marker in both men and women. In this review, TTDE CFVR was evaluated regarding indication, practical and technical aspects, and interpretation of results. Association with symptoms and prognosis, comparison with alternative invasive and non-invasive imaging modalities, and possible interventions in angina patients with low CFVR were discussed, and key research questions were proposed.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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32
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Jansen TPJ, Konst RE, Elias-Smale SE, van den Oord SC, Ong P, de Vos AMJ, van de Hoef TP, Paradies V, Smits PC, van Royen N, Damman P. Assessing Microvascular Dysfunction in Angina With Unobstructed Coronary Arteries: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1471-1479. [PMID: 34593129 DOI: 10.1016/j.jacc.2021.08.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/28/2022]
Abstract
Coronary microvascular dysfunction is a highly prevalent condition of both structural and functional coronary disorders in patients with angina and nonobstructive coronary artery disease (ANOCA). Current diagnostic modalities to assess microvascular function are related to prognosis, but these modalities have several technical shortcomings and lack the opportunity to determine true coronary blood flow and microvascular resistance. Intracoronary continuous thermodilution assessment of absolute coronary flow (Q) and microvascular resistance (R) was recently shown to be safe and feasible in ANOCA. Further exploration and implementation could lead to a better understanding and treatment of patients with ANOCA. This review discuss the coronary pathophysiology of microvascular dysfunction, provides an overview of noninvasive and invasive diagnostics, and focuses on the novel continuous thermodilution method. Finally, how these measurements of absolute Q and R could be integrated and how this would affect future clinical care are discussed.
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Affiliation(s)
| | | | | | | | - Peter Ong
- Robert Bosch Hospital, Stuttgart, Germany
| | | | | | | | | | - Niels van Royen
- Radboudumc, Nijmegen, the Netherlands. https://twitter.com/NielsRoyen
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The evolving role of cardiac imaging in patients with myocardial infarction and non-obstructive coronary arteries. Prog Cardiovasc Dis 2021; 68:78-87. [PMID: 34600948 DOI: 10.1016/j.pcad.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/29/2021] [Indexed: 01/02/2023]
Abstract
Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical conundrum accounting for about 6%-8% of all acute MI who are referred for coronary angiography. Current guidelines and consensus documents recommend that these patients are appropriately diagnosed, uncovering the causes of MINOCA, so that specific therapies can be prescribed. Indeed, there are a variety of causes that can result in this clinical condition, and for this reason diagnostic cardiac imaging has an emerging critical role in the assessment of patients with suspected or confirmed MINOCA. In last years, different cardiac imaging techniques have been evaluated in this context, and the comprehension of their strengths and limitations is of the utmost importance for their effective use in clinical practice. Moreover, recent evidence is clearly suggesting that a multimodality cardiac imaging approach, combining different techniques, seems to be crucial for a proper management of MINOCA. However, great variability still exists in clinical practice in the management of patients with suspected MINOCA, also depending on the availability of diagnostic tools and local expertise. Herein, we review the current knowledge supporting the use of different cardiac imaging techniques in patients with MINOCA, underscoring the importance of a comprehensive multimodality cardiac imaging approach and proposing a practical diagnostic algorithm to properly identify and treat the specific causes of MINOCA, in order to improve prognosis and the quality of life in these patients.
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34
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Lanza GA, Morrone D, Pizzi C, Tritto I, Bergamaschi L, De Vita A, Villano A, Crea F. Diagnostic approach for coronary microvascular dysfunction in patients with chest pain and no obstructive coronary artery disease. Trends Cardiovasc Med 2021; 32:448-453. [PMID: 34384879 DOI: 10.1016/j.tcm.2021.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/15/2022]
Abstract
A large number of studies has demonstrated that abnormalities of coronary microcirculation may be responsible for both acute and chronic cardiac ischemic syndromes. In clinical practice the microvascular origin of myocardial ischemia and angina is usually considered in patients who are found to have normal or near-normal coronary arteries at angiography. In this article, we review the diagnostic approach to patients with suspected coronary microvascular dysfunction as a cause of ischemic syndromes and also suggest a classification of chronic and acute microvascular coronary ischemic syndrome, including myocardial infarction with normal coronary arteries.
