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Benenati S, Campo G, Seitun S, Caglioni S, Leone AM, Porto I. Ischemia with non-obstructive coronary artery (INOCA): Non-invasive versus invasive techniques for diagnosis and the role of #FullPhysiology. Eur J Intern Med 2024; 127:15-24. [PMID: 39039011 DOI: 10.1016/j.ejim.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/23/2024] [Accepted: 07/12/2024] [Indexed: 07/24/2024]
Abstract
Ischemia with non-obstructive coronary arteries (INOCA) is an increasingly recognized entity. It encompasses different pathophysiological subtypes (i.e., endotypes), including coronary microvascular dysfunction (CMD), vasospastic angina (VSA) and mixed entities resulting from the variable combination of both. Diagnosing INOCA and precisely characterizing the endotype allows for accurate medical treatment and has proven prognostic implications. A breadth of diagnostic technique is available, ranging from non-invasive approaches to invasive coronary angiography adjuvated by functional assessment and provocative tests. This review summarizes the strength and limitations of these methodologies and provides the rationale for the routine referral for invasive angiography and functional assessment in this subset of patients.
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Affiliation(s)
- Stefano Benenati
- Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona (FE), Italy
| | - Sara Seitun
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Serena Caglioni
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona (FE), Italy
| | - Antonio Maria Leone
- Catholic University of the Sacred Heart, Rome, Italy; Center of Excellence in Cardiovascular Sciences, Ospedale Isola Tiberina - Gemelli Isola, Roma
| | - Italo Porto
- Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy; Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy.
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Zhang H, Ye X, Pei H. Diagnosis and treatment of coronary spasm in China: a case report. Front Cardiovasc Med 2024; 11:1398675. [PMID: 39221423 PMCID: PMC11363188 DOI: 10.3389/fcvm.2024.1398675] [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: 03/10/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024] Open
Abstract
Background Coronary vasospasm (CVS) is a common cardiovascular condition, yet its implications should not be underestimated. Regrettably, the current diagnostic and treatment standards for CVS in China are not standardized, severely affecting the quality of life for patients with this condition. Case presentation A 68-year-old male presented to the hospital one month prior due to recurrent chest pain. Coronary angiography (CAG) revealed a mid-segment muscle bridge with plaque formation in the left anterior descending artery, followed by pharmacological balloon angioplasty. The primary diagnosis post-operation was acute non-ST elevation myocardial infarction (NSTEMI) and coronary artery myocardial bridging. This time, the patient experienced nocturnal chest pain with a dynamic increase in troponin levels. Emergency CAG showed the left anterior descending and right coronary arteries were fine, with segmental narrowing reaching 95%-99%. Intravascular ultrasound (IVUS) indicated negative remodeling of the mid-segment lumen associated with myocardial bridging, with the smallest lumen area being 2.19 mm2. After intracoronary administration of nitroglycerin, the original most narrowed lumen area increased to 8.81 mm2. Consequently, a definitive diagnosis of CVS with coronary artery myocardial bridging was made, and the medication treatment plan was promptly adjusted. The patient's symptoms disappeared, and he was discharged. Follow-up after more than three months showed no recurrence of symptoms. Conclusion In cases where provocative agents are contraindicated, CAG combined with IVUS can optimize the differential diagnosis of CVS. There is an urgent need in China to improve epidemiological data on CVS and establish standardized diagnostic and treatment protocols.
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Affiliation(s)
- Hongyang Zhang
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Xianglin Ye
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Haifeng Pei
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
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Aoyama R, Sudo H, Okino S, Fukuzawa S. Two case reports of coronary spastic angina accompanied by the menstrual cycle. Eur Heart J Case Rep 2024; 8:ytae381. [PMID: 39132301 PMCID: PMC11310700 DOI: 10.1093/ehjcr/ytae381] [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: 03/31/2024] [Revised: 05/17/2024] [Accepted: 07/22/2024] [Indexed: 08/13/2024]
Abstract
Background Coronary spastic angina (CSA) in premenopausal women is not frequent but has also been suggested to be associated with oestrogen decline during the menstrual cycle and sometimes becomes refractory and difficult to control. We experienced two premenopausal women with CSA that showed the involvement of the menstrual cycle. Case summary Case 1: 41-year-old-woman had ST-segment elevation and chest pain during urosepsis, just 2 days after the onset of menstruation. The acetylcholine stress test was performed according to the menstrual cycle, and multiple coronary spasms were induced. Case 2: 40-year-old-woman had refractory chest pain as a symptom of premenstrual syndrome (PMS). Coronary angiography on drugs at the maximum dose revealed spontaneous multiple coronary spasms. Blood levels of oestrogen were normal, suggesting that hormonal change may be involved, and the introduction of low-dose pills made free from angina and the reduction of drug dose. Discussion In premenopausal female angina pectoris, oestrogen may play a role; it is important to ask about the menstrual cycle and history of PMS. Besides, the timing of catheterization in premenopausal women with suspected CSA should be considered. Low-dose pills may be effective in some cases, and active medical collaboration with other departments such as gynaecology is desirable. .
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Affiliation(s)
- Rie Aoyama
- Department of Cardiology, Heart and Vascular Institute, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Chiba 273-8588, Japan
| | - Hironao Sudo
- Department of Cardiology, Heart and Vascular Institute, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Chiba 273-8588, Japan
| | - Shinichi Okino
- Department of Cardiology, Heart and Vascular Institute, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Chiba 273-8588, Japan
| | - Shigeru Fukuzawa
- Department of Cardiology, Heart and Vascular Institute, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Chiba 273-8588, Japan
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Sueda S, Hayashi Y. Importance of provoked spasms at the sites of nonobstructive stenosis as well as at the sites of obstructive stenosis in patients with obstructive coronary arteries and coronary spasm. Coron Artery Dis 2024:00019501-990000000-00239. [PMID: 38829306 DOI: 10.1097/mca.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVES There are few reports regarding the prognosis in patients with obstructive coronary artery disease (OCAD) and vasospastic angina (VSA). This study investigated the clinical characteristics and clinical outcomes in patients with VSA and OCAD, especially regarding provoked spasm phenotypes and sites. METHODS This was a retrospective, observational, single-center study of 403 patients with typical or atypical angina-like chest pain undergoing acetylcholine (ACH) spasm provocation testing and OCAD. An obstructed coronary artery was defined as ≥50% luminal narrowing. We defined positive epicardial spasm as ≥90% transient stenosis and usual chest symptoms or ischemic ECG changes. RESULTS Among these 403 patients with OCAD, positive spasm by intracoronary ACH testing was observed in 196 patients (49%), whereas negative spasm was found in the remaining 207 patients (51%). The clinical outcomes in the patients with OCAD and provoked spasm were not different according to the provoked-spasm phenotypes. Furthermore, the clinical outcomes were unsatisfactory in the patients with spasm at the site of nonobstructive lesion alone compared with those with spasm at the site of obstructive and nonobstructive lesions. CONCLUSION We should precisely diagnose patients with OCAD who have provoked spasm by using intracoronary ACH testing and medicate the nonobstructive vessels in patients with OCAD and VSA under optimal coronary vasodilators.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Minami Matsuyama Hospital, Matsuyma, Japan
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Pacheco C, Coutinho T, Bastiany A, Beanlands R, Boczar KE, Gulati M, Liu S, Luu J, Mulvagh SL, Paquin A, Saw J, Sedlak T. Canadian Cardiovascular Society/Canadian Women's Heart Health Alliance Clinical Practice Update on Myocardial Infarction With No Obstructive Coronary Artery Disease (MINOCA). Can J Cardiol 2024; 40:953-968. [PMID: 38852985 DOI: 10.1016/j.cjca.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 06/11/2024] Open
Abstract
Myocardial infarction with no obstructive coronary artery disease (MINOCA) represents 6%-15% of all acute coronary syndromes, and women are disproportionately represented. MINOCA is an encompassing preliminary diagnosis, and emerging evidence supports a more expansive comprehensive diagnostic and therapeutic clinical approach. The current clinical practice update summarizes the latest evidence regarding the epidemiology, clinical presentation, and diagnostic evaluation of MINOCA. A cascaded approach to diagnostic workup is outlined for clinicians, for noninvasive and invasive diagnostic pathways, depending on clinical setting and local availability of diagnostic modalities. Evidence concerning the nonpharmacological and pharmacological treatment of MINOCA are presented and summarized according to underlying cause of MINOCA, with practical tips on the basis of expert opinion, outlining a real-life, evidence-based, comprehensive approach to management of this challenging condition.
