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Miner SES, McCarthy MC, Ardern CI, Perry CGR, Toleva O, Nield LE, Manlhiot C, Cantor WJ. The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status. Front Cardiovasc Med 2023; 10:1217731. [PMID: 37719976 PMCID: PMC10501450 DOI: 10.3389/fcvm.2023.1217731] [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: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function. Aims The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function. Methods In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction. Results Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03). Conclusions After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.
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Affiliation(s)
- Steven E. S. Miner
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary C. McCarthy
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Chris I. Ardern
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Chris G. R. Perry
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Olga Toleva
- Department of Cardiology, Emory University, Atlanta, GA, United States
| | - Lynne E. Nield
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cedric Manlhiot
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
| | - Warren J. Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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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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3
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Jovanovic I, Tesic M, Djordjevic-Dikic A, Giga V, Beleslin B, Aleksandric S, Boskovic N, Petrovic O, Marjanovic M, Vratonjic J, Paunovic I, Ivanovic B, Trifunovic-Zamaklar D. Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1134-1142. [PMID: 36218210 DOI: 10.1002/jcu.23313] [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: 07/28/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 06/16/2023]
Abstract
This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.
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Affiliation(s)
- Ivana Jovanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Milorad Tesic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Olga Petrovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Marjanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Ivana Paunovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Branislava Ivanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Trifunovic-Zamaklar
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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4
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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5
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Bonanni A, d’Aiello A, Pedicino D, Di Sario M, Vinci R, Ponzo M, Ciampi P, Lo Curto D, Conte C, Cribari F, Canonico F, Russo G, Montone RA, Trani C, Severino A, Crea F, Liuzzo G. Molecular Hallmarks of Ischemia with Non-Obstructive Coronary Arteries: The "INOCA versus Obstructive CCS" Challenge. J Clin Med 2022; 11:jcm11061711. [PMID: 35330036 PMCID: PMC8951436 DOI: 10.3390/jcm11061711] [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: 02/01/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/27/2022] Open
Abstract
Up to 4 million patients with signs of myocardial ischemia have no obstructive coronary artery disease (CAD). The absence of precise guidelines for diagnosis and treatment in non-obstructive CAD encourages the scientific community to fill the gap knowledge, to provide non-invasive and less expensive diagnostic tools. The aim of our study was to explore the biological profile of Ischemia with Non-Obstructive Coronary Arteries (INOCA) patients with microvascular dysfunction compared to patients presenting with obstructive chronic coronary syndrome (ObCCS) in order to find specific hallmarks of each clinical condition. We performed a gene expression array from peripheral blood mononuclear cells (PBMCs) isolated from INOCA (n = 18) and ObCCS (n = 20) patients. Our results showed a significantly reduced gene expression of molecules involved in cell adhesion, signaling, vascular motion, and inflammation in INOCA as compared to the ObCCS group. In detail, we found lower expression of Platelet and Endothelial Cell Adhesion Molecule 1 (CD31, p < 0.0001), Intercellular Adhesion Molecule-1 (ICAM1, p = 0.0004), Tumor Necrosis Factor (TNF p = 0.0003), Transferrin Receptor (TFRC, p = 0.002), and Vascular Endothelial Growth Factor A (VEGFA, p = 0.0006) in the INOCA group compared with ObCCS. Meanwhile, we observed an increased expression of Hyaluronidase (HYAL2, p < 0.0001) in INOCA patients in comparison to ObCCS. The distinct expression of molecular biomarkers might allow an early and non-invasive differential diagnosis between ObCCS and INOCA, improving clinical management and treatment options, in the era of personalized medicine.
