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Chen CH, Ganesh A. Remote Ischemic Conditioning in Stroke Recovery. Phys Med Rehabil Clin N Am 2024; 35:319-338. [PMID: 38514221 DOI: 10.1016/j.pmr.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Remote ischemic conditioning (RIC) is a therapeutic strategy to protect a vital organ like the brain from ischemic injury through brief and repeat cycles of ischemia and reperfusion in remote body parts such as arm or leg. RIC has been applied in different aspects of the stroke field and has shown promise. This narrative review will provide an overview of how to implement RIC in stroke patients, summarize the clinical evidence of RIC on stroke recovery, and discuss unresolved questions and future study directions.
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Affiliation(s)
- Chih-Hao Chen
- Department of Clinical Neurosciences, University of Calgary, HMRB Room 103, 3280 Hospital Drive, NW Calgary, Alberta, Canada T2N 4Z6; Department of Neurology, National Taiwan University Hospital, No.1, Changde Street, Zhongzheng District, Taipei City 100229, Taiwan (R.O.C.)
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, HMRB Room 103, 3280 Hospital Drive, NW Calgary, Alberta, Canada T2N 4Z6.
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2
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Martis WR, Denehy L, Ismail H, Riedel B. Improving generalisability. Anaesthesia 2024; 79:329. [PMID: 37880920 DOI: 10.1111/anae.16145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/27/2023]
Affiliation(s)
- W R Martis
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - L Denehy
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Ismail
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - B Riedel
- Peter MacCallum Cancer Centre, Melbourne, Australia
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Khan S, Fawaz S, Simpson R, Robertson C, Kelly P, Mohdnazri S, Tang K, Cook CM, Gallagher S, O’Kane P, Spratt J, Brilakis ES, Karamasis GV, Al-Lamee R, Keeble TR, Davies JR. The challenges of a randomised placebo-controlled trial of CTO PCI vs. placebo with optimal medical therapy: The ORBITA-CTO pilot study design and protocol. Front Cardiovasc Med 2023; 10:1172763. [PMID: 37206100 PMCID: PMC10188975 DOI: 10.3389/fcvm.2023.1172763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/13/2023] [Indexed: 05/21/2023] Open
Abstract
Background Percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) has been performed for the improvement of symptoms and quality of life in patients with stable angina. The ORBITA study demonstrated the role of the placebo effect in contemporary PCI in non-CTO chronic coronary syndromes. However, the benefit of CTO PCI beyond that of a placebo has not been demonstrated. Aims The ORBITA-CTO pilot study will be a double-blind, placebo-controlled study of CTO PCI randomising patients who have: (1) been accepted by a CTO operator for PCI; (2) experienced symptoms due to a CTO; (3) evidence of ischaemia; (4) evidence of viability within the CTO territory; and (5) a J-CTO score ≤3. Methods Patients will undergo medication optimisation that will ensure they are on at least a minimum amount of anti-anginals and complete questionnaires. Patients will record their symptoms on an app daily throughout the study. Patients will undergo randomisation procedures, including an overnight stay, and be discharged the following day. All anti-anginals will be stopped after randomisation and re-initiated on a patient-led basis during the 6-month follow-up period. At follow-up, patients will undergo repeat questionnaires and unblinding, with a further 2-week unblinded follow-up. Results The co-primary outcomes are feasibility (blinding) in this cohort and angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include changes in quality-of-life measures, Seattle Angina Questionnaire (SAQ), peak VO2, and anaerobic threshold on the cardiopulmonary exercise test. Conclusion The feasibility of a placebo-controlled CTO PCI study will lead to future studies assessing efficacy. The impact of CTO PCI on angina measured using a novel daily symptom app may provide improved fidelity in assessing symptoms in patients with CTO's.