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Affiliation(s)
- Christine Pacheco
- Department of Medicine, Hôpital Pierre-Boucher, Centre de santé et de services sociaux de la Montérégie-Est, Longueuil, Québec, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Rob Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kevin E Boczar
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shuangbo Liu
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Luu
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sharon L Mulvagh
- Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amelie Paquin
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara Sedlak
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Takahashi K, Kodama A, Uemura S, Okura T. Bilateral isolated coronary ostial stenosis in a middle-aged premenopausal woman with vasospastic angina: a case report. Eur Heart J Case Rep 2024; 8:ytae249. [PMID: 38817315 PMCID: PMC11139352 DOI: 10.1093/ehjcr/ytae249] [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: 10/25/2023] [Revised: 04/29/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
Background Vasospastic angina (VSA) is uncommon in premenopausal women who have less chronic endothelial injury causing vascular remodelling, considered to play a primary role in the pathogenesis for coronary vasospasms. Furthermore, vasospasms rarely occur in the bilateral coronary ostia. Isolated coronary ostial stenosis (ICOS), which often causes severe effort angina and requires surgical intervention, is more commonly reported in middle-aged women, with causes including fibromuscular dysplasia (FMD) and large-vessel vasculitis. However, ICOS associated with VSA is extremely rare. Case summary A 50-year-old premenopausal Japanese woman presented with a complaint of typical chest pain due to angina during light exertion daily in the early morning hours since 3 years. Coronary angiography (CAG) revealed bilateral mild-to-moderate ICOS in addition to multi-vessel spasms involving the bilateral coronary ostia confirmed by the vasospasm provocation test using intracoronary acetylcholine injection. Tests to determine the cause of ICOS did not identify FMD or any other disease. The angina attacks alleviated after calcium channel blocker (CCB) administration without intervention for bilateral ICOS for 24 years since the first presentation. Moreover, coronary computed tomography angiography (CTA) performed 24 years after the first presentation showed no ICOS. Discussion In our patient with typical and frequent VSA symptoms, CAG revealed both mild-to-moderate ICOS and the vasospasms in the bilateral coronary ostia. Fibromuscular dysplasia or large-vessel vasculitis was ruled out as the causes of ICOS. Vasospastic angina rarely occurred after the prescription of CCB, and coronary CTA 24 years after the first presentation showed no ICOS. Bilateral ICOS in our patient might be VSA related.
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Affiliation(s)
- Koji Takahashi
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638 Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Akihiro Kodama
- Department of Internal Medicine, Seiyo Municipal Hospital, 147-1 Nagaosa, Seiyo, Ehime 797-0029, Japan
| | - Shigeki Uemura
- Department of Cardiology, Yawatahama City General Hospital, 1-638 Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Takafumi Okura
- Department of Cardiology, Yawatahama City General Hospital, 1-638 Ohira, Yawatahama, Ehime 796-8502, Japan
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Rinaldi R, Colucci M, Torre I, Ausiello D, Bonanni A, Basile M, Salzillo C, Sanna T, Liuzzo G, Leone AM, Burzotta F, Trani C, Lanza GA, Niccoli G, Crea F, Montone RA. Predicting the response to acetylcholine in ischemia or infarction with non-obstructive coronary arteries: The ABCD score. Atherosclerosis 2024; 391:117503. [PMID: 38447435 DOI: 10.1016/j.atherosclerosis.2024.117503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/19/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response. METHODS We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort). RESULTS 551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652-0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626-0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test. CONCLUSIONS The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.
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Affiliation(s)
- Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Michele Colucci
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Ilaria Torre
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Davide Ausiello
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alice Bonanni
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mattia Basile
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Carmine Salzillo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano A Lanza
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Boivin-Proulx LA, Haddad K, Lombardi M, Chong AY, Escaned J, Mukherjee S, Forcillo J, Potter BJ, Coutinho T, Pacheco C. Pathophysiology of Myocardial Infarction With Nonobstructive Coronary Artery Disease: A Contemporary Systematic Review. CJC Open 2024; 6:380-390. [PMID: 38487045 PMCID: PMC10935701 DOI: 10.1016/j.cjco.2023.11.014] [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: 08/27/2023] [Accepted: 11/14/2023] [Indexed: 03/17/2024] Open
Abstract
Background Myocardial infarction with nonobstructive coronary artery disease (MINOCA) is defined as acute myocardial infarction (AMI) with angiographically nonobstructive coronary artery disease. MINOCA represents 6% of all AMI cases and is associated with increased mortality and morbidity. However, the wide array of pathophysiological factors and causes associated with MINOCA presents a diagnostic conundrum. Therefore, we conducted a contemporary systematic review of the pathophysiology of MINOCA. Methods A comprehensive systematic review of MINOCA was carried out through the utilization of the PubMed database. All systematic reviews, meta-analyses, randomized controlled trials, and cohort studies available in English or French that reported on the pathophysiology of MINOCA published after January 1, 2013 were retained. Results Of the 600 identified records, 80 records were retained. Central to the concept of MINOCA is the definition of AMI, characterized by the presence of myocardial damage reflected by elevated cardiac biomarkers in the setting of acute myocardial ischemia. As a result, a structured approach should be adopted to thoroughly assess and address clinically overlooked obstructive coronary artery disease, and cardiac and extracardiac mechanisms of myocyte injury. Once these options have been ruled out, a diagnosis of MINOCA can be established, and the appropriate multimodal assessment can be conducted to determine its specific underlying cause (plaque disruption, epicardial coronary vasospasm, coronary microvascular dysfunction, and coronary embolism and/or spontaneous coronary dissection or supply-demand mismatch). Conclusions Integrating a suitable definition of AMI and understanding the pathophysiological mechanisms of MINOCA are crucial to ensure an effective multimodal diagnostic evaluation and the provision of adequate tailored therapies.
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Affiliation(s)
- Laurie-Anne Boivin-Proulx
- Division of Cardiology, Interventional Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kevin Haddad
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
| | - Marco Lombardi
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Aun Yeong Chong
- Division of Cardiology, Interventional Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Swati Mukherjee
- Department of Cardiology, Cabrini Health, Malvern, Victoria, New South Wales, Australia
| | - Jessica Forcillo
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | | | - Christine Pacheco
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Hôpital Pierre-Boucher, Longueuil, Quebec, Canada
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Sueda S, Kurokawa K, Sakaue T, Ikeda S. What is the meaning of provoked spasm phenotypes by vasoreactivity testing? J Cardiol 2024; 83:1-7. [PMID: 37453595 DOI: 10.1016/j.jjcc.2023.06.013] [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: 03/28/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
Coronary artery epicardial spasm is involved in the pathogenesis of many cardiac disorders. Vasoreactivity testing, such as intracoronary injection of acetylcholine (ACH) or ergonovine (ER), is the gold standard method for the diagnosis of vasospastic angina. Provoked epicardial spasm phenotypes are classified as focal spasm and diffuse spasm. Multiple factors, including sex, ethnicity, and use of coronary vasoactive stimulators, are related to the provoked phenotypes of epicardial spasm. Diffuse-provoked spasm is often observed in females, where focal-provoked spasm is markedly more common in males. ACH provokes more diffuse and distal spasms, whereas ER induces more focal and proximal spasms. Yellow plaque and coronary thrombi are often observed in lesions with focal spasms, and intimal thickness with a sonolucent zone is significantly more common in lesions with focal spasm. Furthermore, clinical outcomes in patients with focal spasm are unsatisfactory compared with those in patients with diffuse spasm. However, the reproducibility and eternality of provoked spasm phenotypes by vasoreactivity testing is uncertain. Coronary atherosclerosis or endothelial damage may affect coronary vasomotor tone. Although coronary artery spasm may persist in the same coronary artery, provoked coronary spasm phenotypes may exhibit a momentary coronary reaction by intracoronary ACH or ER testing.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan; Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Japan.
| | - Keisho Kurokawa
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan
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11
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Rehan R, Beltrame J, Yong A. Insights into the invasive diagnostic challenges of coronary artery vasospasm - A systematic review. J Cardiol 2024; 83:8-16. [PMID: 37541429 DOI: 10.1016/j.jjcc.2023.07.020] [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: 05/11/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included ≥50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John Beltrame
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, Adelaide, South Australia, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
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12
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Yoshida M, Orita Y, Oshita C, Uchimura Y, Teragawa H. Vasospastic Angina in a Young Woman: A Case Report. Cureus 2023; 15:e49640. [PMID: 38033437 PMCID: PMC10687494 DOI: 10.7759/cureus.49640] [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] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
Vasospastic angina (VSA) is a disease that causes myocardial ischemia due to transient vasoconstriction of the epicardial coronary arteries. This disease generally occurs in middle-aged and older adults, but there are also reports of it occurring in young people. We report a case of VSA in a woman in her 20's. Six months ago, a female patient in her 20s became aware of a strangling sensation in the chest that lasted for approximately 1-20 minutes at rest or during stress. She consulted her family doctor who prescribed nitroglycerin sublingual tablets, which were effective. She was a current smoker and had a history of bronchial asthma, with no family history of coronary artery disease. Resting electrocardiogram and echocardiography revealed no clear abnormalities. The patient was referred to our hospital for coronary angiography (CAG) and spasm provocation test (SPT), primarily to thoroughly examine her chest pain at rest. CAG revealed no significant stenosis. A subsequent SPT using acetylcholine demonstrated diffuse coronary spasm in the left anterior descending coronary artery (LAD). The coronary spasm resolved spontaneously, but the catheter was difficult to maneuver owing to the radial artery spasm at the puncture site; thus, nitroglycerin was administered, which alleviated the radial artery spasm. Another SPT was performed on the right coronary artery (RCA) and revealed no coronary spasm. Coronary microcirculatory function using a pressure wire in response to the peripheral infusion of adenosine triphosphate was assessed in the RCA and LAD, both of which were normal. The patient was discharged from the hospital on an oral calcium channel blocker (CCB). She continued to experience chest pain, but her chest symptoms improved with CCB medication and a change in her workplace. It must be kept in mind that coronary spasms can occur even in young women and should be one of the differentials of chest pain in such patients.