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Affiliation(s)
- Alice Bonanni
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Alessia d’Aiello
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Daniela Pedicino
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Correspondence: ; Tel.: +39-06-3015-4187
| | - Marianna Di Sario
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Ramona Vinci
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Myriana Ponzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Pellegrino Ciampi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Denise Lo Curto
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Cristina Conte
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Francesco Cribari
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
| | - Francesco Canonico
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Giulio Russo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Rocco Antonio Montone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Anna Severino
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.B.); (A.d.); (M.D.S.); (R.V.); (M.P.); (P.C.); (D.L.C.); (C.C.); (F.C.); (G.R.); (R.A.M.); (C.T.); (A.S.); (F.C.); (G.L.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
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6
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Acetylcholine Rechallenge: A First Step Toward Tailored Treatment in Patients With Coronary Artery Spasm. JACC Cardiovasc Interv 2022; 15:65-75. [PMID: 34991826 DOI: 10.1016/j.jcin.2021.10.003] [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: 06/03/2021] [Revised: 09/27/2021] [Accepted: 10/05/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The present study aimed to assess the feasibility and clinical value of acetylcholine (ACh) rechallenge for the detection of coexisting epicardial and microvascular spasm and to determine the efficacy of nitroglycerin in these spasm endotypes. BACKGROUND The coexistence of epicardial and microvascular spasm is difficult to identify; thus, its frequency is unknown. Nitroglycerin treatment is equally recommended for both epicardial and microvascular coronary spasm despite contradictory data. METHODS In this multicenter study, 95 patients with coronary spasm were included to undergo ACh rechallenge, which consisted of repeated ACh provocation 3 minutes after intracoronary nitroglycerin administration using the same dose that previously induced spasm. RESULTS In total, 95 patients (age 61 ± 12 years, 69% female) were included. Fifty-five patients (58%) had microvascular spasm, and 40 patients (42%) had epicardial spasm during initial ACh provocation. In 48% of patients with epicardial spasm, ACh rechallenge revealed coexisting nitroglycerin-persistent microvascular spasm. Nitroglycerin administration before ACh rechallenge prevented reinducibility of epicardial spasm in all patients with focal spasm and in 80% of patients with diffuse spasm. Microvascular spasm was prevented in only 20% by prior nitroglycerin administration but was attenuated in another 49% of patients. CONCLUSIONS This study demonstrates a high frequency of epicardial spasm with coexisting nitroglycerin-persistent microvascular spasm. Intracoronary nitroglycerin was very effective in preventing reinducibility of epicardial spasm, whereas it prevented microvascular spasm in only 20% of patients. ACh rechallenge is a novel method that facilitates the detection of coexisting spasm endotypes and may pave the way towards tailored treatment of vasospastic angina.
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7
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Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J 2021; 42:269-283. [PMID: 33367764 DOI: 10.1093/eurheartj/ehaa820] [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: 01/29/2020] [Revised: 04/17/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.
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Affiliation(s)
- Allan Davies
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | | | - Shmuel Banai
- Slezak Super Centre for Cardiac Research, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Medical Centre, Tel Aviv, Israel
| | | | - Thomas F Lüscher
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK.,University of Zurich, Center for Molecular Cardiology, University of Zurich, Switzerland
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8
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Kunadian V, Chieffo A, Camici PG, Berry C, Escaned J, Maas AHEM, Prescott E, Karam N, Appelman Y, Fraccaro C, Louise Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott JD, Badimon L, Duncker DJ, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J 2021; 41:3504-3520. [PMID: 32626906 DOI: 10.1093/eurheartj/ehaa503] [Citation(s) in RCA: 378] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
| | | | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | | | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk J Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK.,Yale University School of Medicine, New Haven, CT, USA
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9
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Kunadian V, Chieffo A, Camici P, Berry C, Escaned J, Maas A, Prescott E, Karam N, Appelman Y, Fraccaro C, Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott J, Badimon L, Duncker D, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. EUROINTERVENTION 2021; 16:1049-1069. [PMID: 32624456 PMCID: PMC9707543 DOI: 10.4244/eijy20m07_01] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Paolo Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | - Gill Buchanan
- North Cumbria Integrated Care NHS Foundation Trust, Cumbria, United Kingdom
| | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Bart’s Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - J. Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. ‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
- Yale University School of Medicine, New Haven, CT, USA
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10
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Crea F, Bairey Merz CN, Beltrame JF, Berry C, Camici PG, Kaski JC, Ong P, Pepine CJ, Sechtem U, Shimokawa H. Mechanisms and diagnostic evaluation of persistent or recurrent angina following percutaneous coronary revascularization. Eur Heart J 2020; 40:2455-2462. [PMID: 30608528 DOI: 10.1093/eurheartj/ehy857] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/09/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023] Open
Abstract
Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20-40% of patients during short-medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Gemelli - IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Roma, Italy
| | - Cathleen Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd, Los Angeles, CA, USA
| | - John F Beltrame
- Discipline of Medicine, Ward 5B, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, Adelaide, South Australia, Australia
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, University Place, Glasgow, UK
| | - Paolo G Camici
- Department of Cardiology, Vita Salute University and San Raffaele Hospital, Via Olgettina 60, Milano, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Departmant of Medicine, College of Medicine, University of Florida, 1600 SW Archer Rd, Box 100288, Gainesville, FL, USA
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, Stuttgart, Germany
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Japan
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11
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Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
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12
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Ohura-Kajitani S, Shiroto T, Godo S, Ikumi Y, Ito A, Tanaka S, Sato K, Sugisawa J, Tsuchiya S, Suda A, Shindo T, Ikeda S, Hao K, Kikuchi Y, Nochioka K, Matsumoto Y, Takahashi J, Miyata S, Shimokawa H. Marked Impairment of Endothelium-Dependent Digital Vasodilatations in Patients With Microvascular Angina. Arterioscler Thromb Vasc Biol 2020; 40:1400-1412. [DOI: 10.1161/atvbaha.119.313704] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective:
It remains to be elucidated whether and how endothelial functions are impaired in peripheral circulation of patients with coronary functional disorders, such as vasospastic angina (VSA) and microvascular angina (MVA). We simultaneously examined endothelial functions of peripheral conduit and resistance arteries in patients with coronary functional disorders, with a special reference to NO and endothelium-dependent hyperpolarization factors.
Approach and Results:
Based on the results of invasive coronary acetylcholine testing and coronary physiological measurements, we divided 43 patients into 3 groups; VSA, MVA, and VSA+MVA. Endothelium-dependent vasodilatations of the brachial artery and fingertip arterioles to intra-arterial infusion of bradykinin were simultaneously evaluated by ultrasonography and peripheral arterial tonometry, respectively. To assess NO and endothelium-dependent hyperpolarization factors, measurements were repeated after oral aspirin and intra-arterial infusion of N
G
-monomethyl-L-arginine. Additionally, endothelium-independent vasodilatations to sublingual nitroglycerin and plasma levels of biomarkers for endothelial functions were measured. Surprisingly, digital vasodilatations to bradykinin were almost absent in patients with MVA alone and those with VSA+MVA compared with those with VSA alone. Mechanistically, both NO- and endothelium-dependent hyperpolarization–mediated digital vasodilatations were markedly impaired in patients with MVA alone. In contrast, endothelium-independent vasodilatations to nitroglycerin were comparable among the 3 groups. Plasma levels of soluble VCAM (vascular cell adhesion molecule)-1 were significantly higher in patients with MVA alone compared with those with VSA alone.
Conclusions:
These results provide the first evidence that both NO- and endothelium-dependent hyperpolarization–mediated digital vasodilatations are markedly impaired in MVA patients, suggesting that MVA is a cardiac manifestation of the systemic small artery disease.
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Affiliation(s)
- Shoko Ohura-Kajitani
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeo Godo
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Ikumi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akiyo Ito
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shuhei Tanaka
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koichi Sato
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Sugisawa
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Tsuchiya
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akira Suda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shohei Ikeda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoku Kikuchi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kotaro Nochioka
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Miyata
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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13
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Affiliation(s)
- Thomas Joseph Ford
- BHF Cardiovascular Research Centre, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
- Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Colin Berry
- BHF Cardiovascular Research Centre, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
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14
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Cho SG, Kim J, Song HC. Debates over NICE Guideline Update: What Are the Roles of Nuclear Cardiology in the Initial Evaluation of Stable Chest Pain? Nucl Med Mol Imaging 2019; 53:301-312. [PMID: 31723359 PMCID: PMC6821897 DOI: 10.1007/s13139-019-00607-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022] Open
Abstract
Recent clinical trials have demonstrated the values of cardiac computed tomography (CT) in the initial evaluation of stable chest pain which led to drastic changes in the National Institute for Health and Care Excellence (NICE) guidelines in 2016. According to the updated NICE guidelines, cardiac CT should be performed as the initial cardiac testing in stable chest pain regardless of pre-test probability (PTP) of coronary artery disease (CAD). As a result, cardiac CT is now considered as a validated gatekeeper for assessing stable chest pain, which precedes all the functional studies including nuclear myocardial perfusion imaging (MPI). Nuclear MPI, in contrast, has been assigned as one of the second-line studies, which is inevitably dependent on the results of cardiac CT. However, nuclear MPI has genuine values in the diagnosis, treatment decision, and prognostic stratification of stable chest pain, which cannot be replaced by cardiac CT. In this review, the updated NICE guidelines and related cardiac CT trials will be critically reviewed from the view of nuclear physicians and the exceptional values of nuclear MPI will be described along with the future perspectives.
