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Ni TT, Tsang W, Nguyen ET. Approach to Imaging of Patients Presenting With Acute Coronary Syndrome With No Culprit Lesion Identified at Angiography. J Thorac Imaging 2024; 39:69-78. [PMID: 38270459 DOI: 10.1097/rti.0000000000000773] [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: 01/26/2024]
Abstract
Chest pain is a common chief complaint among patients presenting to the emergency department. However, in the scenario where the clinical presentation is consistent with acute coronary syndrome and no culprit lesions are identified on angiography, clinicians and cardiac imagers should be informed of the differential diagnosis and appropriate imaging modalities used to investigate the potential causes. This review describes an imaging-based algorithm that highlights the diagnostic possibilities, their differentiating imaging features, and the important role of cardiovascular magnetic resonance imaging for narrowing the differential diagnosis.
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Affiliation(s)
- Tiffany T Ni
- Temerty Faculty of Medicine, University of Toronto
| | - Wendy Tsang
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto
| | - Elsie T Nguyen
- Temerty Faculty of Medicine, University of Toronto
- Department of Medical Imaging, University of Toronto
- University Medical Imaging Toronto, Peter Munk Cardiac Center, Toronto General Hospital, Toronto, ON, Canada
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Ni TT, Afgani FJ, Brenna CTA, Patel N, Nguyen ET. Cardiac Investigation Trends Among Primary Care Physicians: A Paradigm Shift. Can Assoc Radiol J 2022; 74:305-313. [PMID: 36421010 DOI: 10.1177/08465371221139825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective While numerous recent guidelines support coronary computed tomography angiography (CTA) as a first-line test for stable chest pain, it remains underutilized by primary care physicians (PCPs). We aimed to evaluate cardiac investigation ordering practices following education sessions, as well as the total number of downstream tests and time to diagnosis for patients presenting with stable chest pain. Methods A retrospective chart review was completed for eligible patients assessed at the Women's College Hospital Family Practice Health Centre between 2017 and 2019 following the education sessions. The outcome measures were first-choice cardiac investigation, additional downstream testing, time from presentation to first investigation, and time to final diagnosis. Results 419 patients were included in the final analysis (74.70% female; mean age 61 ± 11 years). Coronary CTA requests by PCPs increased between 2017 and 2019 (18 vs 72 tests; P < .0001). When coronary CTA was the first-line test, patients were less likely to receive additional downstream testing when compared to those receiving other first-line investigations ( P < .0001). Coronary CTA was associated with longer time to diagnosis than stress echocardiography (47 ± 45 vs 27 ± 36 days; P = .0068) due to limited availability of coronary CTA appointment times. There was no significant difference in time to final diagnosis among the cardiac imaging modalities observed in the cohort ( P = .0623). Conclusion Utilization of coronary CTA as the first-line test for stable chest pain increased following our education sessions targeting PCPs. Coronary CTA was associated with less downstream testing compared to other non-invasive cardiac investigations.