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Affiliation(s)
- Misa Yoshida
- Department of Clinical Education, JR Hiroshima Hospital, Hiroshima, JPN
| | - Yuichi Orita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, JPN
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, JPN
| | - Yuko Uchimura
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, JPN
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, JPN
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13
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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14
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Favorini S, Perrin T, Hellige G, Arenja N. Sudden cardiac arrest due to recurrent coronary spasm in a young woman: a case report. Eur Heart J Case Rep 2023; 7:ytad253. [PMID: 37378054 PMCID: PMC10291570 DOI: 10.1093/ehjcr/ytad253] [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: 11/29/2022] [Revised: 01/10/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023]
Abstract
Background Coronary artery spasm (CAS) is a pathological condition resulting from transient functional narrowing of the coronary arteries leading to myocardial ischaemia and in some rare cases even to sudden cardiac arrest (SCA). The most important preventable risk factor is use of tobacco, whereas possible precipitating factors include some medications and psychological stress. Case summary A 32-year-old woman was hospitalized with burning chest pain. The immediate investigations revealed the diagnosis of non-ST-segment elevation myocardial infarction, because of ST elevations in one single lead and increased high-sensitivity troponin. Due to ongoing chest pain and a severe impaired left ventricular ejection fraction (LVEF) of 30% with apical akinesia, a prompt coronary angiography (CAG) was scheduled. After aspirin administration, she developed anaphylaxis with pulseless electrical activity (PEA). She could be resuscitated successfully. CAG revealed multi-vessel CAS for which she received calcium channel blockers. Five days after, she suffered from a second SCA due to ventricular fibrillation and was resuscitated again. Repeated CAG showed no critical coronary artery occlusion. LVEF improved progressively during hospitalization. Drug therapy was increased, and a subcutaneous implantable cardioverter defibrillator (ICD) was implanted for secondary prevention. Discussion CAS may in some instances lead to SCA, especially in case of multi-vessel involvement. Allergic and anaphylactic events can trigger CAS, which are frequently underestimated. Regardless of the cause, cornerstone of CAS prophylaxes remains optimal medical therapy as in the avoidance of predisposing risk factors. In case of life-threatening arrhythmia, the implantation of an ICD should be considered.
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Affiliation(s)
- Serena Favorini
- Department of Cardiology, Spital Uster, Brunnenstrasse 42, 8610 Uster, Switzerland
| | - Tilman Perrin
- Department of Cardiology, Kantonsspital Olten and Bürgerspital Solothurn, Schöngrünstrasse 36A, 4500 Solothurn, Switzerland
| | - Gerrit Hellige
- Department of Cardiology, Kantonsspital Olten and Bürgerspital Solothurn, Schöngrünstrasse 36A, 4500 Solothurn, Switzerland
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15
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Nishimiya K, Takahashi J, Oyama K, Matsumoto Y, Yasuda S, Shimokawa H. Mechanisms of Coronary Artery Spasm. Eur Cardiol 2023; 18:e39. [PMID: 37456775 PMCID: PMC10345984 DOI: 10.15420/ecr.2022.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/22/2023] [Indexed: 07/18/2023] Open
Abstract
Recent clinical trials have highlighted that percutaneous coronary intervention in patients with stable angina provides limited additional benefits on top of optimal medical therapy. This has led to much more attention being paid to coronary vasomotion abnormalities regardless of obstructive or non-obstructive arterial segments. Coronary vasomotion is regulated by multiple mechanisms that include the endothelium, vascular smooth muscle cells (VSMCs), myocardial metabolic demand, autonomic nervous system and inflammation. Over the years, several animal models have been developed to explore the central mechanism of coronary artery spasm. This review summarises the landmark studies on the mechanisms of coronary vasospasm demonstrating the central role of Rho-kinase as a molecular switch of VSMC hypercontraction and the important role of coronary adventitial inflammation for Rho-kinase upregulation in VSMCs.
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Affiliation(s)
- Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Kazuma Oyama
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
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16
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Hung MJ, Yeh CT, Kounis NG, Koniari I, Hu P, Hung MY. Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review. Int J Mol Sci 2023; 24:ijms24087530. [PMID: 37108691 PMCID: PMC10145866 DOI: 10.3390/ijms24087530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.
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Affiliation(s)
- Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung, Chang Gung University College of Medicine, Keelung City 24201, Taiwan
| | - Chi-Tai Yeh
- Department of Medical Research and Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Continuing Education Program of Food Biotechnology Applications, College of Science and Engineering, National Taitung University, Taitung 95092, Taiwan
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, 26221 Patras, Greece
| | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Patrick Hu
- Department of Internal Medicine, School of Medicine, University of California, Riverside, Riverside, CA 92521, USA
- Department of Cardiology, Riverside Medical Clinic, Riverside, CA 92506, USA
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, No.291, Zhongzheng Rd., Zhonghe District, New Taipei City 23561, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 23561, Taiwan
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17
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Hung MY, Hung MJ. Relationship between Inflammation and Vasospastic Angina. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020318. [PMID: 36837519 PMCID: PMC9960836 DOI: 10.3390/medicina59020318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Coronary artery spasm (CAS) is a dynamic coronary stenosis causing vasospastic angina (VSA). However, VSA is a potentially lethal medical condition with multiple presentations, including sudden cardiac death. Despite investigations to explore its pathogenesis, no single mechanism has been found to explain the entire process of VSA occurrence. The roles of elevated local and systemic inflammation have been increasingly recognized in VSA. Treatment strategies to decrease local and systemic inflammation deserve further investigation.
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Affiliation(s)
- Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei 110, Taiwan
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Ming-Jui Hung
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan 333, Taiwan
- Correspondence:
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18
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Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
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19
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Aélion H, Picard F, Jégou A, Allouch P, Varenne O. Abnormal epicardial coronary vasomotor reactivity is associated with altered outcomes. Arch Cardiovasc Dis 2023; 116:33-40. [PMID: 36526570 DOI: 10.1016/j.acvd.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence and significance of abnormal epicardial coronary vasomotor reactivity (ACVR) in patients with symptoms compatible with myocardial ischaemia remains ill-defined. Our diagnostic strategy is to perform a provocative test (PT) in every patient presenting with chest pain at rest, for whom coronary angiography does not reveal significant epicardial coronary artery disease (≥70% stenosis by visual assessment). AIM To evaluate such a strategy in terms of incidence of ACVR, PT safety and patient outcomes. METHODS The present study was a retrospective observational study with a median clinical follow-up of 5years. The primary outcome was incidence of ACVR in patients with PT. Risk factors for ACVR and clinical follow-up were obtained, and the rate of major adverse cardiovascular and cerebrovascular events (MACCE; death, cardiovascular mortality, myocardial infarction, stroke and coronary revascularization) was reported. RESULTS ACVR was documented in 294 (12.4%) of the 2379 patients with PT, out of the 13,654 patients undergoing angiography. Patients with ACVR were more often female (43.9% vs. 30.0%; P<0.0001), current smokers (37.4% vs. 8.7%; P<0.0001) and had a suspected acute coronary syndrome (36.7% vs. 29.1%; P=0.005) at admittance compared with patients without ACVR. During clinical follow-up, MACCE occurred more frequently in patients with (9.8%) than in those without (3.7%) ACVR (hazard ratio [HR] 4.15, 95% confidence interval [CI] 2.62-6.57; P<0.0001), including more myocardial infarctions (4.0% vs. 0.4%; HR 17.8, 95% CI 6.41-49.5; P<0.0001) and more myocardial revascularizations (6.1% vs. 1.1%; HR 9.36, 95% CI 4.67-18.74; P<0.0001) compared with patients with normal PT at baseline. CONCLUSIONS ACVR is frequent in patients with symptoms compatible with myocardial ischaemia at rest, with no significant coronary stenosis. PT is a safe strategy to identify a population at high risk of recurrent ischaemic events.