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Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Ho-Chun Song
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
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15
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Crea F, Bairey Merz CN, Beltrame JF, Kaski JC, Ogawa H, Ong P, Sechtem U, Shimokawa H, Camici PG. The parallel tales of microvascular angina and heart failure with preserved ejection fraction: a paradigm shift. Eur Heart J 2019; 38:473-477. [PMID: 27907892 DOI: 10.1093/eurheartj/ehw461] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/26/2016] [Indexed: 01/09/2023] Open
Affiliation(s)
- Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, UK
| | - Hisao Ogawa
- Faculty of Life Science, Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
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16
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Liew G, Mitchell P, Chiha J, Plant AJH, White A, Joachim N, Wang S, Burlutsky G, Kovoor P, Thiagalingam A, Gopinath B. Retinal microvascular changes in microvascular angina: Findings from the Australian Heart Eye Study. Microcirculation 2019; 26:e12536. [PMID: 30758094 DOI: 10.1111/micc.12536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Microvascular changes in microvascular angina are poorly understood due to difficulties in imaging the coronary microcirculation in vivo. The retinal microvasculature may reflect changes in coronary microcirculation. We assessed microvascular changes in the retina in patients with microvascular angina and compared them with patients with angiographically proven coronary artery disease. METHODS We performed retinal photography and coronary angiography on 915 patients. Retinal vessel calibers were measured using a validated computer-assisted method; coronary artery disease was graded from coronary angiograms. Microvascular angina was defined as angina with <25% stenosis in all coronary epicardial arteries. RESULTS A total of 139 patients (15.2%) had microvascular angina, while 776 (84.8%) had coronary artery disease. Participants with microvascular angina and coronary artery disease had similar retinal arteriolar and venular calibers. After adjustment for age, ethnicity, mean arterial pressure, diabetes, current smoking, body mass index, and fellow vessel caliber, women with smaller venules were threefold more likely to have microvascular angina than women with larger venules (multivariable-adjusted odds ratio 3.54, 95% confidence interval 1.35 to 9.24, P < 0.01). This difference was not observed in men. CONCLUSIONS Microvascular angina in women was associated with microvascular changes distinct from those in coronary artery disease.
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Affiliation(s)
- Gerald Liew
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Mitchell
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Joseph Chiha
- Centre for Heart Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Adam J H Plant
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew White
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Nichole Joachim
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Wang
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - George Burlutsky
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Pramesh Kovoor
- Centre for Heart Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Aravinda Thiagalingam
- Centre for Heart Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Bamini Gopinath
- Centre for Vision Research, The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
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17
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Corcoran D, Ford TJ, Hsu LY, Chiribiri A, Orchard V, Mangion K, McEntegart M, Rocchiccioli P, Watkins S, Good R, Brooksbank K, Padmanabhan S, Sattar N, McConnachie A, Oldroyd KG, Touyz RM, Arai A, Berry C. Rationale and design of the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study. Open Heart 2018; 5:e000924. [PMID: 30687508 PMCID: PMC6326326 DOI: 10.1136/openhrt-2018-000924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/24/2018] [Accepted: 11/12/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction Angina with no obstructive coronary artery disease (ANOCA) is a common syndrome with unmet clinical needs. Microvascular and vasospastic angina are relevant but may not be diagnosed without measuring coronary vascular function. The relationship between cardiovascular magnetic resonance (CMR)-derived myocardial blood flow (MBF) and reference invasive coronary function tests is uncertain. We hypothesise that multiparametric CMR assessment will be clinically useful in the ANOCA diagnostic pathway. Methods/analysis The Stratified Medical Therapy Using Invasive Coronary Function Testing In Angina (CorMicA) trial is a prospective, blinded, randomised, sham-controlled study comparing two management approaches in patients with ANOCA. We aim to recruit consecutive patients with stable angina undergoing elective invasive coronary angiography. Eligible patients with ANOCA (n=150) will be randomised to invasive coronary artery function-guided diagnosis and treatment (intervention group) or not (control group). Based on these test results, patients will be stratified into disease endotypes: microvascular angina, vasospastic angina, mixed microvascular/vasospastic angina, obstructive epicardial coronary artery disease and non-cardiac chest pain. After randomisation in CorMicA, subjects will be invited to participate in the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) substudy. Patients will undergo multiparametric CMR and have assessments of MBF (using a novel pixel-wise fully quantitative method), left ventricular function and mass, and tissue characterisation (T1 mapping and late gadolinium enhancement imaging). Abnormalities of myocardial perfusion and associations between MBF and invasive coronary artery function tests will be assessed. The CorCMR substudy represents the largest cohort of ANOCA patients with paired multiparametric CMR and comprehensive invasive coronary vascular function tests. Ethics/dissemination The CorMicA trial and CorCMR substudy have UK REC approval (ref.16/WS/0192). Trial registration number NCT03193294.