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Affiliation(s)
- Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy.
| | - Doralisa Morrone
- Università di Pisa, Dipartimento di patologia chirurgica, medica, molecolare e dell'area critica, Pisa, Italy
| | - Carmine Pizzi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Isabella Tritto
- Università di Perugia, Dipartimento di Medicina, Sezione di Cardiologia e Fisiopatologia Cardiovascolare, Perugia, Italy
| | - Luca Bergamaschi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Antonio De Vita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
| | - Angelo Villano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
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Bechsgaard DF, Prescott E. Coronary Microvascular Dysfunction: A Practical Approach to Diagnosis and Management. Curr Atheroscler Rep 2021; 23:54. [PMID: 34268637 DOI: 10.1007/s11883-021-00947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of diagnostic and treatment considerations in patients with coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease (CAD). RECENT FINDINGS The prevalence of obstructive CAD in unselected patient populations referred for evaluation of angina is less than 10%. A significant proportion of patients with angina and no obstructive CAD have CMD, a condition associated with impaired cardiovascular prognosis. Non-invasive and invasive evaluation of coronary microvascular function is feasible and widely available, yet CMD is underdiagnosed and undertreated. A patient-tailored treatment approach guided by coronary microvascular testing shows promising results for patient-reported outcomes of symptom burden and quality of life. Coronary microvascular testing should be considered in angina patients with no obstructive CAD, before other causes of chest pain are explored. A patient-tailored treatment approach guided by a complete evaluation of epicardial anatomy and macro-and microvascular function may help optimize treatment strategy and prevent unnecessary medical interventions. More research is needed to establish the long-term effect of patient-tailored therapies on risk reduction in CMD.
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Affiliation(s)
- Daria Frestad Bechsgaard
- Department of Cardiology, North Zealand University Hospital, University of Copenhagen, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
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36
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Yang Y, Hwang E, Lee SA, Lee S, Kim DH, Song JM, Kang DH. Effect of Rosuvastatin on Coronary Flow Reserve in Hypertensive Patients at Cardiovascular Risk. J Cardiovasc Imaging 2021; 29:255-262. [PMID: 34080332 PMCID: PMC8318809 DOI: 10.4250/jcvi.2020.0244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND It has been unclear whether statin therapy directly improves coronary flow reserve (CFR) in hypertensive patients at cardiovascular risk, independent of lifestyle modification and antihypertensive medications. METHODS In this double-blind, randomized controlled trial, we randomly assigned 95 hypertensive patients at cardiovascular risk to receive either rosuvastatin 10 mg or placebo for 12 months, in addition to antihypertensive therapy and lifestyle modification for hypercholesterolemia. Using Doppler echocardiography, coronary flow velocity in the distal left anterior descending artery was measured and CFR was calculated as the ratio of hyperemic to basal averaged peak diastolic flow velocity. The primary end point was change in CFR from baseline to 12 months follow-up. RESULTS Low-density lipoprotein-cholesterol was changed from 157 ± 23 to 84 ± 16 mg/dL in the rosuvastatin group (p < 0.001) and from 152 ± 19 to 144 ± 22 mg/dL in the control group (p = 0.041, but there were no significant differences between the treatment groups in the changes in C-reactive protein, high-density lipoprotein cholesterol, and blood pressures. CFR was changed from 3.03 ± 0.44 to 3.25 ± 0.49 in the rosuvastatin group (p < 0.001) and from 3.15 ± 0.54 to 3.17 ± 0.56 in the control group (p = 0.65). The primary end point of change in CFR was significantly different between the rosuvastatin group and the control group (0.216 ± 0.279 vs. 0.015 ± 0.217; p < 0.001). CONCLUSIONS Compared with lifestyle modification alone, addition of rosuvastatin significantly improved CFR in hypertensive patients at cardiovascular risk.