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Affiliation(s)
- Tiffany T. Ni
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fahmeen J. Afgani
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Connor T. A. Brenna
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nikita Patel
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Family Practice Health Centre, Women’s College Hospital, Toronto, Ontario, Canada
| | - Elsie T. Nguyen
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Afgani FJ, Brenna CTA, Hanneman K, Holzapfel S, Burton C, Harvey PJ, Nguyen ET. Cardiac Link: a retrospective cohort study evaluating a clinical pathway for expedited cardiology referral. CMAJ Open 2022; 10:E1000-E1007. [PMID: 36379587 PMCID: PMC9671298 DOI: 10.9778/cmajo.20210317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Outpatients presenting with chest pain often face long wait times for cardiology consultation and subsequent investigation for obstructive coronary artery disease (CAD), during which adverse cardiovascular events may occur. Our objective was to describe the design of Cardiac Link, a coronary computed tomography angiogram (CCTA)-guided rapid-access program, and evaluate its effect on cardiology consultation wait times in patients who present to primary care physicians with stable chest pain. METHODS We conducted a retrospective cohort study at Women's College Hospital, Toronto, Ontario, Canada, between 2017 and 2020 involving eligible patients from the Family Practice Health Centre who underwent CCTA after presenting with stable chest pain or equivalent symptoms. Referring primary care physicians decided on a patient-by-patient basis to opt into the Cardiac Link program when requesting CCTA. Our primary outcome was measure of time from CCTA to cardiology consultation, and our secondary outcomes were measures of time to diagnosis from primary care consultation and CCTA booking time. RESULTS Our analysis included 148 patients (Cardiac Link n = 98, non-Cardiac Link n = 50). Mean age of the patients was 58.4 (SD 11.2) years and 72% (107/148) were women. We found that the Cardiac Link group had a shorter time from CCTA to cardiology consultation (median 7 [interquartile range {IQR} 6-20] d v. median 100 [IQR 40-138] d; p = 0.01), shorter time to diagnosis (median 33 [IQR 22-55] d v. median 86 [IQR 40-112] d; p < 0.001) and shorter CCTA booking time (median 18 [IQR 11-31] d v. median 65 [IQR 24-92] d; p < 0.001) compared with the non-Cardiac Link group. INTERPRETATION We determined that the Cardiac Link program reduced cardiology consultation wait times for symptomatic patients who were suspected of having CAD. Our study shows the viability of CCTA-guided rapid-access programs to expedite specialist consultation and reduce unnecessary referral for patients presenting to primary care physicians with stable chest pain.
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Affiliation(s)
- Fahmeen J Afgani
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Connor T A Brenna
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Kate Hanneman
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Stephen Holzapfel
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Corwin Burton
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Paula J Harvey
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont
| | - Elsie T Nguyen
- Women's College Research Institute (Afgani, Holzapfel, Burton, Harvey), Women's College Hospital; Postgraduate Medical Education (Brenna), University of Toronto; Joint Department of Medical Imaging (Hanneman, Burton, Nguyen), Toronto General Hospital; Departments of Medical Imaging (Hanneman, Nguyen), Family and Community Medicine (Holzapfel) and Medicine (Harvey), University of Toronto, Toronto, Ont.
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Lee JE, Park HM, Lim Y, Jeong WGI, Kim YH. Pathophysiology and Role of Coronary CT Angiography in Stable Angina. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:42-53. [PMID: 36237352 PMCID: PMC9238201 DOI: 10.3348/jksr.2021.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/11/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
관상동맥질환의 임상적인 개념은 지난 10년 동안 패러다임의 변화를 보여왔다. 관상동맥질환은 대부분 진행성 질환이며, 관상동맥질환 환자는 질병 진행의 어느 시점에서도 급성 관상동맥 증후군에 직면할 수 있다. 이러한 임상적 맥락에서 2019년 유럽심장학회 가이드라인에서는 조기 진단과 꾸준한 관리가 필요한 관상동맥질환의 임상적인 중요성을 반영하여 “만성 관상동맥증후군”이라는 용어의 사용을 발표하였다. 최근 관상동맥 전산화단층촬영 혈관조영술을 이용한 관상동맥질환의 평가는 많은 발전을 이루었고, 안정형 협심증 또는 만성 관상동맥증후군 환자에서 관상동맥 전산화단층촬영 혈관조영술의 임상적 유용성은 초기 무증상 관상동맥질환의 발견에서부터 죽상경화판의 특성 분석 및 관상동맥질환의 치료 전략 결정에 도움을 주는 역할까지 관상동맥질환의 다양한 단계에 걸쳐 입증되고 있다. 이 종설에서는 안정형 협심증 환자의 이해를 돕는 병태생리를 설명하고 이에 대한 관상동맥 전산화단층촬영의 임상적 적용과 역할에 대해 알아보고자 한다.