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Affiliation(s)
- Sarosh Khan
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Samer Fawaz
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Rupert Simpson
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Craig Robertson
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Paul Kelly
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
| | - Shah Mohdnazri
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
| | - Kare Tang
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
| | - Christopher M. Cook
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Sean Gallagher
- Department of Interventional Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter O’Kane
- Department of Interventional Cardiology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - James Spratt
- Department of Interventional Cardiology, St. George's Hospital, London, United Kingdom
| | - Emmanouil S. Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, United States
| | - Grigoris V. Karamasis
- School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Thomas R. Keeble
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
| | - John R. Davies
- Department of Interventional Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Department of Interventional Cardiology, Anglia Ruskin University, Chelmsford, United Kingdom
- Correspondence: John R. Davies
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Thijssen DHJ, Uthman L, Somani Y, van Royen N. Short-term exercise-induced protection of cardiovascular function and health: why and how fast does the heart benefit from exercise? J Physiol 2022; 600:1339-1355. [PMID: 35239189 PMCID: PMC9311195 DOI: 10.1113/jp282000#support-information-section] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/10/2021] [Indexed: 05/28/2023] Open
Abstract
Regular exercise training has potent and powerful protective effects against the development of cardiovascular disease. These cardioprotective effects of regular exercise training are partly explained through the effects of exercise on traditional cardiovascular risk factors and improvement in cardiac and vascular health, which take several weeks to months to develop. This review focuses on the observation that single bouts of exercise may also possess an underrecognized, clinically useful form of immediate cardioprotection. Studies, performed in both animals and humans, demonstrate that single or short-term exercise-induced protection (SEP) attenuates the magnitude of cardiac and/or vascular damage in response to prolonged ischaemia and reperfusion injury. This review highlights preclinical evidence supporting the hypothesis that SEP activates multiple pathways to confer immediate protection against ischaemic events, reduce the severity of potentially lethal ischaemic myocardial injury, and therefore act as a physiological first line of defence against injury. Given the fact that the extent of SEP could be modulated by exercise-related and subject-related factors, it is important to recognize and consider these factors to optimize future clinical implications of SEP. This review also summarizes potential effector signalling pathways (i.e. communication between exercising muscles to vascular/cardiac tissue) and intracellular pathways (i.e. reducing tissue damage) that ultimately confer protection against cardiac and vascular injury. Finally, we discuss potential future directions for designing adequate human and animal studies that will support developing effective SEP strategies for the (multi-)diseased and aged individual. KEY POINTS: Single or short-term exercise-induced protection (SEP) attenuates the magnitude of cardiac and/or vascular damage in response to prolonged ischaemia and reperfusion injury (IR injury). SEP activates multiple pathways to confer cardiac protection, which develops remotely at the site of the activated muscle by release of circulating molecules, which transfer towards activation of intramyocardial signalling that promotes cell survival during episodes of IR injury. SEP represents an attractive intervention in aged individuals and in those with co-morbidities. The immediate protection, low cost and simplicity to increase the 'dose' of SEP offers unique opportunities in the clinical applications of SEP.
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Affiliation(s)
- Dick H. J. Thijssen
- Radboud Institute for Health SciencesDepartments of PhysiologyNijmegenThe Netherlands
- Research Institute for Sport and Exercise SciencesLiverpool John Moores UniversityLeicesterUK
| | - Laween Uthman
- Radboud Institute for Health SciencesDepartments of PhysiologyNijmegenThe Netherlands
- CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Yasina Somani
- Research Institute for Sport and Exercise SciencesLiverpool John Moores UniversityLeicesterUK
| | - Niels van Royen
- CardiologyRadboud University Medical CenterNijmegenThe Netherlands