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Affiliation(s)
- Yujin Yang
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - EunSoon Hwang
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Seung Ah Lee
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Dae Hee Kim
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Jong Min Song
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Duk Hyun Kang
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
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37
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Transthoracic Assessment of Coronary Flow Velocity Reserve: A Practical Approach to Diagnostic Testing in Patients with Angina and No Obstructive Coronary Artery Disease. J Interv Cardiol 2021. [DOI: 10.1155/2021/6689312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
More than half of the patients with symptoms suggestive of myocardial ischemia presenting at invasive angiography have no obstructive coronary artery disease (CAD). A large proportion of these patients have ischemia caused by coronary microvascular dysfunction, a condition associated with adverse cardiovascular prognosis. Measurement of coronary flow velocity reserve by transthoracic Doppler echocardiography is a feasible and reproducible method for the evaluation of coronary microvascular function. This review provides a practical overview of the method in a clinical setting of angina and noobstructive CAD, including technical details and prognostic significance.
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Caiati C, Scardapane A, Iacovelli F, Pollice P, Achille TI, Favale S, Lepera ME. Coronary Flow and Reserve by Enhanced Transthoracic Doppler Trumps Coronary Anatomy by Computed Tomography in Assessing Coronary Artery Stenosis. Diagnostics (Basel) 2021; 11:diagnostics11020245. [PMID: 33562448 PMCID: PMC7914993 DOI: 10.3390/diagnostics11020245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 12/28/2022] Open
Abstract
We report the case of a 71-year-old patient with many risk factors for coronary atherosclerosis, who underwent computed coronary angiography (CTA), in accordance with the guidelines, for recent onset atypical chest pain. CTA revealed critical (>50% lumen diameter narrowing) stenosis of the proximal anterior descending coronary, and the patient was scheduled for invasive coronary angiography (ICA). Before ICA he underwent enhanced transthoracic echo-Doppler (E-Doppler TTE) for coronary flow detection by color-guided pulsed-wave Doppler recording of the left main (LMCA) and whole left anterior descending coronary artery (LAD,) along with coronary flow reserve (CFR) in the distal LAD calculated as the ratio, of peak flow velocity during i.v. adenosine (140 mcg/Kg/m) to resting flow velocity. E-Doppler TTE mapping revealed only mild stenosis (28% area narrowing) of the mid LAD and a CFR of 3.20, in perfect agreement with the color mapping showing no flow limiting stenosis in the LMCA and LAD. ICA revealed only a very mild stenosis in the mid LAD and mild atherosclerosis in the other coronaries (intimal irregularities). Thus, coronary stenosis was better predicted by E-Doppler TTE than by CTA. Coronary flow and reserve as assessed by E-Doppler TTE trumps coronary anatomy as assessed by CTA, without exposing the patient to harmful radiation and iodinated contrast medium.
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Affiliation(s)
- Carlo Caiati
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
- Correspondence: ; Tel.: +39-080-5592117; Fax: +39-080-5478796
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine, Section of Diagnostic Imaging, Bari Medical School, 70124 Bari, Italy;
| | - Fortunato Iacovelli
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
| | - Paolo Pollice
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
| | - Teresa Immacolata Achille
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
| | - Stefano Favale
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
| | - Mario Erminio Lepera
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro”, 70124 Bari, Italy; (F.I.); (P.P.); (T.I.A.); (S.F.); (M.E.L.)