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Affiliation(s)
- Jong Eun Lee
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hye Mi Park
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Yongwhan Lim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Won GI Jeong
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yun-Hyeon Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
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Oikonomou EK, Van Dijk D, Parise H, Suchard MA, de Lemos J, Antoniades C, Velazquez EJ, Miller EJ, Khera R. A phenomapping-derived tool to personalize the selection of anatomical vs. functional testing in evaluating chest pain (ASSIST). Eur Heart J 2021; 42:2536-2548. [PMID: 33881513 PMCID: PMC8488385 DOI: 10.1093/eurheartj/ehab223] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/14/2021] [Accepted: 03/31/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Coronary artery disease is frequently diagnosed following evaluation of stable chest pain with anatomical or functional testing. A more granular understanding of patient phenotypes that benefit from either strategy may enable personalized testing. METHODS AND RESULTS Using participant-level data from 9572 patients undergoing anatomical (n = 4734) vs. functional (n = 4838) testing in the PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial, we created a topological representation of the study population based on 57 pre-randomization variables. Within each patient's 5% topological neighbourhood, Cox regression models provided individual patient-centred hazard ratios for major adverse cardiovascular events and revealed marked heterogeneity across the phenomap [median 1.11 (10th to 90th percentile: 0.52-2.61]), suggestive of distinct phenotypic neighbourhoods favouring anatomical or functional testing. Based on this risk phenomap, we employed an extreme gradient boosting algorithm in 80% of the PROMISE population to predict the personalized benefit of anatomical vs. functional testing using 12 model-derived, routinely collected variables and created a decision support tool named ASSIST (Anatomical vs. Stress teSting decIsion Support Tool). In both the remaining 20% of PROMISE and an external validation set consisting of patients from SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) undergoing anatomical-first vs. functional-first assessment, the testing strategy recommended by ASSIST was associated with a significantly lower incidence of each study's primary endpoint (P = 0.0024 and P = 0.0321 for interaction, respectively), as well as a harmonized endpoint of all-cause mortality or non-fatal myocardial infarction (P = 0.0309 and P < 0.0001 for interaction, respectively). CONCLUSION We propose a novel phenomapping-derived decision support tool to standardize the selection of anatomical vs. functional testing in the evaluation of stable chest pain, validated in two large and geographically diverse clinical trial populations.
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Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - David Van Dijk
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Department of Computer Science, Yale University, 51 Prospect St, New Haven, CT 06520-8285, USA
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, 650 Charles E. Young Drive S, Los Angeles, CA 90095, USA
- Departments of Computational Medicine and Human Genetics, David Geffen School of Medicine at UCLA, University of California, 695 Charles E. Young Drive S, Los Angeles, CA 90095, USA
| | - James de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8830, USA
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, MS 1 Church Street, Suite 200, New Haven, CT 06510, USA
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Guo N, Chen Y, Yang X, Yan H, Fan B, Quan J, Wang M, Yang H. Urinary metabolomic profiling reveals difference between two traditional Chinese medicine subtypes of coronary heart disease. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1179:122808. [PMID: 34218095 DOI: 10.1016/j.jchromb.2021.122808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/28/2022]
Abstract
The World Health Organization has shown that coronary heart disease (CHD) is a more common cause of death than cancer. In traditional Chinese medicine (TCM), CHD is classified as a form of thoracic obstruction that can be divided in different subtypes including Qi stagnation with blood stasis (QS) and Qi deficiency with blood stasis (QD). Different treatment strategies are used based on this subtyping. Owing to the lack of scientific markers in the diagnosis of these subtypes, subjective judgments made by clinicians have limited the objective manner for utility of TCM in the treatment of CHD. Untargeted (UHPLC-QTOF-MS) and targeted (UHPLC-MS/MS) metabolomics approaches were employed to search significantly different metabolites related to the QS or QD subtypes of CHD with angina pectoris in this study. A total of 42 metabolites were obtained in the untargeted metabolomics analysis and 34 amino acids were detected in the targeted metabolomics analysis. In total, 16 metabolites were found significantly different among different groups. The results showed distinct metabolic profiles of urine samples not only between CHD patients and healthy controls, but also between the two subtypes of CHD. Pathway analysis of the significantly varied metabolites revealed that there were subtype-related differences in the activity of pathways. Therefore, urinary metabolomics can reveal the pathological changes of CHD in different subtypes, make the diagnosis of CHD in different subtypes in an objective manner and comprehensive and contribute to personalized treatment by providing scientific evidence.