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Affiliation(s)
- Hélène Aélion
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France
| | - Fabien Picard
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France; Paris Sudden Death Expertise Centre, 75015 Paris, France
| | - Arnaud Jégou
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Philippe Allouch
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Olivier Varenne
- Cardiology Department, Cochin Hospital, AP-HP, 75014 Paris, France; Faculty of Medicine, University of Paris Cité, 75014 Paris, France; Paris Sudden Death Expertise Centre, 75015 Paris, France.
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20
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Ang DTY, Berry C, Kaski JC. Phenotype-based management of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:3332-3340. [PMID: 35672569 PMCID: PMC9834338 DOI: 10.1007/s12350-022-03000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/10/2022] [Indexed: 01/22/2023]
Abstract
40-70% of patients undergoing invasive coronary angiography with signs and symptoms of ischemia are found to have no obstructive coronary artery disease (INOCA). When this heterogeneous group undergo coronary function testing, approximately two-thirds have demonstrable coronary microvascular dysfunction (CMD), which is independently associated with adverse prognosis. There are four distinct phenotypes, or subgroups, each with unique pathophysiological mechanisms and responses to therapies. The clinical phenotypes are microvascular angina, vasospastic angina, mixed (microvascular and vasospastic), and non-cardiac symptoms (reclassification as non-INOCA). The Coronary Vasomotor Disorders International Study Group (COVADIS) have proposed standardized criteria for diagnosis. There is growing awareness of these conditions among clinicians and within guidelines. Testing for CMD can be done using invasive or non-invasive modalities. The CorMicA study advocates the concept of 'functional angiography' to guide stratified medical therapy. Therapies broadly fall into two categories: those that modulate cardiovascular risk and those to alleviate angina. Management should be tailored to the individual, with periodic reassessment for efficacy. Phenotype-based management is a worthy endeavor for both patients and clinicians, aligning with the concept of 'precision medicine' to improve prognosis, symptom burden, and quality of life. Here, we present a contemporary approach to the phenotype-based management of patients with INOCA.
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Affiliation(s)
- Daniel Tze Yee Ang
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
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21
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Lin X, Lin Z, Zhao X, Liu Z, Xu C, Yu B, Gao P, Wang Z, Ge J, Shen Y, Li L. Serum SELENBP1 and VCL Are Effective Biomarkers for Clinical and Forensic Diagnosis of Coronary Artery Spasm. Int J Mol Sci 2022; 23:13266. [PMID: 36362053 PMCID: PMC9655542 DOI: 10.3390/ijms232113266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 09/29/2023] Open
Abstract
Coronary artery spasm (CAS) plays an important role in the pathogenesis of many ischemic heart entities; however, there are no established diagnostic biomarkers for CAS in clinical and forensic settings. This present study aimed to identify such serum biomarkers by establishing a rabbit CAS provocation model and integrating quantitative serum proteomics, parallel reaction monitoring/mass spectrometry-based targeted proteomics, and partial least-squares discriminant analysis (PLS-DA). Our results suggested that SELENBP1 and VCL were potential candidate biomarkers for CAS. In independent clinical samples, SELENBP1 and VCL were validated to be significantly lower in serum but not blood cells from CAS patients, with the reasons for this possibly due to the decreased secretion from cardiomyocytes. The areas under the curve of the receiver operating characteristics (ROC) analysis were 0.9384 for SELENBP1 and 0.9180 for VCL when diagnosing CAS. The CAS risk decreased by 32.3% and 53.6% for every 10 unit increases in the serum SELENBP1 and VCL, respectively. In forensic samples, serum SELENBP1 alone diagnosed CAS-induced deaths at a sensitivity of 100.0% and specificity of 72.73%, and its combination with VCL yielded a diagnostic specificity of 100.0%, which was superior to the traditional biomarkers of cTnI and CK-MB. Therefore, serum SELENBP1 and VCL could be effective biomarkers for both the clinical and forensic diagnosis of CAS.
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Affiliation(s)
- Xinyi Lin
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Zijie Lin
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Xin Zhao
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zheng Liu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Chenchao Xu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Bokang Yu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Pan Gao
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhimin Wang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yiwen Shen
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Liliang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 849] [Impact Index Per Article: 424.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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23
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Montone RA, Rinaldi R, Del Buono MG, Gurgoglione F, La Vecchia G, Russo M, Caffè A, Burzotta F, Leone AM, Romagnoli E, Sanna T, Pelargonio G, Trani C, Lanza GA, Niccoli G, Crea F. Safety and prognostic relevance of acetylcholine testing in patients with stable myocardial ischaemia or myocardial infarction and non-obstructive coronary arteries. EUROINTERVENTION 2022; 18:e666-e676. [PMID: 35377315 PMCID: PMC10241282 DOI: 10.4244/eij-d-21-00971] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/07/2022] [Indexed: 07/25/2023]
Abstract
BACKGROUND Intracoronary provocation testing with acetylcholine (ACh) is crucial for the diagnosis of functional coronary alterations in patients with suspected myocardial ischaemia and non-obstructive coronary arteries. AIMS Our intention was to assess the safety and predictive value for major adverse cardiovascular and cerebrovascular events (MACCE) in patients presenting with ischaemia with non-obstructive coronary arteries (INOCA) or with myocardial infarction with non-obstructive coronary arteries (MINOCA). METHODS We prospectively enrolled consecutive INOCA or MINOCA patients undergoing intracoronary ACh provocation testing. RESULTS A total of 317 patients were enrolled: 174 (54.9%) with INOCA and 143 (45.1%) with MINOCA. Of these, 185 patients (58.4%) had a positive response to the ACh test. Complications during ACh provocative testing were all mild and transient and occurred in 29 (9.1%) patients, with no difference between patients with positive or negative responses to ACh testing, nor between INOCA and MINOCA patients. A history of paroxysmal atrial fibrillation, moderate/severe diastolic dysfunction and a higher QT dispersion at baseline electrocardiogram were independent predictors of complications. MACCE occurred in 30 patients (9.5%) during a median follow-up of 22 months. The incidence of MACCE was higher among patients with a positive ACh test (24 [13.0%] vs 6 [4.5%], p=0.017), and a positive ACh test was an independent predictor of MACCE. CONCLUSIONS ACh provocation testing is associated with a low risk of mild and transient complications, with a similar prevalence in both INOCA and MINOCA patients. Importantly, ACh provocation testing can help to identify patients at higher risk of future clinical events, suggesting a net clinical benefit derived from its use in this clinical setting.
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Affiliation(s)
- Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Filippo Gurgoglione
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Michele Russo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Andrea Caffè
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Gemma Pelargonio
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart Rome, Italy
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Cellular Mechanisms of Coronary Artery Spasm. Biomedicines 2022; 10:biomedicines10102349. [PMID: 36289612 PMCID: PMC9599037 DOI: 10.3390/biomedicines10102349] [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: 08/29/2022] [Revised: 09/13/2022] [Accepted: 09/17/2022] [Indexed: 11/17/2022] Open
Abstract
Coronary artery spasm (CAS) is a reversible phenomenon caused by spontaneous excessive vascular smooth muscle contractility and vascular wall hypertonicity, which results in partial or complete closure of the lumen of normal or atherosclerotic coronary arteries. The clinical picture of CAS includes chest discomfort which is similar in quality to that of stable effort angina. Mechanisms underlying the development of CAS are still unclear. CAS certainly is a multifactorial disease. In this review, we paid attention to the role of the main pathophysiologic mechanisms in CAS: endothelial dysfunction, chronic inflammation, oxidative stress, smooth muscle hypercontractility, atherosclerosis and thrombosis, and mutations leading to deficient aldehyde dehydrogenase 2 (ALDH2) activity. These findings might shed novel insight on the underlying mechanisms and identify potential diagnostic and therapeutic targets for cardiovascular diseases in the future.
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Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment. J Clin Med 2022; 11:jcm11195497. [PMID: 36233366 PMCID: PMC9571924 DOI: 10.3390/jcm11195497] [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: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.