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Bechsgaard DF, Hove JD, Michelsen MM, Mygind ND, Pena A, Hansen PR, Hansen HS, Kastrup J, Høst N, Gustafsson I, Prescott E. Myocardial CT perfusion compared with transthoracic Doppler echocardiography in evaluation of the coronary microvascular function: An iPOWER substudy. Clin Physiol Funct Imaging 2020; 41:85-94. [PMID: 33030280 DOI: 10.1111/cpf.12669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 08/20/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A significant number of women with angina and no obstructive coronary artery disease (CAD; <50% stenosis) have coronary microvascular dysfunction (CMD) which carries an adverse cardiovascular prognosis. Coronary microvascular function can be evaluated by transthoracic Doppler echocardiography (TTDE) as a coronary flow velocity reserve (CFVR) and by static CT myocardial perfusion (CTP) as a myocardial perfusion reserve (MPR). Whether these methods are correlated is not known. We assessed the correlation between CFVR and MPR and investigated whether women with angina, CMD and no obstructive CAD have reduced MPR compared with asymptomatic women. METHODS Static CTP with adenosine-induced vasodilation and TTDE of the left anterior descending artery with dipyridamole-induced vasodilation were successfully performed and analysed in 99 women with stable angina and no obstructive CAD and 33 asymptomatic women with no obstructive CAD. CMD was defined as CFVR < 2. RESULTS Correlation between rate-pressure product corrected MPR and CFVR was weak but significant (r = .23; p = .007). MPR was highest among asymptomatic women with normal CFVR (median [interquartile range; IQR] 158 [145-181] %). Symptomatic women with normal CFVR had reduced MPR (148 [134-162] %; age-adjusted p < .001); however, the lowest MPR was found in symptomatic women with CMD (140 [129-164] %; age-adjusted p < .001), independent of cardiovascular risk factors and haemodynamic parameters (p = .017). CONCLUSION Women with angina, CMD and no obstructive CAD had markedly diminished MPR compared with asymptomatic women. Correlation between CFVR and MPR was weak, suggesting that CTP and TTDE are not interchangeable for detection of CMD.
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Affiliation(s)
- Daria F Bechsgaard
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Hove
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark.,Center for Functional and Diagnostic Imaging, Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Naja D Mygind
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Adam Pena
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter R Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Henrik S Hansen
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
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40
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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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41
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Radhakrishnan A, Price AM, Pickup LC, Law JP, McGee KC, Fabritz L, Senior R, Steeds RP, Ferro CJ, Townend JN. Coronary flow velocity reserve and inflammatory markers in living kidney donors. Int J Cardiol 2020; 320:141-147. [PMID: 32805328 PMCID: PMC7584109 DOI: 10.1016/j.ijcard.2020.08.013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction is prevalent in chronic kidney disease (CKD), and may contribute to the development of myocardial dysfunction in CKD. Coronary flow velocity reserve (CFVR) is a marker of coronary microvascular function and falls with increasing CKD stage. Living kidney donors have renal function consistent with early stage CKD and concern has been raised about their cardiovascular risk. No studies to date have investigated the presence of coronary microvascular dysfunction in living kidney donors. METHODS 25 healthy controls and 23 living kidney donors were recruited and underwent assessment with transthoracic echocardiography, Doppler CFVR, myocardial contrast echocardiography and serum multiplex immunoassay panels. RESULTS Doppler CFVR was significantly reduced in living kidney donors compared to controls (mean CFVR 3.4 ± 0.7 vs 3.8 ± 0.6, mean difference 0.4 95% confidence interval 0.03-0.8, p =.036). Quantitative myocardial contrast echocardiography showed a trend towards reduced coronary flow reserve in living kidney donors. Compared to controls, living kidney donors had higher serum high sensitivity C reactive peptide (hsCRP) and lower levels of uromodulin. CONCLUSIONS This is the first study of CFVR in living kidney donors. We have shown that the modest drop in estimated glomerular filtration rate in living kidney donors is associated with lower values of Doppler CFVR compared to controls, suggesting that isolated reductions in renal function may lead to altered microvascular function. The increase in hsCRP and reduction in uromodulin suggests that chronic subclinical inflammation may contribute to altered microvascular function in this population.
