Myocardial ischemia during everyday life in patients with arterial hypertension: prevalence, risk factors, triggering mechanism and circadian variability

Restenosis of Coronary Arteries in Patients with Coronavirus Infection: Case Series

Introduction

Coronavirus infection is a risk factor for vascular thrombosis. This is of particular importance for patients undergoing myocardial revascularization since this infection can be a trigger for the formation of restenosis in the area of a previously implanted coronary stent. Understanding the risk factors for stent thrombosis and restenosis is of particular importance in individuals at risk for adverse outcomes. The rarity of such situations makes the present study unique.

Objective

Studying the peculiarities of restenosis and thrombosis of the coronary arteries in patients after coronavirus infection.

Methods

The study was performed in the Department of Cardiovascular Surgery of Emergency Hospital, Semey City, in 2021. We have examined the medical records of 10 consecutive patients with restenosis of coronary arteries after coronavirus infection and 10 matched-by-age patients with similar restenosis of coronary arteries who did not have coronavirus infection as a comparison group. To determine statistically significant differences between independent samples, we calculated the Mann-Whitney U test.

Results

The average age of patients was 65.7 years. Only one case was classified as early restenosis (within 8 days of previous revascularization), two cases represented late restenosis, and seven cases were very late restenoses. In 70% of cases, restenosis was localized in the left anterior descending artery, in 30% of cases, it was in the right coronary artery, and in 40% of cases, it was in the left circumflex artery. In comparison with patients who did not have a coronavirus infection, there were statistically significant differences regarding IgG (P < 0.001) and fibrinogen (P=0.019).

Conclusion

Patients with myocardial revascularization in the past have a higher risk of stent restenosis against the background of coronavirus infection due to excessive neointimal hyperplasia, hypercoagulability, increased inflammatory response, and endothelial dysfunction.

Dynamic detection and reversal of myocardial ischemia using an artificially intelligent bioelectronic medicine

Myocardial ischemia is spontaneous, frequently asymptomatic, and contributes to fatal cardiovascular consequences. Importantly, myocardial sensory networks cannot reliably detect and correct myocardial ischemia on their own. Here, we demonstrate an artificially intelligent and responsive bioelectronic medicine, where an artificial neural network (ANN) supplements myocardial sensory networks, enabling reliable detection and correction of myocardial ischemia. ANNs were first trained to decode spontaneous cardiovascular stress and myocardial ischemia with an overall accuracy of ~92%. ANN-controlled vagus nerve stimulation (VNS) significantly mitigated major physiological features of myocardial ischemia, including ST depression and arrhythmias. In contrast, open-loop VNS or ANN-controlled VNS following a caudal vagotomy essentially failed to reverse cardiovascular pathophysiology. Last, variants of ANNs were used to meet clinically relevant needs, including interpretable visualizations and unsupervised detection of emerging cardiovascular stress. Overall, these preclinical results suggest that ANNs can potentially supplement deficient myocardial sensory networks via an artificially intelligent bioelectronic medicine system.

Risk factors for silent myocardial ischemia in patients with well-controlled essential hypertension

Silent myocardial ischemia (SMI) is frequently observed in patients with essential hypertension (EH). The major risk factor for SMI is uncontrolled blood pressure (BP), but SMI is also observed in patients with well-controlled BP. To evaluate the prevalence of SMI and the factors associated with SMI in EH patients with well-controlled BP. The medical records of 859 EH patients who underwent simultaneous 24-h ambulatory blood pressure monitoring (ABPM) and 24-h ambulatory electrocardiogram recording (AECG) were retrospectively evaluated. Each SMI episode was characterized by: (a) ST segment depression ≥0.5 mm; (b) duration of ST segment depression >60 s; and (c) reversibility of the ST segment depression. Overall 126 EH patients (14.7 %) had at least one episode of SMI. The SMI events were more frequent among patients with poorly controlled compared to those with well-controlled BP [86/479 (17.95 %) vs. 40/380 (10.52 %), p < 0.01]. Among EH patients with well-controlled BP, current and past smoking as well as the presence of an additional metabolic syndrome (MetS) constitutive element (obesity, impaired fasting glucose level or dyslipidemia) were significantly associated with the occurrence of SMI. In all EH patients with well-controlled BP and AECG evidence of SMI, there were one or more coronary artery stenotic lesions greater than 50 % found at coronary angiography. In EH patients who are current smokers, or have one or more additional components of a MetS there is markedly reduced benefit associated with good BP control with regard to the occurrence of myocardial ischemia: in this patient category, an AECG may help detect this condition.