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Thijssen DHJ, Uthman L, Somani Y, Royen N. Short term exercise‐induced protection of cardiovascular function and health: Why and how fast does the heart benefit from exercise? J Physiol 2021; 600:1339-1355. [PMID: 35239189 PMCID: PMC9311195 DOI: 10.1113/jp282000] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract Regular exercise training has potent and powerful protective effects against the development of cardiovascular disease. These cardioprotective effects of regular exercise training are partly explained through the effects of exercise on traditional cardiovascular risk factors and improvement in cardiac and vascular health, which take several weeks to months to develop. This review focuses on the observation that single bouts of exercise may also possess an underrecognized, clinically useful form of immediate cardioprotection. Studies, performed in both animals and humans, demonstrate that single or short‐term exercise‐induced protection (SEP) attenuates the magnitude of cardiac and/or vascular damage in response to prolonged ischaemia and reperfusion injury. This review highlights preclinical evidence supporting the hypothesis that SEP activates multiple pathways to confer immediate protection against ischaemic events, reduce the severity of potentially lethal ischaemic myocardial injury, and therefore act as a physiological first line of defence against injury. Given the fact that the extent of SEP could be modulated by exercise‐related and subject‐related factors, it is important to recognize and consider these factors to optimize future clinical implications of SEP. This review also summarizes potential effector signalling pathways (i.e. communication between exercising muscles to vascular/cardiac tissue) and intracellular pathways (i.e. reducing tissue damage) that ultimately confer protection against cardiac and vascular injury. Finally, we discuss potential future directions for designing adequate human and animal studies that will support developing effective SEP strategies for the (multi‐)diseased and aged individual. Key points Single or short‐term exercise‐induced protection (SEP) attenuates the magnitude of cardiac and/or vascular damage in response to prolonged ischaemia and reperfusion injury (IR injury). SEP activates multiple pathways to confer cardiac protection, which develops remotely at the site of the activated muscle by release of circulating molecules, which transfer towards activation of intramyocardial signalling that promotes cell survival during episodes of IR injury. SEP represents an attractive intervention in aged individuals and in those with co‐morbidities. The immediate protection, low cost and simplicity to increase the ‘dose’ of SEP offers unique opportunities in the clinical applications of SEP.
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Affiliation(s)
- Dick H. J. Thijssen
- Radboud Institute for Health Sciences Departments of Physiology Nijmegen The Netherlands
- Research Institute for Sport and Exercise Sciences Liverpool John Moores University Leicester United Kingdom
| | - Laween Uthman
- Radboud Institute for Health Sciences Departments of Physiology Nijmegen The Netherlands
- Cardiology Radboud University Medical Center Nijmegen The Netherlands
| | - Yasina Somani
- Research Institute for Sport and Exercise Sciences Liverpool John Moores University Leicester United Kingdom
| | - Niels Royen
- Cardiology Radboud University Medical Center Nijmegen The Netherlands
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Meeder JG, Hartzema-Meijer MJ, Jansen TPJ, Konst RE, Damman P, Elias-Smale SE. Outpatient Management of Patients With Angina With No Obstructive Coronary Arteries: How to Come to a Proper Diagnosis and Therapy. Front Cardiovasc Med 2021; 8:716319. [PMID: 34796207 PMCID: PMC8592903 DOI: 10.3389/fcvm.2021.716319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/22/2021] [Indexed: 12/28/2022] Open
Abstract
Two-thirds of women and one-third of men who undergo a clinically indicated coronary angiography for stable angina, have no obstructive coronary artery disease (CAD). Coronary vascular dysfunction is a highly prevalent underlying cause of angina in these so called “Angina with No Obstructive Coronary Arteries (ANOCA)” patients, foremost in middle aged women. Coronary vascular dysfunction encompasses various endotypes, namely epicardial and microvascular coronary spasms, impaired vasodilatation, and increased microvascular resistance. ANOCA patients, especially those with underlying coronary vascular dysfunction, have an adverse cardiovascular prognosis, poor physical functioning, and a reduced quality of life. Since standard ischemia detection tests and coronary angiograms are not designed to diagnose coronary vascular dysfunction, this ischemic heart disease is often overlooked and hence undertreated. But adequate diagnosis is vital, so that treatment can be started to reduce symptoms, reduce healthcare costs and improve quality of life and cardiovascular prognosis. The purpose of this review is to give a contemporary overview of ANOCA with focus on coronary vascular dysfunction. We will provide a possible work-up of patients suspected of coronary vascular dysfunction in the outpatient clinical setting, based on the latest scientific insights and international consensus documents. We will discuss the value of ischemia detection testing, and non-invasive and invasive methods to diagnose coronary vascular dysfunction. Furthermore, we will go into pharmacological and non-pharmacological therapeutic options including anti-anginal regimens and lifestyle interventions.