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Affiliation(s)
- Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom.
| | - Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Kirsty C McGee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Larissa Fabritz
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Roxy Senior
- Cardiac Research Unit, Northwick Park Hospital, London, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Mathew RC, Bourque JM, Salerno M, Kramer CM. Cardiovascular Imaging Techniques to Assess Microvascular Dysfunction. JACC Cardiovasc Imaging 2020; 13:1577-1590. [PMID: 31607665 PMCID: PMC7148179 DOI: 10.1016/j.jcmg.2019.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/02/2019] [Accepted: 09/03/2019] [Indexed: 02/08/2023]
Abstract
The understanding of microvascular dysfunction without evidence of epicardial coronary artery disease pales in comparison with that of obstructive epicardial coronary artery disease. A primary limitation in the past had been the lack of development of noninvasive methods of detecting and quantifying microvascular dysfunction. This limitation has particularly affected the ability to study the pathophysiology, morbidity, and treatment of this disease. More recently, almost all of the noninvasive cardiac imaging modalities have been used to quantify blood flow and advance understanding of microvascular dysfunction.
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Affiliation(s)
- Roshin C Mathew
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia
| | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Michael Salerno
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia; Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher M Kramer
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia.
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43
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Zhang RH, Zhao W, Shu LP, Wang N, Cai YH, Yang JK, Zhou JB, Qi L. Obstructive sleep apnea is associated with coronary microvascular dysfunction: A systematic review from a clinical perspective. J Sleep Res 2020; 29:e13046. [PMID: 32293774 PMCID: PMC7685100 DOI: 10.1111/jsr.13046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/10/2020] [Accepted: 03/18/2020] [Indexed: 12/15/2022]
Abstract
There is now increasing evidence demonstrating that obstructive sleep apnea (OSA) contributes to microvascular disorder. However, whether OSA is associated with impaired coronary flow reserve is still unclear. Therefore, we conducted this systematic review and meta‐analysis to summarize current evidence. In a systematic review, PubMed, Embase, the Cochrane Library and Web of Science were searched; five observational studies fulfilled the selection criteria and were included in this study. Data were extracted from selected studies and meta‐analysis was performed using random‐effects modelling. In all, 829 OSA patients and 507 non‐OSA subjects were included and assessed for coronary flow reserve (CFR), the clinical indicator of coronary microvascular dysfunction (CMD). For all studies, OSA was significantly associated with reduced CFR. The pooled weighted mean difference (WMD) of CFR was −0.78 (95% confidence interval [CI] −1.25 to −0.32, p < 0.001, I2 = 84.4%). The difference in the apnea–hypopnea index (AHI) between studies can explain 89% of heterogeneity (coef = −0.05, 95% CI −0.12 to 0.02, p = .078) in a meta‐regression, indicating the CFR tended to negatively correlate with severity of OSA. The Egger regression test did not show statistical significance (p = .49). In conclusion, there are plausible biological mechanisms linking OSA and CMD, and the preponderance of evidence from this systematic review suggests that OSA, especially severe OSA, is associated with reduced CFR. Future studies are warranted to further delineate the exact role of OSA in CMD occurrence and development in a prospective setting.
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Affiliation(s)
- Rui-Heng Zhang
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wei Zhao
- Department of Geriatrics, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lin-Ping Shu
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Nan Wang
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yao-Hua Cai
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jin-Kui Yang
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Zhou
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lu Qi
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
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44
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Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116:841-855. [DOI: 10.1093/cvr/cvz339] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, Australia
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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46
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Groepenhoff F, Bots SH, Kessler EL, Sickinghe AA, Eikendal ALM, Leiner T, den Ruijter HM. Sex-Specific Aspects in the Pathophysiology and Imaging of Coronary Macro- and Microvascular Disease. J Cardiovasc Transl Res 2019; 13:39-46. [PMID: 31471830 PMCID: PMC7010630 DOI: 10.1007/s12265-019-09906-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022]
Abstract
Sex differences in coronary artery disease (CAD) are well established, with women presenting with non-obstructive CAD more often than men do. However, recent evidence has identified coronary microvascular dysfunction as the underlying cause for cardiac complaints, yet sex-specific prevalence numbers are inconclusive. This review summarises known sex-specific aspects in the pathophysiology of both macro- and microvascular dysfunction and identifies currently existing knowledge gaps. In addition, this review describes current diagnostic approaches and whether these should take underlying sex differences into account by, for example, using different techniques or cut-off values for women and men. Future research into both innovation of imaging techniques and perfusion-related sex differences is needed to fill evidence gaps and enable the implementation of the available knowledge in daily clinical practice.