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Affiliation(s)
- Na Guo
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China; State Key Laboratory Breeding Base of Dao-di Herbs, National Resource Center for Chinese Materia Medica, Center for Post-doctoral Research, China Academy of Chinese Medical Sciences, Beijing 100700, China; State Key Laboratory of Generic Manufacture Technology of Traditional Chinese Medicine, Lunan Pharmaceutical Group Co. Ltd, Shandong 276006, China
| | - Yangan Chen
- LU-European Center for Chinese Medicine and Natural Compounds, Institute of Biology, Leiden University, Sylviusweg 72, 2333 BE Leiden, the Netherlands
| | - Xiaofang Yang
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Han Yan
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Bin Fan
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Jianye Quan
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Mei Wang
- LU-European Center for Chinese Medicine and Natural Compounds, Institute of Biology, Leiden University, Sylviusweg 72, 2333 BE Leiden, the Netherlands; SU BioMedicine, Post Bus 546, 2300 AM Leiden, the Netherlands.
| | - Hongjun Yang
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China.
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Tangelloju S, Little BB, Esterhay RJ, Brock G, LaJoie S. Statins are associated with new onset type 2 diabetes mellitus (T2DM) in Medicare patients ≥65 years. Diabetes Metab Res Rev 2020; 36:e3310. [PMID: 32162770 PMCID: PMC9078214 DOI: 10.1002/dmrr.3310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/05/2020] [Accepted: 03/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND To evaluate the association of statins and co-morbidities with new onset type 2 diabetes mellitus (T2DM) in patients 65 years and older. METHODS This retrospective study used de-identified administrative healthcare claims and enrolment data from a Medicare Advantage Prescription Drug (MAPD) health plan offered by a large multistate healthcare company. The plan covered >2.4 million individuals, of whom >1.7 million individuals were ≥65 years. Of these, 265 554 individuals had continuous MAPD enrolment January 2008 to December 2015. The unadjusted model assessed demographic, pharmacy and T2DM co-morbidities as covariates. Significant variables (P < .05) in the unadjusted model were then included in the adjusted model. The adjusted model used Cox proportional hazards to evaluate covariate effects. Matched propensity score analysis was used to analyse the association of statins and T2DM onset. RESULTS The cumulative rate of diagnosed T2DM onset in the study cohort was 4.82% (4314/89 390). Annualised incidence of T2DM diagnosis was 0.82%, 0.88%, 1.04% and 2.09% in 2012, 2013, 2014 and 2015, respectively. T2DM onset was associated with male sex, non-white (African American or Hispanic ethnicity), statin use, hypertension, hyperlipidaemia, heart failure, lower limb ulceration, atherosclerosis, other retinopathy, angina pectoris, poor vision and blindness and absence ischaemic heart disease (IHD). Matched propensity score analysis showed that statin use was significantly associated with T2DM onset (Odds Ratio = 1.26, 95% Confidence Interval: 1.12-1.41, P < .0001) in the adjusted model. CONCLUSIONS Analyses indicated that statin usage was associated with new onset T2DM after adjusting for covariates.
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Affiliation(s)
- Srikanth Tangelloju
- HUMANA Inc., Louisville, Kentucky, USA
- School of Public Health and Information Sciences, Department of Health Management and Systems Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Bert B Little
- School of Public Health and Information Sciences, Department of Health Management and Systems Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Robert J Esterhay
- School of Public Health and Information Sciences, Department of Health Management and Systems Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Guy Brock
- Department of Biostatistics and Center for Biostatistics, Ohio State University, Columbus, Ohio, USA
| | - Scott LaJoie
- School of Public Health and Information Sciences, Department of Behavioral Science and Health Promotion, University of Louisville, Louisville, Kentucky, USA
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Parasuraman S, Schwarz K, Singh S, Abraham D, Garg D, Frenneaux MP. Cardiopulmonary exercise test in myocardial ischemia detection. Future Cardiol 2020; 16:113-121. [PMID: 32081024 DOI: 10.2217/fca-2019-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Exercise electrocardiography has low sensitivity for detection of myocardial ischemia. However, when combined with cardiopulmonary exercise testing (CPEX), the sensitivity and specificity of ischemia detection improves significantly. CPEX offers unique advantages over imaging techniques in tricky situations such as balanced ischemia. Early abnormal oxygen uptake would point toward profound coronary stenosis that could be missed in perfusion imaging. CPEX could be an invaluable tool in asymptomatic left bundle branch block pattern, without exposing patients to the risks of computerized tomography or invasive coronary angiography. Normal oxygen uptake curves would rule out significant coronary stenosis as the cause of left bundle branch block pattern. Elseways, abnormal oxygen uptake in patients with normal coronary arteries could indicate microvascular angina. Furthermore, exercise capacity is an excellent predictor of cardiovascular risk in those with and without heart disease. Using two clinical cases we introduce the concept of gas-exchange and hemodynamic changes encountered in ischemic heart disease.