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Affiliation(s)
- Joan G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, Netherlands
| | | | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
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Myat A, Redwood SR, Arri S, Gersh BJ, Bhatt DL, Marber MS. Liraglutide to Improve corONary haemodynamics during Exercise streSS (LIONESS): a double-blind randomised placebo-controlled crossover trial. Diabetol Metab Syndr 2021; 13:17. [PMID: 33579317 PMCID: PMC7881597 DOI: 10.1186/s13098-021-00635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/03/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Glucagon-like peptide-1 receptor (GLP-1R) activation may improve myocardial performance in the context of ischaemia, independent of glycaemic control, in individuals with and without type 2 diabetes mellitus. METHODS The LIONESS trial was a single-centre randomised double-blind placebo-controlled crossover study to determine whether prolonged GLP-1R activation could improve exercise haemodynamics in chronic stable angina patients. Eligibility criteria comprised angiographic evidence of obstructive coronary artery disease (CAD) and an abnormal baseline exercise tolerance test (ETT) demonstrating > 0.1 mV of planar or downsloping ST-segment depression (STD). Those randomised to active agent started with a 1-week run-in phase of 0.6 mg liraglutide daily, an established injectable GLP-1R agonist, followed by 1 week of 1.2 mg liraglutide, after which patients performed a week 2 ETT. Patients then self-administered 1.8 mg liraglutide for a week before completing a week 3 ETT. The placebo arm received visually and temporally matched daily saline injections. Participants then crossed over to a 3-week course of saline injections interspersed with a week 5 ETT and week 6 ETT and vice versa. Co-primary endpoints were rate pressure product (RPP) at 0.1 mV STD and magnitude of STD at peak exercise. RESULTS Twenty-two patients (21 without diabetes) were randomised. There was no significant difference between saline versus liraglutide in the co-primary endpoints of RPP achieved at 0.1 mV STD (saline vs. liraglutide 1.2 mg p = 0.097; saline vs. liraglutide 1.8 mg p = 0.48) or the degree of STD at peak exercise (saline vs. liraglutide 1.2 mg p = 0.68; saline vs. liraglutide 1.8 mg p = 0.57). Liraglutide did not cause symptomatic hypoglycaemia, renal dysfunction, acute pancreatitis or provoke early withdrawal from the trial. Liraglutide significantly reduced weight (baseline 88.75 ± 16.5 kg vs. after liraglutide 87.78 ± 16.9 kg; p = 0.0008) and improved the lipid profile (mean total cholesterol: at baseline 3.97 ± 0.88 vs. after liraglutide 3.56 ± 0.71 mmol/L; p < 0.0001). CONCLUSION Liraglutide did not enhance exercise tolerance or haemodynamics compared with saline placebo during serial treadmill testing in patients with established obstructive CAD. It did, however, significantly reduce weight and improve the lipid profile. Trial Registration ClinicalTrials.gov Identifier NCT02315001. Retrospectively registered on 11th December 2014.
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Affiliation(s)
- Aung Myat
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Frimley, GU16 7UJ, Camberley, UK.
| | - Simon R Redwood
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Satpal Arri
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Centre and Harvard Medical School, Boston, MA, 02115, USA
| | - Michael S Marber
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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Bigler MR, Stoller M, Tschannen C, Grossenbacher R, Seiler C. Effect of permanent right internal mammary artery occlusion on right coronary artery supply: A randomized placebo-controlled clinical trial. Am Heart J 2020; 230:1-12. [PMID: 32949505 DOI: 10.1016/j.ahj.2020.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
Abstract
Natural, nonsurgical internal mammary artery (IMA) bypasses to the coronary circulation have been shown to function as extracardiac sources of myocardial blood supply. The goal of this randomized, placebo-controlled, double-blind trial was to test the efficacy of permanent right IMA (RIMA) device occlusion on right coronary artery (RCA) occlusive blood supply and on clinical and electrocardiographic (ECG) signs of myocardial ischemia. METHODS This was a prospective superiority trial in 100 patients with chronic coronary artery disease randomly allocated (1:1) to RIMA vascular device occlusion (verum group) or to RIMA sham procedure (placebo group). The primary study end point was RCA collateral flow index (CFI) as obtained during a 1-minute ostial RCA balloon occlusion at baseline before and at follow-up examination 6 weeks after the trial intervention. CFI is the ratio between simultaneous mean coronary occlusive divided by mean aortic pressure both subtracted by central venous pressure. Simultaneously obtained secondary study end points were the registration of angina pectoris and quantitative intracoronary ECG ST-segment shift. RESULTS CFI change during the follow-up period was +0.036 ± 0.068 in the verum group and -0.021 ± 0.097 in the placebo group (P = .0011). Angina pectoris during the same RCA balloon occlusions had disappeared at follow-up in 14/49 patients of the verum group and in 4/49 patients of the placebo group (P = .0091). Simultaneous intracoronary ECG ST-segment shift change revealed diminished myocardial ischemia at follow-up in the verum group and more severe ischemia in the placebo group. CONCLUSIONS Permanent RIMA device occlusion augments RCA supply to the effect of diminishing clinical and electrocardiographic signs of myocardial ischemia during a brief controlled coronary occlusion.