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Affiliation(s)
- Floor Groepenhoff
- Laboratory for Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie H Bots
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elise L Kessler
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ariane A Sickinghe
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk L M Eikendal
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht University, P. O. Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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47
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Montisci R, Ruscazio M, Tona F, Corbetti F, Sarais C, Marchetti MF, Cacciavillani L, Iliceto S, Perazzolo Marra M, Meloni L. Coronary flow reserve is related to the extension and transmurality of myocardial necrosis and predicts functional recovery after acute myocardial infarction. Echocardiography 2019; 36:844-853. [PMID: 31002185 DOI: 10.1111/echo.14337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/06/2019] [Accepted: 03/21/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Few studies have examined the effect of transmurality of myocardial necrosis on coronary microcirculation. The aim of this study was to examine the influence of cardiac magnetic resonance-derived (GE-MRI) structural determinants of coronary flow reserve (CFR) after anterior myocardial infarction (STEMI), and their predictive value on regional functional recovery. METHODS Noninvasive CFR and GE-MRI were studied in 37 anterior STEMI patients after primary coronary angioplasty. The wall motion score index in the left descending anterior coronary artery territory (A-WMSI) was calculated at admission and follow-up (FU). Recovery of regional left ventricular (LV) function was defined as the difference in A-WMSI at admission and FU. The necrosis score index (NSI) and transmurality score index (TSI) by GE-MRI were calculated in the risk area. Baseline (BMR) and hyperemic (HMR) microvascular resistance, arteriolar resistance index (ARI), and coronary resistance reserve (CRR) were calculated at the Doppler echocardiography. RESULTS Bivariate analysis indicated that the CPK and troponin I peak, heart rate, NSI, TSI, BMR, the ARI, and CRR were related to CFR. Multivariable analysis revealed that TSI was the only independent determinant of CFR. The CFR value of >2.27, identified as optimal by ROC analysis, was 77% specific and 73% sensitive with accuracy of 76% in identifying patients with functional recovery. CONCLUSIONS Preservation of microvascular function after AMI is related to the extent of transmurality of myocardial necrosis, is an important factor influencing regional LV recovery, and can be monitored by noninvasive CFR.
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Affiliation(s)
- Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Massimo Ruscazio
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Tona
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Cristiano Sarais
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Maria Francesca Marchetti
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Luisa Cacciavillani
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Martina Perazzolo Marra
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Luigi Meloni
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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48
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Hadid M, Kodumuri V, Singh M. Combining functional assessment with coronary flow evaluation with vasodilator stress echocardiography in post CABG patients: Improving insight into coronary pathophysiology. Int J Cardiol 2019; 277:272-273. [PMID: 30429081 DOI: 10.1016/j.ijcard.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Mazen Hadid
- Department of Cardiology, Swedish American Heart Institute, Rockford, IL, United States
| | - Vamsi Kodumuri
- RUSH University Medical Center, Chicago, IL, United States; Department of Cardiology, Cook County Hospital, Chicago, IL, United States
| | - Mukesh Singh
- Department of Cardiology, Swedish American Heart Institute, Rockford, IL, United States; University of Illinois College of Medicine at Rockford, IL, United States.