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26
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Zhai C, Fan H, Zhu Y, Chen Y, Shen L. Coronary functional assessment in non-obstructive coronary artery disease: Present situation and future direction. Front Cardiovasc Med 2022; 9:934279. [PMID: 36082113 PMCID: PMC9445206 DOI: 10.3389/fcvm.2022.934279] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Non-obstructive coronary artery disease (CAD), which is defined as coronary stenosis <50%, has been increasingly recognized as an emerging entity in clinical practice. Vasomotion abnormality and coronary microvascular dysfunction are two major mechanisms contributing to the occur of angina with non-obstructive CAD. Although routine coronary functional assessment is limited due to several disadvantages, functional evaluation can help to understand the pathophysiological mechanism and/or to exclude specific etiologies. In this review, we summarized the potential mechanisms involved in ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA), the two major form of non-obstructive CAD. Additionally, we reviewed currently available functional assessment indices and their use in non-obstructive CAD. Furthermore, we speculated that novel technique combined anatomic and physiologic parameters might provide more individualized therapeutic choice for patients with non-obstructive CAD.
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Affiliation(s)
- Changlin Zhai
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Hongyan Fan
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yujuan Zhu
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yunqing Chen
- Department of Infectious Diseases, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Liang Shen
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Liang Shen
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27
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Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081124. [PMID: 36013303 PMCID: PMC9409871 DOI: 10.3390/life12081124] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 12/26/2022]
Abstract
Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.
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Bil J, Pietraszek N, Gil RJ, Gromadziński L, Onichimowski D, Jalali R, Kern A. Complete Blood Count-Derived Indices as Prognostic Factors of 5-Year Outcomes in Patients With Confirmed Coronary Microvascular Spasm. Front Cardiovasc Med 2022; 9:933374. [PMID: 35845050 PMCID: PMC9279657 DOI: 10.3389/fcvm.2022.933374] [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: 04/30/2022] [Accepted: 06/15/2022] [Indexed: 12/08/2022] Open
Abstract
Background Coronary microcirculatory dysfunction is a meaningful factor in the development of ischemic heart disease. We investigated the relationship between coronary microvascular spasm and complete blood count indices. Methods Between 2010 and 2013, we performed acetylcholine test (AChT) in subjects with suspicion of angina evoked by epicardial coronary spasm or coronary microvascular spasm according to COVADIS criteria. We administered acetylcholine in increasing doses of 25, 50, and 75 μg into the right coronary artery and 25, 50, and 100 μg into the left coronary artery. Patients were followed up for 60 months. Results In total, 211 patients (60.5 ± 7.8 years, 67.8% women) were included in the study. The AChT revealed angina due to epicardial coronary spasm in 99 patients (46.9%) and coronary microvascular spasm in 72 (34.1%). White blood cell (WBC), red blood cell distribution width (RDW), platelets (PLT), mean platelet volume (MPV), and platelet distribution width (PDW) values were significantly higher in patients with coronary microvascular spasm than in patients from the other two groups, i.e., epicardial coronary spasm and negative AChT. PDW showed the highest sensitivity (65%) and specificity (72%) at the cutoff value of 15.32% [area under the curve, 0.723; 95% confidence interval (CI) 0.64-0.83; P < 0.001]. Independent risk factors for coronary microvascular spasm diagnosis using AChT were as follows: female sex (OR, 1.199), PDW (OR, 2.891), and RDW (OR, 1.567). Conclusion PDW and RDW are significantly associated with the diagnosis of coronary microvascular spasm in patients undergoing AChT as well as with poor prognosis in such patients at 5 years.
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Affiliation(s)
- Jacek Bil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Natalia Pietraszek
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Robert J. Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Leszek Gromadziński
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Dariusz Onichimowski
- Department of Anesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
- Clinical Department of Anesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
| | - Rakesh Jalali
- Emergency Medicine Department, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Clinical Emergency Department, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
| | - Adam Kern
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Department of Cardiology, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
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29
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Takahashi T, Samuels BA, Li W, Parikh MA, Wei J, Moses JW, Fearon WF, Henry TD, Tremmel JA, Kobayashi Y. Safety of Provocative Testing With Intracoronary Acetylcholine and Implications for Standard Protocols. J Am Coll Cardiol 2022; 79:2367-2378. [PMID: 35710187 DOI: 10.1016/j.jacc.2022.03.385] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/29/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heterogeneity in diagnostic criteria and provocation protocols has posed challenges in understanding the safety of coronary provocation testing with intracoronary acetylcholine (ACh) for the contemporary diagnosis of epicardial and microvascular spasm. OBJECTIVES We examined the safety of testing and subgroup differences in procedural risks based on ethnicity, diagnostic criteria, and provocation protocols. METHODS PubMed and Embase were searched in November 2021 to identify original articles reporting procedural complications associated with intracoronary ACh administration. The primary outcome was the pooled estimate of the incidence of major complications including death, myocardial infarction, ventricular tachycardia/fibrillation, and shock. RESULTS A total of 16 studies with 12,585 patients were included in the meta-analysis. The overall pooled estimate of the incidence of major complications was 0.5% (95% CI: 0.0%-1.3%) without any reports of death. Exploratory subgroup analyses revealed that the pooled incidence of major complications was significantly higher in the studies that followed the contemporary diagnosis criteria for epicardial spasm defined as ≥90% diameter reduction (1.0%; 95% CI: 0.3%-2.0%) but significantly lower in Western populations (0.0%; 95% CI: 0.0%-0.45%). The rate of positive epicardial spasm and the incidence of major complications were similar between provocation protocols using the maximum ACh doses of 100 μg and 200 μg. CONCLUSIONS Intracoronary ACh administration for the contemporary diagnosis of epicardial and microvascular spasm is a safe procedure. Moreover, excellent safety records are observed in Western populations primarily presenting with myocardial ischemia and/or infarction with nonobstructive coronary arteries. This study will help standardize ACh testing to improve clinical diagnosis and ensure procedural safety.
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Affiliation(s)
- Tatsunori Takahashi
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Weijia Li
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Manish A Parikh
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medicine, Brooklyn, New York, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffery W Moses
- Department of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Yuhei Kobayashi
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medicine, Brooklyn, New York, USA.
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30
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Kim HJ, Jo SH, Lee MH, Seo WW, Kim HL, Lee KY, Yang TH, Her SH, Lee BK, Park KH, Ahn Y, Rha SW, Gwon HC, Choi DJ, Baek SH. Nitrates vs. Other Types of Vasodilators and Clinical Outcomes in Patients with Vasospastic Angina: A Propensity Score-Matched Analysis. J Clin Med 2022; 11:jcm11123250. [PMID: 35743321 PMCID: PMC9225129 DOI: 10.3390/jcm11123250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 12/04/2022] Open
Abstract
Although vasodilators are widely used in patients with vasospastic angina (VA), few studies have compared the long-term prognostic effects of different types of vasodilators. We investigated the long-term effects of vasodilators on clinical outcomes in VA patients according to the type of vasodilator used. Study data were obtained from a prospective multicenter registry that included patients who had symptoms suggestive of VA. Patients were classified into two groups according to use of nitrates (n = 239) or other vasodilators (n = 809) at discharge. The composite clinical events rate, including acute coronary syndrome (ACS), cardiac death, new-onset arrhythmia (including ventricular tachycardia and ventricular fibrillation), and atrioventricular block, was significantly higher in the nitrates group (5.3% vs. 2.2%, p = 0.026) during one year of follow-up. Specifically, the prevalence of ACS was significantly more frequent in the nitrates group (4.3% vs. 1.5%, p = 0.024). After propensity score matching, the adverse effects of nitrates remained. In addition, the use of nitrates at discharge was independently associated with a 2.69-fold increased risk of ACS in VA patients. In conclusion, using nitrates as a vasodilator at discharge can increase the adverse clinical outcomes in VA patients at one year of follow-up. Clinicians need to be aware of the prognostic value and consider prescribing other vasodilators.
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Affiliation(s)
- Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Korea;
| | - Sang-Ho Jo
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang-si 14068, Korea
- Correspondence: ; Tel.: +82-031-380-3722
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea;
| | - Won-Woo Seo
- Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul 05355, Korea;
| | - Hack-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul 07061, Korea;
| | - Kwan Yong Lee
- Division of Cardiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Korea; (K.Y.L.); (S.H.B.)
| | - Tae-Hyun Yang
- Department of Cardiovascular Medicine, Busan Paik Hospital, Inje University, Busan 04551, Korea;
| | - Sung-Ho Her
- Department of Cardiovascular Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Suwon 16249, Korea;
| | - Byoung-Kwon Lee
- Department of Cardiovascular Medicine, Gangnam Severance Hospital, Yonsei University, Seoul 06273, Korea;
| | - Keun-Ho Park
- Division of Cardiology, Department of Internal Medicine, Chosun Medical Center, Gwangju 61453, Korea;
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61469, Korea;
| | - Seung-Woon Rha
- Department of Cardiovascular Medicine, Guro Hospital, Korea University, Seoul 08308, Korea;
| | - Hyeon-Cheol Gwon
- Department of Cardiovascular Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Korea;
| | - Dong-Ju Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Sang Hong Baek
- Division of Cardiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Korea; (K.Y.L.); (S.H.B.)