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3648] [Impact Index Per Article: 912.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Rossello X, Rodriguez-Sinovas A, Vilahur G, Crisóstomo V, Jorge I, Zaragoza C, Zamorano JL, Bermejo J, Ordoñez A, Boscá L, Vázquez J, Badimón L, Sánchez-Margallo FM, Fernández-Avilés F, Garcia-Dorado D, Ibanez B. CIBER-CLAP (CIBERCV Cardioprotection Large Animal Platform): A multicenter preclinical network for testing reproducibility in cardiovascular interventions. Sci Rep 2019; 9:20290. [PMID: 31889088 PMCID: PMC6937304 DOI: 10.1038/s41598-019-56613-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
Despite many cardioprotective interventions have shown to protect the heart against ischemia/reperfusion injury in the experimental setting, only few of them have succeeded in translating their findings into positive proof-of-concept clinical trials. Controversial and inconsistent experimental and clinical evidence supports the urgency of a disruptive paradigm shift for testing cardioprotective therapies. There is a need to evaluate experimental reproducibility before stepping into the clinical arena. The CIBERCV (acronym for Spanish network-center for cardiovascular biomedical research) has set up the "Cardioprotection Large Animal Platform" (CIBER-CLAP) to perform experimental studies testing the efficacy and reproducibility of promising cardioprotective interventions based on a pre-specified design and protocols, randomization, blinding assessment and other robust methodological features. Our first randomized, control-group, open-label blinded endpoint experimental trial assessing local ischemic preconditioning (IPC) in a pig model of acute myocardial infarction (n = 87) will be carried out in three separate sets of experiments performed in parallel by three laboratories. Each set aims to assess: (A) CMR-based outcomes; (B) histopathological-based outcomes; and (C) protein-based outcomes. Three core labs will assess outcomes in a blinded fashion (CMR imaging, histopathology and proteomics) and 2 methodological core labs will conduct the randomization and statistical analysis.
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Affiliation(s)
- Xavier Rossello
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Antonio Rodriguez-Sinovas
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Laboratorio de Investigación en Enfermedades Cardiovasculares, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Gemma Vilahur
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Programa ICCC-Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Verónica Crisóstomo
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain
| | - Inmaculada Jorge
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Carlos Zaragoza
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Servicio de Cardiologia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Universidad Francisco de Vitoria, Madrid, Spain
| | - José L Zamorano
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Servicio de Cardiologia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Javier Bermejo
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio Ordoñez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Lisardo Boscá
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de Investigaciones Biomédicas Alberto Sols (Centro Mixto CSIC-UAM), Madrid, Spain
| | - Jesús Vázquez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Lina Badimón
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Programa ICCC-Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Francisco M Sánchez-Margallo
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain
| | - Francisco Fernández-Avilés
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - David Garcia-Dorado
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Laboratorio de Investigación en Enfermedades Cardiovasculares, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Borja Ibanez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
- Cardiology Department, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain.