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Affiliation(s)
| | | | - Satnam Singh
- Royal Bournemouth Hospital, Castle Lane East, Bournemouth, UK
| | - Dilip Abraham
- Norfolk & Norwich University Hospital, Colney Lane, Norwich, UK
| | - Deepak Garg
- Dr Gray's Hospital, Pluscarden Road, Elgin, UK
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Severino P, D'Amato A, Netti L, Pucci M, Infusino F, Maestrini V, Mancone M, Fedele F. Myocardial Ischemia and Diabetes Mellitus: Role of Oxidative Stress in the Connection between Cardiac Metabolism and Coronary Blood Flow. J Diabetes Res 2019; 2019:9489826. [PMID: 31089475 PMCID: PMC6476021 DOI: 10.1155/2019/9489826] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/23/2019] [Accepted: 03/13/2019] [Indexed: 12/27/2022] Open
Abstract
Ischemic heart disease (IHD) has several risk factors, among which diabetes mellitus represents one of the most important. In diabetic patients, the pathophysiology of myocardial ischemia remains unclear yet: some have atherosclerotic plaque which obstructs coronary blood flow, others show myocardial ischemia due to coronary microvascular dysfunction in the absence of plaques in epicardial vessels. In the cross-talk between myocardial metabolism and coronary blood flow (CBF), ion channels have a main role, and, in diabetic patients, they are involved in the pathophysiology of IHD. The exposition to the different cardiovascular risk factors and the ischemic condition determine an imbalance of the redox state, defined as oxidative stress, which shows itself with oxidant accumulation and antioxidant deficiency. In particular, several products of myocardial metabolism, belonging to oxidative stress, may influence ion channel function, altering their capacity to modulate CBF, in response to myocardial metabolism, and predisposing to myocardial ischemia. For this reason, considering the role of oxidative and ion channels in the pathophysiology of myocardial ischemia, it is allowed to consider new therapeutic perspectives in the treatment of IHD.
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Affiliation(s)
- Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Andrea D'Amato
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Lucrezia Netti
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mariateresa Pucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Fabio Infusino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, 00161 Rome, Italy
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Soldani G, Murzi M, Faita F, Di Lascio N, Al Kayal T, Spanò R, Canciani B, Losi P. In vivo evaluation of an elastomeric small‐diameter vascular graft reinforced with a highly flexible Nitinol mesh. J Biomed Mater Res B Appl Biomater 2018; 107:951-964. [DOI: 10.1002/jbm.b.34189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 05/22/2018] [Accepted: 06/12/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Giorgio Soldani
- Laboratory for Biomaterials & Graft TechnologyIstituto di Fisiologia Clinica CNR Massa 54100 Italy
| | - Michele Murzi
- Fondazione Toscana Gabriele Monasterio (FTGM) Massa 54100 Italy
| | - Francesco Faita
- Laboratory for Experimental UltrasoundIstituto di Fisiologia Clinica CNR Pisa 56127 Italy
| | - Nicole Di Lascio
- Laboratory for Experimental UltrasoundIstituto di Fisiologia Clinica CNR Pisa 56127 Italy
- Institute of Life SciencesScuola Superiore Sant'Anna Pisa 56127 Italy
| | - Tamer Al Kayal
- Laboratory for Biomaterials & Graft TechnologyIstituto di Fisiologia Clinica CNR Massa 54100 Italy
| | - Raffaele Spanò
- Laboratory of Regenerative MedicineDIMES, University of Genoa Genoa 16132 Italy
| | - Barbara Canciani
- Laboratory of Regenerative MedicineDIMES, University of Genoa Genoa 16132 Italy
| | - Paola Losi
- Laboratory for Biomaterials & Graft TechnologyIstituto di Fisiologia Clinica CNR Massa 54100 Italy
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Prakash S, Panchani N, Rathore C, Makwana P, Rathod M. Cardiac cephalalgia: First case from India. Ann Indian Acad Neurol 2016; 19:252-4. [PMID: 27293340 PMCID: PMC4888692 DOI: 10.4103/0972-2327.165467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