Hypertension, Left Ventricular Hypertrophy, and Myocardial Ischemia

The risks associated with hypertension emerge through a series of complex interactions. Myocardial ischemia is the major contributor to this risk. The mechanisms driving ischemia reflect many of the key factors in hypertension, including endothelial and neurohumoral factors, fibrosis, and hemodynamics. Left ventricular hypertrophy and fibrosis are of fundamental importance and together with hemodynamics provide an optimal template for myocardial ischemia. Understanding the pathophysiology has aided a more rational management approach but challenges remain which, if surmounted, will have an impact on the morbidity and mortality caused by myocardial ischemia in patients with hypertension.

Effects of percutaneous coronary intervention on the ambulatory blood pressure of patients with hypertension and coronary heart disease

OBJECTIVE

The aim of this study was to investigate the dynamic characteristics and changing trends of ambulatory blood pressure in patients with hypertension and coronary heart disease before and after percutaneous coronary intervention (PCI), and to determine the effects of PCI on the ambulatory blood pressure of patients with hypertension and coronary heart disease.

METHODS

A total of 126 patients with hypertension and unstable angina and who were hospitalized and received complete revascularization were enrolled in the study. The ambulatory blood pressure of the patients was monitored at three time points: 1-3 days before PCI (baseline), 3-6 days after PCI (1 week) and 1 month after PCI (1 month). The parameters between the time points were then compared using a t test.

RESULTS

Each ambulatory blood pressure index after PCI was not statistically different from those before PCI (P > 0.05). However, 1 month after the PCI, all ambulatory blood pressure indices significantly decreased and statistically differed from those before PCI (P < 0.01).

CONCLUSION

PCI can significantly improve the autonomic nerve function and ambulatory blood pressure indices of patients with hypertension and coronary heart disease.

Mood and transient cardiac dysfunction in everyday life

Emotion in daily life may be associated with transient myocardial ischemia, ventricular tachycardia and impaired autonomic function in cardiac patients, but the precise temporal sequence is unclear. Eighty-eight patients with suspected coronary artery disease underwent 24-h electrocardiographic monitoring, and affect was measured with the Day Reconstruction Method. Thirteen patients (15%) experienced one or more episodes of ST depression or ventricular tachycardia, nine of whom provided concurrent mood data. Mood and heart rate variability were analyzed for the 15 min before, during, and 15 min after each ST depression/ventricular tachycardia episode, and were compared with control periods not associated with cardiac dysfunction. Patients reported more negative mood in the 15 min preceding cardiac dysfunction compared with control periods (P = 0.02). Heart rate increased in the 5 min before cardiac dysfunction (P = 0.005), whereas low frequency heart rate variability was reduced at onset but not before cardiac dysfunction (P = 0.007). There were not changes in high frequency heart rate variability. This small study indicates that emotional state may contribute to vulnerability of cardiac dysfunction in everyday life.