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Affiliation(s)
- David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Li-Yueh Hsu
- Advanced Cardiovascular Imaging Laboratory, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, Department of Cardiovascular Imaging, King's College London, London, UK
| | - Vanessa Orchard
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Kenneth Mangion
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Richard Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Katriona Brooksbank
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Sandosh Padmanabhan
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Rhian M Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Andrew Arai
- Advanced Cardiovascular Imaging Laboratory, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
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18
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Ford TJ, Rocchiccioli P, Good R, McEntegart M, Eteiba H, Watkins S, Shaukat A, Lindsay M, Robertson K, Hood S, Yii E, Sidik N, Harvey A, Montezano AC, Beattie E, Haddow L, Oldroyd KG, Touyz RM, Berry C. Systemic microvascular dysfunction in microvascular and vasospastic angina. Eur Heart J 2018; 39:4086-4097. [PMID: 30165438 PMCID: PMC6284165 DOI: 10.1093/eurheartj/ehy529] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/17/2018] [Accepted: 08/23/2018] [Indexed: 12/20/2022] Open
Abstract
Aims Coronary microvascular dysfunction and/or vasospasm are potential causes of ischaemia in patients with no obstructive coronary artery disease (INOCA). We tested the hypothesis that these patients also have functional abnormalities in peripheral small arteries. Methods and results Patients were prospectively enrolled and categorised as having microvascular angina (MVA), vasospastic angina (VSA) or normal control based on invasive coronary artery function tests incorporating probes of endothelial and endothelial-independent function (acetylcholine and adenosine). Gluteal biopsies of subcutaneous fat were performed in 81 subjects (62 years, 69% female, 59 MVA, 11 VSA, and 11 controls). Resistance arteries were dissected enabling study using wire myography. Maximum relaxation to ACh (endothelial function) was reduced in MVA vs. controls [median 77.6 vs. 98.7%; 95% confidence interval (CI) of difference 2.3-38%; P = 0.0047]. Endothelium-independent relaxation [sodium nitroprusside (SNP)] was similar between all groups. The maximum contractile response to endothelin-1 (ET-1) was greater in MVA (median 121%) vs. controls (100%; 95% CI of median difference 4.7-45%, P = 0.015). Response to the thromboxane agonist, U46619, was also greater in MVA (143%) vs. controls (109%; 95% CI of difference 13-57%, P = 0.003). Patients with VSA had similar abnormal patterns of peripheral vascular reactivity including reduced maximum relaxation to ACh (median 79.0% vs. 98.7%; P = 0.03) and increased response to constrictor agonists including ET-1 (median 125% vs. 100%; P = 0.02). In all groups, resistance arteries were ≈50-fold more sensitive to the constrictor effects of ET-1 compared with U46619. Conclusions Systemic microvascular abnormalities are common in patients with MVA and VSA. These mechanisms may involve ET-1 and were characterized by endothelial dysfunction and enhanced vasoconstriction. Clinical trial registration ClinicalTrials.gov registration is NCT03193294.