A 67-year-old male smoker had exertional headaches for 2 years. The headaches were holocephalic, very severe, excruciating, and occasionally accompanied by nausea. Physical examinations and neuroimaging were normal. Electrocardiogram (ECG) showed old infarct in inferior leads. Sublingual nitrate provided relief in headaches. Stress test was positive with recurrence of similar headaches with ECG changes suggestive of myocardial ischemia. Coronary angiogram revealed three-vessel disease. Coronary artery bypass surgery provided complete resolution of headaches.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt Bhikhiben Kantilal Shah Medical Institute and Research Centre Medical College, Waghodia, Vadodara, Gujarat, India
| | - Nirav Panchani
- Department of Cardiology, Smt Bhikhiben Kantilal Shah Medical Institute and Research Centre Medical College, Waghodia, Vadodara, Gujarat, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt Bhikhiben Kantilal Shah Medical Institute and Research Centre Medical College, Waghodia, Vadodara, Gujarat, India
| | - Prayag Makwana
- Department of Neurology, Smt Bhikhiben Kantilal Shah Medical Institute and Research Centre Medical College, Waghodia, Vadodara, Gujarat, India
| | - Mitali Rathod
- Department of Medicine, Smt Bhikhiben Kantilal Shah Medical Institute and Research Centre Medical College, Waghodia, Vadodara, Gujarat, India
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Huebner T, Schuepbach WMM, Seeck A, Sanz E, Meier B, Voss A, Pilgram R. Cardiogoniometric parameters for detection of coronary artery disease at rest as a function of stenosis localization and distribution. Med Biol Eng Comput 2010; 48:435-46. [PMID: 20300872 DOI: 10.1007/s11517-010-0594-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Accepted: 02/28/2010] [Indexed: 11/30/2022]
Abstract
Cardiogoniometry (CGM), a spatiotemporal electrocardiologic 5-lead method with automated analysis, may be useful in primary healthcare for detecting coronary artery disease (CAD) at rest. Our aim was to systematically develop a stenosis-specific parameter set for global CAD detection. In 793 consecutively admitted patients with presumed non-acute CAD, CGM data were collected prior to elective coronary angiography and analyzed retrospectively. 658 patients fulfilled the inclusion criteria, 405 had CAD verified by coronary angiography; the 253 patients with normal coronary angiograms served as the non-CAD controls. Study patients--matched for age, BMI, and gender--were angiographically assigned to 8 stenosis-specific CAD categories or to the controls. One CGM parameter possessing significance (P < .05) and the best diagnostic accuracy was matched to one CAD category. The area under the ROC curve was .80 (global CAD versus controls). A set containing 8 stenosis-specific CGM parameters described variability of R vectors and R-T angles, spatial position and potential distribution of R/T vectors, and ST/T segment alterations. Our parameter set systematically combines CAD categories into an algorithm that detects CAD globally. Prospective validation in clinical studies is ongoing.
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Affiliation(s)
- Thomas Huebner
- Department for Human and Economic Sciences, University for Health Sciences, Medical Informatics and Technology (UMIT), Eduard-Wallnoefer-Zentrum 1, 6060, Hall, Austria.
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Abstract
The extensive worldwide disease burden attributable to tobacco smoking is reviewed, with particular attention to the epidemiologic and clinical aspects, molecular and cellular mechanisms, and pathophysiology of a variety of smoking-related pulmonary diseases, and the epidemiology and clinical presentation of smoking-related atherosclerotic disease as it affects the cardiovascular system cerebral circulation, the aorta, and the peripheral arterial tree.
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Affiliation(s)
- Stephan L Kamholz
- Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, 300 Community Drive, Manhasset, NY 11030, USA.
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