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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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Impact of statins in patients with vasospastic angina: A multicenter registry study of the Japanese Coronary Spasm Association. J Cardiol 2022; 80:226-231. [DOI: 10.1016/j.jjcc.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 12/24/2022]
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Nishi T, Kume T, Yamada R, Okamoto H, Koto S, Yamashita M, Ueno M, Kamisaka K, Sasahira Y, Enzan A, Sudo Y, Tamada T, Koyama T, Imai K, Neishi Y, Uemura S. Layered Plaque in Organic Lesions in Patients With Coronary Artery Spasm. J Am Heart Assoc 2022; 11:e024880. [PMID: 35322674 PMCID: PMC9075431 DOI: 10.1161/jaha.121.024880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Coronary artery spasm plays a vital role in the pathogenesis of coronary plaques. We sought to investigate the plaque characteristics of co‐existing organic lesions in patients with coronary artery spasm in comparison to those without coronary artery spasm by intracoronary optical coherence tomography (OCT). Methods and Results We included 39 patients who presented with a symptom suspected of coronary spastic angina and had an organic lesion, defined as ≥plaque burden of 50% assessed by OCT. Coronary artery spasm was diagnosed by positive acetylcholine provocation test, or by spontaneous spasm detected during coronary angiography. A total of 51 vessels with an organic lesion were identified. Of these, coronary artery spasm was observed in 30 vessels (spasm), while not in 21 vessels (non‐spasm). Organic lesions in the spasm vessels, compared with those in the non‐spasm vessels, had a higher prevalence of layered plaque (93% versus 38%, P<0.001), macrophages (80% versus 43%, P=0.016), and intraplaque microchannels (73% versus 24%, P<0.001), and lower prevalence of macrocalcification (23% versus 62%, P=0.009) as assessed by OCT. Conclusions Layered plaque, macrophages, and intraplaque microchannels, were frequently observed in organic lesions in patients with coronary artery spasm. These findings suggest that coronary artery spasm induces local thrombus formation as well as active inflammatory response, therefore increasing the risk of rapid plaque progression and ischemic events in patients with coronary artery spasm.
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Affiliation(s)
- Takeshi Nishi
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Teruyoshi Kume
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Ryotaro Yamada
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Hiroshi Okamoto
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Satsohi Koto
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | | | - Masahiko Ueno
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Kyo Kamisaka
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | | | - Ayano Enzan
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yasuyuki Sudo
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Tomoko Tamada
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Terumasa Koyama
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Koichiro Imai
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yoji Neishi
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
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Minhas AS, Michos ED, Hays AG. Is Vasospastic Coronary Disease More Common Than We Realize? JACC Case Rep 2022; 4:298-300. [PMID: 35257106 PMCID: PMC8897046 DOI: 10.1016/j.jaccas.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Anum S. Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Erin D. Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Allison G. Hays
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Marrone A, Pavasini R, Scollo E, Gibiino F, Pompei G, Caglioni S, Biscaglia S, Campo G, Tebaldi M. Acetylcholine Use in Modern Cardiac Catheterization Laboratories: A Systematic Review. J Clin Med 2022; 11:jcm11041129. [PMID: 35207403 PMCID: PMC8880288 DOI: 10.3390/jcm11041129] [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: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The use of acetylcholine for the diagnosis of vasospastic angina is recommended by international guidelines. However, its intracoronary use is still off-label due to the absence of safety studies. We aimed to perform a systematic review of the literature to identify adverse events related to the intracoronary administration of acetylcholine for vasoreactivity testing to fill this gap. METHODS AND RESULTS We conducted a systematic review of observational studies and randomized controlled trials dealing with the intracoronary administration of acetylcholine. Articles were searched in MEDLINE (PubMed) using the MeSH strategy. Three independent reviewers determined whether the studies met the inclusion and exclusion criteria. A total of 434 articles were selected. Data concerning clinical characteristics, study population, acetylcholine dosage, and adverse effects were retrieved from the articles. Overall, 71,566 patients were included, of which only 382 (0.5%) developed one adverse event, and there were no fatal events reported (0%). CONCLUSIONS Intracoronary administration of acetylcholine in the setting of coronary spasm provocation testing is safe and plays a central role in the evaluation of coronary vasomotion disorders, making it worthy of becoming a part of clinical practice in all cardiac catheterization laboratories.
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Feenstra RG, Seitz A, Boerhout CK, Bukkems LH, Stegehuis VE, Teeuwisse PJ, de Winter RJ, Sechtem U, Piek JJ, van de Hoef TP, Ong P, Beijk MA. Principles and pitfalls in coronary vasomotor function testing. EUROINTERVENTION 2022; 17:1271-1280. [PMID: 34278990 PMCID: PMC9725006 DOI: 10.4244/eij-d-21-00402] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Coronary vasomotor dysfunction can be diagnosed in a large proportion of patients with angina in the presence of non-obstructive coronary artery disease (ANOCA) using comprehensive protocols for coronary vasomotor function testing (CFT). Although consensus on diagnostic criteria for endotypes of coronary vasomotor dysfunction has been published, consensus on a standardised study testing protocol is lacking. AIMS In this review we provide an overview of the variations in CFT used and discuss the practical principles and pitfalls of CFT. METHODS For the purposes of this review, we assessed study protocols that evaluate coronary vasomotor response as reported in the literature. We compared these protocols regarding a number of procedural aspects and chose six examples to highlight the differences and uniqueness. RESULTS Currently, numerous protocols co-exist and vary in vascular domains tested, the manner in which to test these domains (e.g., preprocedural discontinuation of medication, provocative agent, solution, infusion time, and target artery) and techniques used for measurements (e.g., Doppler vs thermodilution technique). CONCLUSIONS This lack of consensus on a uniform functional testing protocol hampers both a broader clinical acceptance of the concepts of coronary vasomotor dysfunction, and the widespread adoption of such testing protocols in current clinical practice. Furthermore, the endotype of coronary vasomotor dysfunction might differ among the few specialised centres that perform CFT as a result of the use of different protocols.
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Affiliation(s)
- Rutger G.T. Feenstra
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Coen K.M. Boerhout
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Laura H. Bukkems
- Department of Clinical Pharmacy, Amsterdam UMC, Amsterdam, the Netherlands
| | - Valérie E. Stegehuis
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Robbert J. de Winter
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Jan J. Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Tim P. van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Marcel A.M. Beijk
- AMC Heartcenter, Room B2-250, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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Ang DTY, Berry C. What an Interventionalist Needs to Know About INOCA. Interv Cardiol 2021; 16:e32. [PMID: 34950239 PMCID: PMC8674629 DOI: 10.15420/icr.2021.16] [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: 05/30/2021] [Accepted: 09/23/2021] [Indexed: 12/23/2022] Open
Abstract
Ischaemia with non-obstructed coronary artery disease (INOCA) remains a diagnostic and therapeutic challenge. An anatomical investigationbased approach to ischaemic heart disease fails to account for disorders of vasomotion. The main INOCA endotypes are microvascular angina, vasospastic angina, mixed (both) or non-cardiac symptoms. The interventional diagnostic procedure (IDP) enables differentiation between clinical endotypes, with linked stratified medical therapy leading to a reduced symptom burden and a better quality of life. Interventionists are therefore well placed to make a positive impact with more personalised care. Despite adjunctive tests of coronary function being supported by contemporary guidelines, IDP use in daily practice remains limited. More widespread adoption should be encouraged. This article reviews a stratified approach to INOCA, describes a streamlined approach to the IDP and highlights some practical and safety considerations.
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Affiliation(s)
- Daniel Tze Yee Ang
- University of Glasgow Glasgow, UK.,Golden Jubilee National Hospital Clydebank, UK
| | - Colin Berry
- University of Glasgow Glasgow, UK.,Golden Jubilee National Hospital Clydebank, UK
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38
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Kim M, Jang AY, Oh PC, Suh SY, Lee K, Kang WC, Ahn T, Han SH. Diagnostic and prognostic role of nitroglycerin-induced dilation in patients with suspected vasospastic angina, combined with ergonovine provocation test. Sci Rep 2021; 11:23834. [PMID: 34903772 PMCID: PMC8668896 DOI: 10.1038/s41598-021-03338-0] [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: 06/06/2021] [Accepted: 12/01/2021] [Indexed: 11/12/2022] Open
Abstract
The diagnostic and prognostic role of nitroglycerin-induced dilation (NID) combined with ergonovine provocation test in patients with suspected VSA patients is not clear. A total of 438 consecutive patients who underwent the ergonovine provocation test for the diagnosis of vasospastic angina (VSA) were enrolled. Patients with VSA (n = 52) had a significantly greater coronary response to ergonovine (− 84.3 ± 10.5% vs. − 38.4 ± 17.9%, p < 0.001) and NID (26.3 ± 31.0% vs. 12.5 ± 19.0%, p < 0.001) than non-VSA patients. However, positive NID (more than 13.8% dilation, n = 170) showed a poor accuracy (AUC 0.64 [95% CI: 0.56–0.73], p = 0.001, sensitivity 60.4%, specificity 61.3%) for the diagnosis of VSA by ergonovine provocation test. Major adverse cardiovascular events (MACE) occurred more frequently in the VSA group than in the non-VSA group (9.6% vs. 2.2%, p = 0.006). In addition, the positive NID group showed a lower rate of MACE than the negative NID group (1.2% vs. 4.3%, p = 0.021). Interestingly, the group of VSA with negative NID had poor prognosis than any other combinations (Log-rank, p < 0.0001). Although NID had a limited role in the detection of VSA defined by ergonovine provocation test, NID combined with the ergonovine provocation test has an additive prognostic role in the clinical outcomes in patients with suspected VSA.