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Rezende PC, Ribas FF, Serrano CV, Hueb W. Clinical significance of chronic myocardial ischemia in coronary artery disease patients. J Thorac Dis 2019; 11:1005-1015. [PMID: 31019790 DOI: 10.21037/jtd.2019.02.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Almohanna AM, Wray S. Hypoxic conditioning in blood vessels and smooth muscle tissues: effects on function, mechanisms, and unknowns. Am J Physiol Heart Circ Physiol 2018; 315:H756-H770. [PMID: 29702009 DOI: 10.1152/ajpheart.00725.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hypoxic preconditioning, the protective effect of brief, intermittent hypoxic or ischemic episodes on subsequent more severe hypoxic episodes, has been known for 30 yr from studies on cardiac muscle. The concept of hypoxic preconditioning has expanded; excitingly, organs beyond the heart, including the brain, liver, and kidney, also benefit. Preconditioning of vascular and visceral smooth muscles has received less attention despite their obvious importance to health. In addition, there has been no attempt to synthesize the literature in this field. Therefore, in addition to overviewing the current understanding of hypoxic conditioning, in the present review, we consider the role of blood vessels in conditioning and explore evidence for conditioning in other smooth muscles. Where possible, we have distinguished effects on myocytes from other cell types in the visceral organs. We found evidence of a pivotal role for blood vessels in conditioning and for conditioning in other smooth muscle, including the bladder, vascular myocytes, and gastrointestinal tract, and a novel response in the uterus of a hypoxic-induced force increase, which helps maintain contractions during labor. To date, however, there are insufficient data to provide a comprehensive or unifying mechanism for smooth muscles or visceral organs and the effects of conditioning on their function. This also means that no firm conclusions can be drawn as to how differences between smooth muscles in metabolic and contractile activity may contribute to conditioning. Therefore, we have suggested what may be general mechanisms of conditioning occurring in all smooth muscles and tabulated tissue-specific mechanistic findings and suggested ideas for further progress.
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Affiliation(s)
- Asmaa M Almohanna
- Department of Molecular and Cellular Physiology, Institute of Translational Medicine University of Liverpool , Liverpool , United Kingdom.,Princess Nourah bint Abdulrahman University , Riyadh , Saudi Arabia
| | - Susan Wray
- Department of Molecular and Cellular Physiology, Institute of Translational Medicine University of Liverpool , Liverpool , United Kingdom
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13
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Stoller M, Seiler C. Effect of Permanent Right Internal Mammary Artery Closure on Coronary Collateral Function and Myocardial Ischemia. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.116.004990. [PMID: 28566292 PMCID: PMC5482561 DOI: 10.1161/circinterventions.116.004990] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/07/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND The objective of this study is to test the effect of permanent right internal mammary artery device closure on coronary collateral function and myocardial ischemia. METHODS AND RESULTS This was a prospective, open-label clinical trial in 50 patients with coronary artery disease. The primary study end point was coronary collateral flow index as obtained during a 1-minute proximal right coronary artery (RCA) and left coronary artery balloon occlusion at baseline before and at follow-up examination 6 weeks after distal right internal mammary artery device closure. Collateral flow index is the ratio between simultaneously recorded mean coronary occlusive pressure divided by mean aortic pressure, both subtracted by central venous pressure. Secondary study end points were fractional flow reserve during vessel patency, the quantitative intracoronary ECG ST-segment elevation, and angina pectoris during the same 1-minute coronary occlusion. Collateral flow index in the untreated RCA and left coronary artery changed from 0.071±0.082 at baseline to 0.132±0.117 (P<0.0001) at follow-up examination and from 0.106±0.092 to 0.081±0.079 (P=0.29), respectively. RCA fractional flow reserve increased significantly (P=0.0029) from baseline to follow-up examination, despite deferral of coronary intervention in all patients. There was a decrease in intracoronary ECG ST-elevation during RCA occlusion from baseline to follow-up examination (P=0.0015); it did not change in the left coronary artery. Angina pectoris during RCA occlusion tended to occur in fewer patients at follow-up versus baseline examination (P=0.06). CONCLUSIONS Permanent right internal mammary artery device closure seems to augment extracardiac ipsilateral coronary supply to the effect of reducing ischemia in the dependent myocardial region. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02475408.