Hypertension and myocardial ischemia

Detailed studies over the past 30 years have built up an impressive evidence base for the presence of myocardial ischemia in patients who have hypertension. This relationship ranges from the obvious association with obstructive coronary artery disease to mechanisms related to hemodynamic, microcirculatory, and neuroendocrine abnormalities. All of these factors serve to destabilize the critical balance between myocardial oxygen supply and demand. We have at our disposal a range of sophisticated investigations that allow us to demonstrate the presence and extent of the ischemia and therefore to target specific therapies to reduce the risk to these patients. Achieving target BP and managing all reversible components of the patient's cardiovascular risk status reduce to a minimum the clinical sequelae of myocardial ischemia in this vulnerable population..

ST segment depression in hypertensive patients: a comparison of exercise test versus Holter ECG

Introduction:

This study compared ST segment depression (ST depression) during cycle ergometry (ergometry) versus simultaneous 24-hour ambulatory blood pressure measurement and electrocardiogram recording (24-h ABPM/ECG) during everyday life.

Methods:

In a German multicenter study, ergometry and 24-h ABPM/ECG records of 239 hypertensive patients were retrospectively analyzed. ST depression was defined as an ST segment depression (1 mm limb or chest recordings V1 to V6) in an incremental cycle ergometry, or 1 mm in the 24-h ABPM/ECG recording under everyday conditions. Blood pressure parameters at the onset of ST depression in the context of the respective method were compared.

Results:

18 patients had ST depression only in ergometry (group B), 23 had ST depression only during 24-h ABPM/ECG monitoring (group C) and 28 patients had ST depression with both methods (group D). Group A had no ST depression with any method. In group D, at the onset of ST depression with 24-h ABPM/ECG investigation, all parameters except diastolic blood pressure were significantly lower compared with the corresponding parameters at the onset of ST depression with ergometry (systolic blood pressure: 148 ± 19 vers 188 ± 35 mmHg, p × 0.001; heart rate: 93 ± 12 vs 120 ± 21 beat/min, p < 0.0001; double product: 13,714 ± 2315 vs 22,992 ± 3,985 mmHg/min), p < 0.0001).

Conclusion:

ST depressions during everyday life detected by 24-h ABPM/ECG are characterized by a substantially lower triggering threshold for blood pressure level parameters compared with ergometry. The two methods detecting ischemia do not replace but complement each other.

Clinical and research issues regarding chronic advanced coronary artery disease: part I: Contemporary and emerging therapies

The following report is based on a working group meeting about advanced coronary artery disease for patients with refractory ischemia who cannot receive revascularization. The aims were to review currently available treatment strategies, define unmet clinical needs, explore clinical trial design issues, and identify promising novel therapeutic targets and approaches for patients with chronic ischemia. The Working Group brought together medical experts in the management of refractory angina with representatives from regulatory agencies, Centers for Medicare and Medicaid Services, and industry. The meeting began with presentations reviewing the limitations of the current medical therapies and revascularization strategies and focused on lessons learned from past therapeutic attempts to optimize outcomes and on what are considered to be the most promising new approaches. Perspectives from clinical experts and from regulatory agencies were juxtaposed against needs and concerns of industry regarding development of new therapeutic strategies. This report presents the considerations and conclusions of the meeting on December 4-5, 2006. This document has been developed as a 2-part article, with contemporary and emerging therapies for advanced coronary artery disease reviewed first. Trial design, end points, and regulatory issues will be discussed in the second part of the article.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Reviewing myocardial silent ischemia: specific patient subgroups

Silent myocardial ischemia (SMI) is a relatively common, yet poorly understood, clinical entity. The most accurate means of detecting SMI and the precise treatment endpoints remain unclear. However, the presence of SMI correlates with the likelihood of future adverse cardiac events. Evidence suggests that patients at high risk of severe cardiac ischemia, even with the absence of symptoms, derive the greatest benefit from an aggressive diagnostic and therapeutic approach. This paper is giving a detailed review of SMI in regards to specific patient subgroups, i.e. populations with diabetes mellitus, hypertension, elderly patients, post-revascularization patients, women, the suggested screening procedures for each subgroup, as well as the emersion of new markers for the selection of high-risk patients for screening.