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Affiliation(s)
- Minsu Kim
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Albert Youngwoo Jang
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Pyung Chun Oh
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Soon Yong Suh
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Kyounghoon Lee
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Woong Chol Kang
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Taehoon Ahn
- Division of Cardiovascular Diseases, Department of Internal Medicine, Korea University, Anam Hospital, Seoul, Republic of Korea
| | - Seung Hwan Han
- Division of Cardiology, Department of Internal Medicine, Gachon University College of Medicine, Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea.
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Wu BT. Percutaneous coronary intervention to refractory left main coronary artery spasm. J Cardiol Cases 2021; 25:300-303. [DOI: 10.1016/j.jccase.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/08/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022] Open
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Chow E, Diep B, Getman T, Kilani A, Khiatah B, Jazayeri S, Mansour C. Clinical presentation and management of myocardial infarction with nonobstructive coronary arteries (MINOCA): A literature review. Heliyon 2021; 7:e08362. [PMID: 34816048 PMCID: PMC8591493 DOI: 10.1016/j.heliyon.2021.e08362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022] Open
Abstract
Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.
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Affiliation(s)
- Erica Chow
- Western University of Health Sciences, Pomona, CA 91766, USA.,Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Brian Diep
- Western University of Health Sciences, Pomona, CA 91766, USA.,Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Tatiana Getman
- Western University of Health Sciences, Pomona, CA 91766, USA.,Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Amir Kilani
- Western University of Health Sciences, Pomona, CA 91766, USA.,Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Bashar Khiatah
- Department of Internal Medicine, Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Sam Jazayeri
- Department of Internal Medicine, Community Memorial Hospital, 147 N Brent St, Ventura CA 93003, USA
| | - Craig Mansour
- Cardiology Associates Medical Group, 168 North Brent Street Suite 503, Ventura, CA 93003, USA
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Mangiacapra F, Viscusi MM, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. The Pivotal Role of Invasive Functional Assessment in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA). Front Cardiovasc Med 2021; 8:781485. [PMID: 34869695 PMCID: PMC8637881 DOI: 10.3389/fcvm.2021.781485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/25/2021] [Indexed: 01/10/2023] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) encompasses several pathophysiological mechanisms not yet fully understood. Among the latter, vasomotion abnormalities and coronary microvascular dysfunction (CMD) play a major role for both epidemiological and prognostic reasons. Despite current guidelines do not recommend routine physiological assessment of both epicardial and microvascular coronary compartments within the context of an acute myocardial infarction, several recent evidence support the critical role of a comprehensive invasive functional assessment in order to identify the underlying pathophysiological mechanism and consequently to select an appropriate therapeutic strategy. Unfortunately, optimal medical therapy for these patients is not currently established due to the lack of dedicated trials evaluating clinical outcomes of commonly used medications for secondary prevention in MINOCA patients. For this reason, additional research is warranted to provide personalized treatments for patients affected by this puzzling clinical entity.
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Affiliation(s)
- Fabio Mangiacapra
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
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42
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Bèze NE, Millien V, Lefèvre T, Chevalier B, Garot P, Hovasse T, Unterseeh T, Champagne S, Sanguineti F, Neylon A, Benamer H. [Methergin pour le diagnostic de l'angor spastique : voie intraveineuse ou intracoronaire ?]. Ann Cardiol Angeiol (Paris) 2021; 70:446-450. [PMID: 34635330 DOI: 10.1016/j.ancard.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vasospastic angina is an infrequent underlying cause of angina and is under-diagnosed. Ergonovine provocation tests can be performed via intravenous or intracoronary injections. Although the safety profile of intracoronary injection has been well documented, no study has yet compared the intracoronary and intravenous injections regarding the positivity rate of the test. AIMS This study sought to compare the positivity rate of intravenous versus intracoronary injection of ergonovine in the diagnosis of vasospastic angina. METHODS Between January 2010 and February 2018, 427 patients with suspected vasospastic angina underwent an ergonovine provocation test in 2 tertiary hospitals in France and were retrospectively included in this study. Injection was performed via the intravenous or the intracoronary route. The primary endpoint was the positivity rate of the test. Propensity score matching was used to account for confounding factors. RESULTS 427 patients were included in the study. Mean age was 60.3 (+/- 12.4) years. There were 247 (58%) females and 97 (23%) smokers. The intracoronary route was used in 199 (47%) patients. The indication for the test was acute coronary syndrome for 121 (28%). No rhythmic complications or deaths were reported. After propensity-matching, the baseline characteristics of the 2 groups (148 patients in each) were comparable. The positivity rate was 24% in the intracoronary group and 9% in the intravenous group (OR [95%CI]: 3.2 [1.6, 6.4]). CONCLUSIONS Intracoronary injection of ergonovine is safe and associated with a positivity rate of the test three times higher compared to intravenous injection.
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Affiliation(s)
- Nathan El Bèze
- Cardiology department, Hôpital Foch, 40 Rue Worth, 92150Suresnes, France
| | - Vincent Millien
- Cardiology department, Centre Hospitalier de Saint Quentin, 1 Rue Michel De L'Hospital, 02100Saint Quentin, France
| | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Bernard Chevalier
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Antoinette Neylon
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Hakim Benamer
- Cardiology department, Hôpital Foch, 40 Rue Worth, 92150Suresnes, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France.
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Takahashi J, Suda A, Nishimiya K, Godo S, Yasuda S, Shimokawa H. Pathophysiology and Diagnosis of Coronary Functional Abnormalities. Eur Cardiol 2021; 16:e30. [PMID: 34603510 PMCID: PMC8478147 DOI: 10.15420/ecr.2021.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/07/2021] [Indexed: 01/17/2023] Open
Abstract
Approximately one-half of patients undergoing diagnostic coronary angiography for angina have no significant coronary atherosclerotic stenosis. This clinical condition has recently been described as ischaemia with non-obstructive coronary arteries (INOCA). Coronary functional abnormalities are central to the pathogenesis of INOCA, including epicardial coronary spasm and coronary microvascular dysfunction composed of a variable combination of increased vasoconstrictive reactivity and/or reduced vasodilator function. During the last decade - in INOCA patients in particular - evidence for the prognostic impact of coronary functional abnormalities has accumulated and various non-invasive and invasive diagnostic techniques have enabled the evaluation of coronary vasomotor function in a comprehensive manner. In this review, the authors briefly summarise the recent advances in the understanding of pathophysiology and diagnosis of epicardial coronary artery spasm and coronary microvascular dysfunction.
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Affiliation(s)
- Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
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Ikeda S, Takeda M, Sato K, Miki K, Fukuda K, Shiba N. A case of vasospastic angina with exertional sign. J Cardiol Cases 2021; 24:199-202. [DOI: 10.1016/j.jccase.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022] Open
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Prognostic Links Between OCT-Delineated Coronary Morphologies and Coronary Functional Abnormalities in Patients With INOCA. JACC Cardiovasc Interv 2021; 14:606-618. [PMID: 33736768 DOI: 10.1016/j.jcin.2020.12.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Whether there are prognostic links between coronary morphologies and coronary functional abnormalities was examined in ischemia and nonobstructive coronary artery disease (INOCA) patients. BACKGROUND Although INOCA has attracted much attention, little is known about the prognostic impact of coronary morphologies in this disorder. METHODS A total of 329 consecutive INOCA patients were enrolled and underwent spasm provocation testing combined with lactate sampling for diagnosis of epicardial and microvascular spasm (MVS). On the basis of the functional tests, the patients were classified into 4 groups: a control group without epicardial spasm or MVS (n = 32), MVS alone (n = 51), diffuse spasm in ≥2 coronary segments (n = 204), and focal spasm in 1 segment (n = 42). In this population, optical coherence tomography imaging of the left anterior descending coronary artery was performed for evaluation of adventitial vasa vasorum (AVV) and intraplaque neovessels (IPN). Index of microcirculatory resistance was also measured. RESULTS MVS frequently coexisted with diffuse (70%) and focal spasm (68%) with a good correlation between AVV and index of microcirculatory resistance (R = 0.353; p = 0.022). For a median follow-up of 1,043 days, focal spasm showed the worst prognosis (log rank p = 0.005), for which IPN was a significant prognostic factor. By contrast, diffuse spasm showed the greatest AVV with an intermediate prognosis. The prognostic value of INOCA was significantly enhanced by adding AVV and IPN to the physiological indices (area under the curve = 0.88 vs. 0.76; p = 0.048). CONCLUSIONS These results provide the first evidence that there are important prognostic links between coronary morphologies (evaluated by optical coherence tomography) and coronary functional abnormalities in patients with INOCA, indicating the importance of both evaluations in this population.