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Affiliation(s)
- Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Richard Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Aadil Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Keith Robertson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Stuart Hood
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Eric Yii
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Novalia Sidik
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Adam Harvey
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Augusto C Montezano
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Elisabeth Beattie
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Laura Haddow
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
| | - Rhian M Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, GJNH, Agamemnon St, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, University of Glasgow, Glasgow, UK
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19
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Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. HEART (BRITISH CARDIAC SOCIETY) 2017; 104:284-292. [PMID: 29030424 PMCID: PMC5861393 DOI: 10.1136/heartjnl-2017-311446] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/13/2022]
Abstract
The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,University of New South Wales, Sydney, NSW, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
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20
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Wang SB, Mitchell P, Liew G, Wong TY, Phan K, Thiagalingam A, Joachim N, Burlutsky G, Gopinath B. A spectrum of retinal vasculature measures and coronary artery disease. Atherosclerosis 2017; 268:215-224. [PMID: 29050745 DOI: 10.1016/j.atherosclerosis.2017.10.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/07/2017] [Accepted: 10/06/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIMS We aimed to comprehensively describe a spectrum of retinal vessel measures including fractal dimension (Df) and their associations with indices of coronary artery disease (CAD) extent and severity, as well as hypertension and diabetes. METHODS The Australian Heart Eye Study (AHES) is an observational study that surveyed 1680 participants presenting to a tertiary referral hospital for the evaluation of potential CAD by coronary angiography. A range of newer retinal vessel geometric measures (Df, curvature tortuosity, and branching angle) were quantified from retinal photographs using semi-automated software, the Singapore 'I' Vessel Assessment (SIVA) tool. A combined retinal score was constructed, aiming to assess the joint effect of multiple retinal vessel parameters on CAD, comprising of those variables that were most strongly significant in multivariate analysis - Df, arteriolar curvature tortuosity, and retinal arteriolar calibre. CAD was objectively quantified using a range of measures obtained from coronary angiography. RESULTS A total of 1187 participants had complete data on retinal vessel measurements and coronary vessel evaluation. Retinal vascular Df and curvature tortuosity decreased with increasing age; women had significantly lower Df than men (p<0.003). Straighter retinal vessels were associated with CAD extent and Gensini scores in multivariable analysis (p<0.02). Accounting for media opacity by sub-group analysis in pseudophakic patients, the combined retinal score was associated with stenosis greater than 50% in any coronary artery segment (vessel score) and obstructive coronary stenosis in all three main coronary arteries (segment score) (p = 0.01). Lower Df and narrower arteriolar branching angle were associated with CAD vessel score (p<0.03). In sex-stratified multivariate analyses, straighter arterioles were associated with greater odds of CAD in men, and narrower venular branching angle was associated with CAD in women. CONCLUSIONS A range of retinal vessel measures were associated with CAD extent and severity. A sparser retinal microvascular network (smaller Df) was associated with older age and female gender. After accounting for the impact of media opacity, retinal vessel measures were associated with more diffuse and severe CAD.
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Affiliation(s)
- Sarah B Wang
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Paul Mitchell
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Gerald Liew
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Kevin Phan
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Aravinda Thiagalingam
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Nichole Joachim
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - George Burlutsky
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia
| | - Bamini Gopinath
- Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, NSW, Australia.
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21
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Niccoli G, Montone RA, Lanza GA, Crea F. Angina after percutaneous coronary intervention: The need for precision medicine. Int J Cardiol 2017; 248:14-19. [PMID: 28807510 DOI: 10.1016/j.ijcard.2017.07.105] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/13/2017] [Accepted: 07/27/2017] [Indexed: 01/23/2023]
Abstract
Persistence or recurrence of angina after successful percutaneous coronary intervention (PCI) represent an important clinical issue involving from one fifth to one third of patients undergoing myocardial revascularization at one-year follow-up. A systematic approach to this syndrome is strongly needed. Precision medicine is particularly important in addressing angina after successful PCI because of the multiple underlying causes. Restenosis or coronary atherosclerosis progression explain symptom recurrence after successful PCI in some patients, while functional causes, including vasomotor abnormalities of epicardial coronary arteries and/or coronary microvascular dysfunction, explain symptoms in the remaining patients. In this review, we summarize the mechanisms of persistent or recurrent angina after PCI, proposing a diagnostic algorithm and a systematic therapeutic approach.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy; Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
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22
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Lüscher TF. Troponin: the basis of decision-making in suspected acute coronary syndromes and beyond. Eur Heart J 2016; 37:2385-7. [DOI: 10.1093/eurheartj/ehw329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Lüscher TF. Syncope and sudden cardiac death: some answers to clinical challenges. Eur Heart J 2016; 37:1481-4. [DOI: 10.1093/eurheartj/ehw168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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