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Affiliation(s)
- Michael Stoller
- From the Department of Cardiology, Bern University Hospital, Switzerland
| | - Christian Seiler
- From the Department of Cardiology, Bern University Hospital, Switzerland.
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Ejlersen H, Andersen ZJ, von Euler-Chelpin MC, Johansen PP, Schnohr P, Prescott E. Prognostic impact of physical activity prior to myocardial infarction: Case fatality and subsequent risk of heart failure and death. Eur J Prev Cardiol 2017; 24:1112-1119. [DOI: 10.1177/2047487317702046] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hanne Ejlersen
- Department of Cardiology, University of Copenhagen, Denmark
| | | | | | - Pernille Palm Johansen
- Department of Cardiology, University of Copenhagen, Denmark
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Peter Schnohr
- Copenhagen City Heart Studies, University of Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, University of Copenhagen, Denmark
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16
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17
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Bulluck H, Hausenloy DJ. Ischaemic conditioning: are we there yet? Heart 2015; 101:1067-77. [DOI: 10.1136/heartjnl-2014-306531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 03/08/2015] [Indexed: 11/04/2022] Open
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Myat A, Arri S, Bhatt DL, Gersh BJ, Redwood SR, Marber MS. Design and rationale for the randomised, double-blinded, placebo-controlled Liraglutide to Improve corONary haemodynamics during Exercise streSS (LIONESS) crossover study. Cardiovasc Diabetol 2015; 14:27. [PMID: 25848859 PMCID: PMC4358711 DOI: 10.1186/s12933-015-0193-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/07/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Glucagon-like peptide-1 is an incretin hormone essential for normal human glucose homeostasis. Expression of the glucagon-like peptide-1 receptor in the myocardium has fuelled growing interest in the direct and indirect cardiovascular effects of native glucagon-like peptide-1, its degradation product glucagon-like peptide-1(9-36), and the synthetic glucagon-like peptide-1 receptor agonists. Preclinical studies have demonstrated cardioprotective actions of all three compounds in the setting of experimental myocardial infarction and left ventricular systolic dysfunction. This has led to Phase 2 trials of native glucagon-like peptide-1 and incretin-based therapies in humans with and without Type 2 diabetes mellitus. These studies have demonstrated the ability of glucagon-like peptide-1, independent of glycaemic control, to positively modulate the metabolic and haemodynamic parameters of individuals with coronary artery disease and left ventricular systolic dysfunction. We aim to add to this growing body of evidence by studying the effect of chronic glucagon-like peptide-1 receptor activation on exercise-induced ischaemia in patients with chronic stable angina managed conservatively or awaiting revascularisation. The hypothesis being liraglutide, a subcutaneously injectable glucagon-like peptide-1 receptor agonist, is able to improve exercise haemodynamics in patients with obstructive coronary artery disease when compared with saline placebo. METHODS AND DESIGN The Liraglutide to Improve corONary haemodynamics during Exercise streSS (LIONESS) trial is an investigator-initiated single-centre randomised double-blinded placebo-controlled crossover proof-of-principle physiological study. Primary endpoints are change in rate pressure product at 0.1 mV ST-segment depression and change in degree of ST-segment depression at peak exercise during sequential exercise tolerance testing performed over a 6-week study period in which 26 patients will be randomised to either liraglutide or saline with crossover to the opposing regimen at week 3. DISCUSSION The study will be conducted in accordance with the principles of Good Clinical Practice and the Declaration of Helsinki. The local Research Ethics Committee and Medicines and Healthcare Products Regulatory Agency have approved the study. TRIAL REGISTRATION National Institute of Health Research Clinical Research Network (NIHR CRN) Portfolio ID 11112 and ClinicalTrials.gov Identifier NCT02315001.
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Affiliation(s)
- Aung Myat
- />King’s College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Satpal Arri
- />King’s College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Deepak L Bhatt
- />Brigham and Women’s Hospital Heart & Vascular Centre and Harvard Medical School, Boston, MA 02115 USA
| | - Bernard J Gersh
- />Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905 USA
| | - Simon R Redwood
- />King’s College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Michael S Marber
- />King’s College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
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