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Prognostic implications of coronary artery stenosis and coronary spasm in patients with stable angina: 5-year follow-up of the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries (ACOVA) study. Coron Artery Dis 2021; 31:530-537. [PMID: 32168049 DOI: 10.1097/mca.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries study, we showed that 62% of patients with stable angina and unobstructed coronary arteries had coronary spasm. In this study, we sought to assess the 5-year prognosis in these patients. METHODS Data regarding the following endpoints were obtained: death, non-fatal myocardial infarction, coronary event (=cardiac death or non-fatal myocardial infarction), persistent angina and repeated coronary angiography. Quality of life was assessed using the Seattle Angina Questionnaire. RESULTS Among patients with unobstructed coronary arteries there were three deaths (2.9%) and no non-fatal myocardial infarction. Among those with obstructive CAD 15 died (13.8%) and three had a non-fatal myocardial infarction (2.8%). Patients with obstructive CAD had a higher rate of all-cause death and coronary events compared to those without (P = 0.004). Persistent angina was more prevalent in patients with unobstructed coronaries (P = 0.042). Prognosis of patients with unobstructed coronaries regarding hard clinical events, persistent angina and repeated coronary angiography was independent of the presence of coronary spasm (all P > 0.05). However, spasm patients were more likely to take nitrate medication at follow-up (P = 0.029). CONCLUSION Patients with stable angina and unobstructed coronary arteries have a favorable prognosis regarding mortality and non-fatal myocardial infarction after 5 years compared to patients with obstructive CAD irrespective of the presence of coronary artery spasm. However, persistent angina remains a common issue in patients with unobstructed coronary arteries leading to a similar frequency of repeated invasive procedures as in patients with obstructive CAD.
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Kim HJ, Lee MH, Jo SH, Seo WW, Kim HL, Lee KY, Yang TH, Her SH, Han SH, Lee BK, Park KH, Rha SW, Gwon HC, Choi DJ, Baek SH. Effect of Significant Coronary Artery Stenosis on Prognosis in Patients with Vasospastic Angina: A Propensity Score-Matched Analysis. J Clin Med 2021; 10:jcm10153341. [PMID: 34362125 PMCID: PMC8347544 DOI: 10.3390/jcm10153341] [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: 07/14/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Vasospastic angina (VA) is a functional disease of the coronary artery and occurs in an angiographically normal coronary artery. However, it may also occur with coronary artery stenosis. We investigated the effect of coronary artery stenosis on clinical outcomes in VA patients. Study data were obtained from a prospective multicenter registry that included patients who had symptoms of VA. Patients were classified into two groups according to presence of significant coronary artery stenosis. Among 1920 patients with VA, 189 patients were classified in the "significant stenosis" group. The one-year composite clinical events rate was significantly higher in the significant stenosis group than in the "no significant stenosis" group (5.8% vs. 1.4%, respectively; p < 0.001). Additionally, the prevalence of ACS was significantly greater in the "significant stenosis" group (4.8% vs. 0.9%, respectively; p < 0.001). After propensity score matching, the adverse effects of significant stenosis remained. In addition, significant stenosis was independently associated with a 6.67-fold increased risk of ACS in VA patients. In conclusion, significant coronary artery stenosis can increase the adverse clinical outcomes in VA patients at long-term follow-up. Clinicians should manage traditional risk factors associated with atherosclerosis and control vasospasm as well as reduce the burden of atherosclerosis.
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Affiliation(s)
- Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Korea;
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea;
| | - Sang-Ho Jo
- Cardiovascular Center, Hallym University Sacred Heart Hospital, Anyang-si 14068, Korea
- Correspondence: ; Tel.: +82-031-380-3722
| | - Won-Woo Seo
- Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul 05355, Korea;
| | - Hack-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul 07061, Korea;
| | - Kwan-Yong Lee
- Department of Cardiovascular Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon 21431, Korea;
| | - Tae-Hyun Yang
- Department of Cardiovascular Medicine, Busan Paik Hospital, Inje University, Busan 47392, Korea;
| | - Sung-Ho Her
- Department of Cardiovascular Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Suwon 16247, Korea;
| | - Seung-Hwan Han
- Department of Cardiovascular Medicine, Gil Medical Center, Gachon University, Incheon 21565, Korea;
| | - Byoung-Kwon Lee
- Department of Cardiovascular Medicine, Gangnam Severance Hospital, Yonsei University, Seoul 06273, Korea;
| | - Keun-Ho Park
- The Heart Center, Chosun Medical Center, Gwangju 61453, Korea;
| | - Seung-Woon Rha
- Department of Cardiovascular Medicine, Guro Hospital, Korea University, Seoul 08308, Korea;
| | - Hyeon-Cheol Gwon
- Department of Cardiovascular Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Korea;
| | - Dong-Ju Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Sang-Hong Baek
- Division of Cardiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06649, Korea;
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Revisiting the use of the provocative acetylcholine test in patients with chest pain and nonobstructive coronary arteries: A five-year follow-up of the AChPOL registry, with special focus on patients with MINOCA. Transl Res 2021; 231:64-75. [PMID: 33232803 DOI: 10.1016/j.trsl.2020.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/25/2020] [Accepted: 11/17/2020] [Indexed: 12/31/2022]
Abstract
This study aimed to assess the angiographic characteristics, feasibility and safety of the provocative test with acetylcholine (AChT), and the influence on further treatment and prognosis of Middle European patients in 5-year follow-up, especially focusing on those with a history of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA). The AChPOL Registry was an ongoing prospective single-center registry that included patients undergoing AChT from December 2010 to March 2013 for further diagnostic evaluation of a suspicious variant angina or coronary microvascular spasm, based on the COVADIS criteria. AChT was injected in incremental doses of 25, 50, and 75µg into the right coronary artery and 25, 50, and 100 µg into the left coronary artery, and the patients were followed up for 5 years. We enrolled 211 patients in the AChPOL Registry. Their mean age was 60.5 ± 7.8 years, with women accounting for 67.8%. The median follow-up was 56 months. AChT revealed variant angina in 99 patients (46.9%) and coronary microvascular spasm in the remaining 72 patients (34.1%). In patients with variant angina, spasm was most frequently observed in the left anterior descending artery (89.9%) and was most frequently diffuse (61.6%). In the microvascular spasm subgroup, there was a significantly higher rate of recurrent chest pain requiring hospitalization in the follow-up than in AChT negative patients. Interestingly, patients with a history of MINOCA had higher rates of MI and recurrent chest pain requiring hospitalization in the follow-up. We showed that AChT was safe in Middle European patients. In the follow-up patients with microvascular spasm and a history of MINOCA had the highest risk of MI and recurrent chest pain requiring hospitalization.
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Nakamura T, Takami M, Fukuzawa K, Kiuchi K, Kono H, Kobori A, Sakamoto Y, Watanabe R, Okumura Y, Yamashita S, Yamashiro K, Miyamoto K, Kusano K, Kanda T, Masuda M, Yoshitani K, Yoshida A, Hirayama Y, Adachi K, Mine T, Shimane A, Takeda M, Takei A, Okajima K, Fujiwara R, Hirata KI. Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures - Large-Scale Multicenter Analysis. Circ J 2021; 85:264-271. [PMID: 33431721 DOI: 10.1253/circj.cj-20-1096] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures.Methods and Results:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae. CONCLUSIONS CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.
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Affiliation(s)
- Toshihiro Nakamura
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiroyuki Kono
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Atsushi Kobori
- Department of Cardiology, Kobe City Medical Center General Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University of Medicine
| | | | | | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Kazuyasu Yoshitani
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | - Takanao Mine
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Akira Shimane
- Department of Cardiology, Himeji Cardiovascular Center
| | | | - Asumi Takei
- Department of Cardiology, Kobe Rosai Hospital
| | | | - Ryudo Fujiwara
- Cardiovascular Division, Osaka Saiseikai Nakatsu Hospital
| | - Ken-Ichi Hirata
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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50
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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