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Zanatta E, Famoso G, Boscain F, Montisci R, Pigatto E, Polito P, Schiavon F, Iliceto S, Cozzi F, Doria A, Tona F. Nailfold avascular score and coronary microvascular dysfunction in systemic sclerosis: A newsworthy association. Autoimmun Rev 2018; 18:177-183. [PMID: 30572139 DOI: 10.1016/j.autrev.2018.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to assess the relationship between nailfold videocapillaroscopy (NVC) abnormalities and coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD) in patients with systemic sclerosis (SSc). METHODS We studied 39 SSc patients (33 females, mean ± SD age 54 ± 12 years, median disease duration 11 years, range 6-22) and 22 controls (matched for age and sex) without any evidence of cardiovascular disease. Clinical assessment was performed by modified Rodnan skin score (mRss) and EUSTAR score. Coronary flow velocities in the left anterior descending coronary artery were measured by transthoracic echocardiography. Average peak flow velocities, CFR and microvascular resistance at baseline (BMR) and in hyperaemic (HMR) condition were assessed. CFR ≤2.5 was considered marker of CMD. Six NVC-abnormalities were evaluated by a semi quantitative scoring system: enlarged and giant capillaries (diameter > 20 μm and >50 μm, respectively), hemorrhages, disarray, capillary ramifications and loss of capillaries (avascular score). Statistic was performed using SPSS. RESULTS CFR was lower in SSc patients than in controls (2.6 ± 0.5 vs 3.3 ± 0.5). CMD was detected in 24 patients (61.5%) vs 0 controls (p < .0001). CFR was inversely correlated with NVC-avascular score (rho =-0.750, p < .0001). Avascular and capillary ramifications scores (p = .001 and p = .03, respectively), mRss (p = .003) and EUSTAR score (p = .01) were higher in patients with CMD than in those without. At multivariable analysis, avascular score was independently associated with CMD (p = .01). HMR was directly correlated with avascular score (rho = 0.416, p = .008). CONCLUSIONS In our SSc patients NVC-avascular score was associated with CMD which seems to be the result of a structural microvascular remodeling.
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Affiliation(s)
- Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesca Boscain
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
| | - Erika Pigatto
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pamela Polito
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Franco Schiavon
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Franco Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy.
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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50
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Bozbas SS, Eroglu S, Ozyurek BA, Eyuboglu FO. Coronary flow reserve is impaired in patients with obstructive sleep apnea. Ann Thorac Med 2017; 12:272-277. [PMID: 29118860 PMCID: PMC5656946 DOI: 10.4103/atm.atm_195_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is common in adult populations. Accumulating data indicate that it is independently associated with a variety of cardiovascular diseases and has prognostic importance in affected cases. In this study, we aimed to evaluate coronary flow reserve (CFR) in patients with OSA and controls. METHODS Sixty-one patients undergoing an overnight polysomnography were enrolled in this study. Patients with an apnea-hypopnea index (AHI) >5 were accepted as OSA group (n = 45) and those with an AHI <5 were taken as controls (n = 16). Using Doppler echocardiography at baseline and following dipyridamole infusion, coronary peak flow velocities were obtained. CFR was calculated as the ratio of peak diastolic flow to baseline diastolic flow. A CFR value <2 was accepted as impaired coronary microvascular function. RESULTS The mean age was 50.8 ± 10.8 years, of which 16 (26.2%) were female. Both groups had similar features with regard to demographic and clinical variables. The mean value of CFR was significantly lower in patients with OSA compared to those controls (2.24 ± 0.46 vs. 2.74 ± 0.62, respectively, P = 0.001). An abnormal CFR value was observed in 12 (26.7%) patients with OSA and in 1 (6.3%) participant in control group. CONCLUSIONS The findings of this study indicate that CFR, an indicator of coronary microvascular function, is significantly impaired in patients with OSA. Coronary microvascular function, an early sign of atherosclerosis, can be evaluated noninvasively in these patients might be used as a predictor of cardiovascular risk.
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Affiliation(s)
- Serife Savas Bozbas
- Department of Pulmonary Medicine, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Serpil Eroglu
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Berna Akinci Ozyurek
- Department of Pulmonary Medicine, Ataturk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
| | - Fusun Oner Eyuboglu
- Department of Pulmonary Medicine, Faculty of Medicine, Baskent University, Ankara, Turkey
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